The federal government is following the path of some private payors by crafting legislation that ties payment for advanced imaging services to accreditation.

In the past two decades, non-invasive diagnostic imaging has become a first-line protocol in the evaluation process of the estimated 61 million people in the U.S. with known or suspected heart disease. Because of the prevalence of the disease, quality cardiovascular imaging and interpretation are critical components in the diagnostic armamentarium. In response to this need, professional medical societies have formed accreditation bodies to ensure those performing diagnostic cardiac imaging procedures demonstrate a commitment to quality and accepted standards of practice.

There are two nationally accepted accrediting bodies in the U.S. for the medical imaging modalities of noninvasive vascular technology, nuclear medicine (including SPECT and PET), MR and CT: the Intersocietal Accreditation Commission (IAC), which has five divisions dedicated to cardiac imaging accreditation, and the accreditation programs offered by the American College of Radiology (ACR).

“Laboratory accreditation offers the means necessary to demonstrate a commitment to quality in patient care, quality in imaging, quality in interpretation, quality in reporting and, most of all, the overall quality of the facility,” says Gary V. Heller, MD, PhD, director of nuclear cardiology and the cardiovascular fellowship program at Hartford Hospital in Hartford, Conn., and co-author of a recent article on cardiovascular accreditation (J Am Coll Cardiol Img 2008;1:390-397).

Historically, cardiac imaging accreditation has been a voluntary effort by facilities electing to participate in the process. By many indications, mandatory compliance with accreditation may soon be compulsory.

The American College of Cardiology (ACC) Statement on Accreditation/Certification, adopted by the ACC Board of Trustees on March 5, 2005, delivered emphatic support for cardiac imaging accreditation. The ACC emphasized that it “encourages governments and payors to make accreditation/certification programs mandatory conditions of participation.”

Though the ACC supports accreditation solely as a mechanism to improve quality, not as a growth- or cost-containment mechanism, “the inference is clear: unaccredited facilities risk losing business as well as public confidence,” notes Wayne Schellhammer, executive vice president of Kardia Health Systems, a Rochester, Minn.-based provider of echocardiography information management systems and cardiac accreditation consulting.

Applications for Accreditation on the Rise The number of applications for echo and nuclear lab accreditation has grown exponentially since the accrediting bodies were initiated more than a decade ago. Source: Gary V. Heller et al, J Am Coll Cardiol Img 2008;1;390-397

Imaging societies get onboard

On April 27, 2005, the American Society of Echocardiography (ASE) released a statement, in the form of a proposed local coverage determination which clearly indicates its position on accreditation.

“The accuracy of a transthoracic echocardiogram depends on the knowledge, skill, and experience of both the individual performing the study and the physician interpreting the study. For this reason, a transthoracic echocardiogram must be performed in a laboratory that is accredited in transthoracic echocardiography by the Intersocietal Commission for the Accreditation of Echocardiography Laboratories (ICAEL) and interpreted by a physician who is subject to the quality assurance program established by that laboratory,” the ASE wrote.

The American Society of Nuclear Cardiology (ASNC) also came out strongly in favor of facility and personnel accreditation in 2005, stating that it “supports the mandatory accreditation of nuclear cardiology laboratories and mandatory certification of physicians practicing nuclear cardiology by January 1, 2008.”

As chair of the ACR board of chancellors in 2005, James Borgstede, MD, testified before Congress that the use of “accreditation standards is one mechanism to help attain the goal of increasing quality and safety, while at the same time reducing utilization costs to Medicare.”

These unequivocal statements endorsing mandatory accreditation did not sit well with all members of these professional societies. “Our organizations got to be a little unpopular with some of the membership,” observes Kim A. Williams, MD, director of nuclear cardiology at the University of Chicago and past president of the ASNC.


From voluntary to mandatory

However, the positions taken by the ASNC, ASE, ACC, and ACR were prescient of reimbursement requirements that have been undertaken by private healthcare insurance payors.

Highmark Blue Cross Blue Shield in Pennsylvania, Oxford Health Plans in New England, Health Insurance Plan of Greater New York, and Group Health Incorporated and HealthNet in New York and New Jersey were among the first private insurers to address accreditation requirements for physicians performing diagnostic cardiac imaging. Tufts Health Plan in Massachusetts and Humana Kentucky also inaugurated program requirements in the past few years.

Highmark requires that echocardiography, MRI, nuclear cardiology, peripheral ultrasound and PET services for its beneficiaries must be conducted in accredited facilities, or those in the process of receiving accreditation, from the ACR or the IAC. More than 25 percent of the services, approximately 325 facilities, applied for accreditation after it became a requirement by the payor.

Last year, United Healthcare announced mandatory accreditation by IAC or ACR for echocardiography, nuclear medicine and nuclear cardiology, PET, MRI and CT for reimbursement for these services conducted on its estimated 50 million members by March 1, 2008. The company recently extended that deadline to the fourth quarter of 2009 to give their providers more time to comply with the accreditation requirement.

Recently, Senate legislation (S. 3101) contained an ACR-backed imaging utilization provision that calls for providers of advanced diagnostic imaging services (MR, CT, PET and nuclear medicine) to be accredited by 2012 to receive payment from the Centers for Medicare & Medicaid Services (CMS) for the technical component of those services. The original bill, which was introduced on June 6 this year, failed to garner the necessary 60 votes needed to invoke cloture on debate and moved to a vote by a tally of 54-39.?

However, the House overwhelmingly passed the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331) on June 24, 2008, by a tally of 355-59. The legislation is similar to the Senate measure, but addresses significant points of concern that had been raised at the time by Senate Republicans.

The legislation also calls for providers of advanced diagnostic imaging services to be accredited to receive payment for the technical component of those services and establishes a two-year voluntary demonstration program to test the use of physician developed appropriateness criteria.


Not ‘if’, but ‘when’

These actions by private and public healthcare payors are a clear indication that mandatory accreditation of cardiac imaging facilities and personnel is no longer a question of if, but rather of when. As such, savvy cardiovascular administrators and business managers who have not yet accredited their facilities would be prudent in developing an accreditation strategy for their practice.

Once accredited by an IAC organization or ACR, a facility is approved to promote that designation to the public and its referring physician base.

“If a facility is not accredited, I think it does give [consumers] pause,” notes John R. Florio, executive director of cardiovascular services at the University of Kansas Hospital, in Kansas City, Kan. “There are a number of ways that people get to your doors, and the public is becoming more educated, even if they don’t understand all of it. Physicians in the community form an opinion as well if a hospital’s not doing a good job. They have lots of other choices where they can practice.”