The old saw is that police deal with 10 percent of the public 90 percent of the time. And according to the Medicare Payment Advisory Commission, a similar ratio applies to imaging: with 10 percent of doctors ordering 50 percent of advanced imaging tests.

Now for the first time, MedPAC, which advises Congress about Medicare, is calling for these high-use doctors to require prior authorization before ordering tests, in a move slammed by the imaging industry as based on "out-of-date" data.

On Thursday, a MedPAC panel voted 15-1 to call for prior authorization for the high orders of CT, PET, MRI and nuclear medicine exams, according to reports.
The group also called for lower payments for successive imaging exams performed in the same patient visit. In a presentation on MedPAC's website by Ariel Winter, the group said Medicare should align policies for the professional and technical component for multiple studies. Currently, technical component fees are reduced for second and subsequent studies performed during the same session.

"Efficiencies [are] likely when imaging and other tests are ordered and performed by same practitioner," the presentation said. For instance, record and patient history reviews would already have been done.

MedPAC said the motive is to limit what's perceived as the runaway growth of imaging services. And while self-referral is a concern -- the group said a "significant" share of the top 10 percent of doctors ordering advanced imaging self-refer -- the new proposals would apply to imaging centers, offices and outpatient departments, regardless of whether they self-refer.

The Medical Imaging & Technology Alliance, an equipment manufacturers lobby, criticized the basis of the decision, saying that "since 2006 payments for imaging procedures are down significantly and the utilization growth is flat."

"There are real-world consequences to again imposing reimbursement cuts on these procedures -- new innovations don't come to market, patients lose access to life-saving technologies and people lose their jobs as imaging equipment manufacturing is artificially slowed by short-sighted policy," MITA said in a statement.

The two groups had a different view on the state of imaging. Citing its March report, MedPAC said that the volume of all imaging for fee-for-service beneficiaries rose 2 percent. But growth for advanced imaging pretty much remained flat, at 0.1 percent.

However, the group said the imaging industry suggested all-imaging volume dropped 7.1 percent, and that advanced imaging declined 0.1 percent.

How it could work

In Winter's presentation, a slide illustrated how a prior authorization program could work.

According to the slide, prior authorization would only be required for doctors with a high rate of "inappropriate use" who order "substantially" more imaging studies than their peers. Doctors who order substantially more studies but have a low rate of "inappropriate use" would only require prior notification, the slide said.

Doctors who don't order substantially more studies than normal would not be subject to the system.

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