President Barack Obama's proposal to trim trillions from the deficit and hundreds of billions from Medicare also puts advanced imaging services in the budget-cutting crosshairs.

In the proposal, the government hopes to realize about $1.3 billion in savings by raising the assumed utilization rate on some imaging equipment and by requiring referring doctors to first get authorization, likely from a radiology benefits management service, before ordering a scan.

But these ideas are not new, and they are, as expected, not popular in the imaging community.

"In Washington, there is a dearth of new thinking," Cynthia Moran, Assistant Executive Director of Government Relations with the American College of Radiology, which has about 34,000 members, told DOTmed News, when we spoke this week. She said the calls for raising the utilization rate and pre-authorization for imaging have been floating around the Capitol in one form or another for years.

The administration's proposal, revealed Monday, which includes roughly $320 billion in cuts from Medicare and Medicaid, now heads to Congress. There, Moran says the real action will take place in the so-called supercommittee -- a team of 12 Senators and members of Congress that has to hammer out a plan to slash $1.2 trillion from the deficit by Thanksgiving. The proposal then must be voted on in a simple yea-or-nay vote by Christmas.

"This is no longer the president's game," Moran said.

But the suggestions still are a broad and powerful outline which Congress could follow. In any case, Moran says it could help cast the shape of the debate.

Earlier in the summer, for instance, there was talk of raising the eligibility age for Medicare up from 65 to 67. But those painful, large-scale conversations have been ditched in an effort to simply squeeze out money where possible, according to Moran.

"The regrettable thing is the supercommittee has an opportunity to think in big terms, to really try to move the needle and make significant, systemic changes to the entitlement programs," Moran said. "And I think the rhetoric of the last few days from the White House, from congressional leadership, ensures the supercommittee, instead of thinking big, will think: 'What's the least amount we can do to meet this obligation, then get the hell out of Dodge?'"

The new proposals

The administration says the two-part plan should save Medicare about $1.3 billion. The first part, which the government estimates will save $400 million, involves increasing the utilization rate for advanced imaging services -- which in this context, likely means MRI, CT and nuclear medicine.

This policy basically works by assuming how long the varied equipment is in use, and would affect the technical component of Medicare payments.

It's not totally clear, but it's thought the new plan calls for raising the assumed utilization rate to 90 percent, up from its current 75 percent rate. While the Affordable Care Act was being drafted, Moran said the Obama administration had initially tried to push the 90 percent utilization rate, before both sides compromised at 75 percent, the number included in the final bill. And a similar proposal also appeared in June as a provision attached to a trade bill. (The Office of Management and Budget did not respond to DOTmed News requests for comment on the utilization rate formula by press time.)

Before health care reform passed, the utilization rate was 50 percent, Moran said. She said estimates for the true utilization rate usually fall somewhere between 45 and 55 percent.

Prior authorization

The second bit of the imaging proposal involves pre-authorization. Before ordering an exam on expensive advanced imaging equipment, doctors will first need approval, probably from a radiology benefits management service.

The administration said it was inspired by Government Accountability Office recommendations. But it's also a somewhat tougher implementation of a proposal from MedPAC. In a spring report, the group called for doctors who ordered a high amount of clinically inappropriate advanced imaging tests to first undergo prior authorization. However, unlike that proposal, the current one applies to all doctors, regardless of their resource usage.

The administration says it could save $900 million with the plan over the next 10 years, but ACR disputed those numbers, saying they were likely based on older data, as advanced imaging's growth remains sluggish.

"Any estimates of savings were based on a bottom-line imaging utilization number that was certainly higher in 2008 than it is in 2011," Moran said. "All of advanced diagnostic imaging rates have flattened if not dipped in the last three years."

According to a recent Access to Medical Imaging Coalition report, for instance, advanced imaging is no longer enjoying the wild growth spurt it lived through in the early 2000s. According to the report, advanced imaging procedures grew only one-tenth of one percent from 2008 to 2009.

The ACR also says that some research has suggested the savings might be less than estimated because of the costs of setting up RBMs, and that in any case the costs might fall on providers. For example, a Journal of the American College of Radiology study from June, prepared by an economist with GE Healthcare, estimated that 28 percent of projected RBM savings would actually be shifted onto doctors and their staff.

SGR fix

Of course, looming over the whole discussion is the so-called "doc fix" -- that is, the repeal of the sustainable growth-rate formula.

The offspring of a bout of budget-hawkery in the early 1990s, the SGR is meant to keep Medicare payments to doctors in line with the growth of the economy. Long delayed, if it should go into effect this January, as scheduled, it would represent a 29.4 percent cut to physicians' Medicare reimbursements.

But the Obama administration's deficit-cutting proposals were built around an assumed SGR fix, presumably to be tackled by the supercomittee.

How exactly this fix will be reached is unknown. But to help come up with the nearly $300 billion required for a 10-year fix, MedPAC recommended last week to freeze the payment rate for primary care doctors, while docking specialists 5.9 percent every year for the next three years, and then instituting a seven-year pay rate freeze.

In a MedPAC transcript released this week, the group further called for about $233 billion in offsets to help pay for the SGR repeal, including reduced payment for clinical lab services and the above-mentioned prior authorization for "outlier" doctors.

Predictably, the specialist-docking plan brought denunciations from groups representing surgeons, cardiologists and others who would bear the brunt of the changes.

Moran thinks the recommendation all but ensures that when the supercommittee argues the SGR issue, they will again reach for a short-term patch, delaying the cuts for another six months or a year, as has been done practically since the program started, rather than reach a final compromise.

"It's so non-credible," she said. "That policy of penalizing specialist medicine: there's not one winner in that argument. It would create civil war in the house of medicine, and the people that are going to be the most disadvantaged by that are the patients who depend on primary care physicians and specialists talking with each other."

But what will actually happen remains to be seen. Right now, Moran says, all eyes in Washington will be on the 12 members of the supercommittee as they work towards their deadlines.

As for the impact on imaging, the medical society says it's gearing up for a fight. But it can be hard to undo proposals, especially when there's a promise of savings.

"Once an idea is out there and it's in print, and there's one dollar savings attached to it, it becomes very difficult to get that off the table," Moran said.