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How has DXA reimbursement affected your practice?
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Cuts from CMS will drop reimbursement below operating cost.
The Centers for Medicare and Medicaid Services has cut DXA reimbursement in the non-facility or office-based setting by more than 75% since 2006. The declines are the result of a recalculation of the relative value units (RVUs) in the last five-year review.
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As CMS used a new formula to calculate RVUs, we previously have shown input errors that contribute to this dramatic decline. With a proposed reimbursement of $45 in 2010, this will drop reimbursement below the operating cost for virtually all practices based on a Lewin Group study performed in 2007. Based on a survey performed by the ISCD, The Endocrine Society, American Association of Clinical Endocrinologists, ASBMR and American College of Rheumatology in March 2009, 71% of physicians in office-based practices have canceled plans to purchase new equipment, and 19% of the 700 respondents have stopped DXA testing; 49% have delayed hiring or laid off staff and 81% indicated that they have curtailed activities such as CME or certification.
The impact extends across all practice types: both urban and rural, large and small and specialty or primary care. We have introduced legislation in this session of Congress to return reimbursement rates to 2006 levels ($139), arguing that osteoporosis is a preventable disease and screening by DXA is recommended by the U.S. Preventive Services Task Force. HR 1894 and S769 have broad sponsorship from Democrats and Republicans alike. Given that only 13% of eligible Medicare beneficiaries have a DXA study each year and that current reimbursement severely undervalues DXA testing, passage of this legislation would be an important step in the battle to fight osteoporosis and improve patient access to care.
Andrew Laster, MD, FACR, is President of the International Society for Clinical Densitometry.
DXA reimbursement cutbacks caused my practice to close.
I bought a DXA machine in 1999 and opened a practice in rural Arizona, which led to buying several additional machines and placing them in other practices in the area. In 2007, the rural designation for Mohave County, Ariz., where my practice is, changed and I could no longer refer patients to my own DXA machine. I had two choices: buy another $100,000 DXA machine, put it in my office and scan my patients in my office and everyone else’s patients elsewhere, or move the machine to my office; but if more than a certain percentage of scans were coming from an outside source, Medicare requested that I register as an independent diagnostic facility. However, a series of red tape prevented me from doing so. The only way to provide this service to patients in my community was by doubling the overhead by having two machines, two offices and two receptionists. Then these DXA reimbursement cuts started to happen, and within one year, I was losing about $40 per scan, which eventually led to the closing of my office.
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I have since left my practice as an internist and joined a bariatric surgery practice in San Antonio. I am burned out and upset because being an internist is what I set out to, what I devoted my life to do. But, overall, this is about the patient — they are left with nothing. The crisis in osteoporosis care is the perfect microcosm of what is wrong with the whole system. DXA provides an early indication for risk for a devastating medical outcome, and we have outstanding therapies to prevent this outcome, yet are not using DXA to diagnose and prevent early possible fractures, and instead waiting until the fracture happens and then spending $30,000 for hip surgery down the line. We are going about this all wrong.
Brian Sabowitz, MD, internist at Blue Water Internal Medicine in Arizona.