Medicare for All: Considerations for Neuroradiologists

Financial Implications for Providers

In the United States, approximately 49% of the general population receives health insurance through their employers; 20%, through Medicaid; and 14%, through Medicare. About 9% of the population is uninsured. Other coverage comprises individual/nongroup insurance (6%) and military (1%).⁷ Under MFA, private health insurers would be prohibited from offering benefits included in the public program. The transition from a multipayer to single-payer system could have negative financial consequences for many radiologists because private insurer fees typically exceed those of Medicare.^8,9 With regard to neuroradiology, brain MR imaging payments from private insurers were shown to be more than twice as high as Medicare fee-for-service payments in a 2018 study published by the Congressional Budget Office.⁸

The difference between Medicare and private insurance fees is affected by factors including the negotiating power of a practice with private insurers, case mix, and the Geographic Practice Cost Index. As an example of variation between Medicare and private insurance reimbursement for a neuroradiology practice, Table 2 shows a brain examination case mix from the primary author’s radiology department with fees from Medicare and estimated average reimbursements from private insurers.

The shift to MFA could be especially disruptive for practices that currently treat a large portion of privately insured patients because private insurer fees are typically higher than those of Medicare throughout the country.^8,-,10 Conversely, MFA could increase revenue for some practices by reducing their uncompensated care for uninsured patients as well as by increasing their reimbursement for care of patients currently covered by lower-paying Medicaid.¹¹ Previous research found the average national Medicaid-to-Medicare fee index is 0.72,¹² though inpatient Medicaid fees vary on the basis of specific hospital cost-to-charge ratios. Some also argue that MFA would reduce costs for providers by decreasing their administrative burdens.¹³ Furthermore, practices might benefit from reduced time between when services are rendered and reimbursed. A current advantage of Medicare over private insurers is that Medicare often reimburses sooner.

To illustrate the impact on reimbursement in transitioning to a single-payer system, we present in Table 3, a simplified hypothetic general radiology case mix of 5 examinations, including MR imaging of the brain. These data are based on the case mix from the primary author’s radiology department and reimbursement figures for this locale to provide as realistic an example as possible of radiology reimbursement in the US multipayer system. Current Procedural Terminology codes were used to obtain volumes of the corresponding examinations performed in the first half of 2019. The finance department of the institution providing these data advised against publishing department-specific reimbursement data. With this condition, the analysis includes commonly performed examinations outside neuroradiology because high-volume studies typically make up a large proportion of overall reimbursements. Furthermore, a variety of imaging modalities more accurately reflects the impact on neuroradiologists who tend to practice in broader radiology environments.

In the general Louisiana population, approximately 13.1% of individuals are enrolled in Medicare, while about half have private health insurance.⁷ Typically, Medicare enrollees use more health services than privately insured individuals, which is reflected in the inpatient population payer mix (Medicare accounts for 25.8%) derived from national data.^14,15 Table 4 presents these examples of payer mixes. The payer mix of a typical radiology practice in Louisiana likely lies between these 2 examples if the practice performs both inpatient and outpatient imaging.

If we assume no change in the use of health services, if all patients in Louisiana were transitioned to Medicare at current Medicare PC fees, overall PC reimbursements for all 5 examinations in this analysis would decrease—with MR imaging of the brain leading that decline. The estimated revenue reduction for our simplified radiology case mix is 14%–20% (Table 5). Given the larger decrease for MR imaging payments, practices with higher percentages of MR imaging brain examinations could be more affected. The change in reimbursement is smaller in the inpatient scenario because Medicare and Medicaid currently make up larger proportions of payers in this setting.

Considerations for Neuroradiology Practices

The 14%–20% figure in Table 5 pertains to the primary author’s institution and is meant to serve as an example in discussing generalizable topics under MFA. A separate study by Galvani et al¹⁶ projected a 7.4% reduction if all physician and clinical services were reimbursed at Medicare rates. For practices that own equipment, technical fees contribute largely to the total cost of an imaging study. Louisiana Medicaid does not reimburse the technical component separately but rather reimburses for an imaging examination either by full service if the provider owns the equipment or by the PC alone.¹⁷ Other states may have nuanced differences in the way Medicaid reimburses the technical component.

The size of a practice is an important determinant of reimbursement. Because larger practices tend to negotiate higher prices with private health plans than smaller practices, smaller groups may experience less drastic reimbursement decreases under MFA. There is also a smaller reduction in the inpatient payer scenario because Medicare and Medicaid make up larger proportions of payers in this setting. This is concordant with the hypothesis that practices with more privately insured patients will experience more drastic reimbursement reductions compared with those that treat a high percentage of Medicare, Medicaid, and uninsured patients. Louisiana has a high proportion of Medicaid patients and around an average proportion of uninsured patients compared with the national US averages.⁷ In accounting for uncompensated care and lower PC fees from Medicaid, this analysis still showed an overall decrease in PC reimbursement in a Medicare single-payer scenario. Neuroradiologists in states with higher proportions of privately insured patients may experience a more drastic impact on reimbursements under MFA.

The analysis does not factor in fluctuations in imaging volume that may occur in a single-payer system. The volume of imaging examinations would likely increase due to decreased cost-sharing for patients.¹⁸ Further research is also needed to examine realistic cost-savings opportunities (eg, administrative costs) in evaluating the overall financial impact of MFA on radiology.

The estimated decrease in PC reimbursement in this analysis is based on 2019 Medicare PC fees. The Medicare Physician Fee Schedule for 2020 entailed cuts in reimbursement for radiology to boost reimbursement for care-related evaluation and management services. It is estimated this change will cost radiologists $450 million in 1 year alone, and $5.6 billion during the next decade.¹⁹ We also note that with reimbursement changes following passages of the Patient Protection and Affordable Care Act and Medicare Access and CHIP Reauthorization Act of 2015, it is also possible that fee-for-service may be substantially or completely replaced by alternative payment models (eg, bundled or episode-based payments, capitated payments, global budgets, and government salaried providers).¹³

Is Medicare for All Better for Our Patients?

Compared with patients in other high-income countries, Americans are more likely to report financial barriers to health care,^20,21 with a third of US adults reporting difficulty paying medical bills in 2018.²² This situation is often sensationalized in the media, creating a perception that the US health care industry takes advantage of sick people. Such a belief can undermine public trust in our health care system. Below, we discuss concerns commonly brought up by American patients and concerns regarding MFA.

In 2018, approximately 30.4 million persons in the United States were uninsured.²³ MFA would certainly extend coverage to more patients, and proponents of this system argue that increasing access to preventative care will reduce overall health care costs (eg, by decreasing emergency department use or hospital admissions for acute exacerbations of chronic illnesses). Prior research found that extending Medicaid coverage resulted in more health care use, including emergency department visits, without immediate improvement in health measures such as blood pressure or cardiovascular risk. It did, however, reduce the prevalence of depression and medical debt.²⁴

In addition to expanding coverage, proponents argue that MFA would provide more stable coverage. Currently, many Americans receive health insurance through their employers, and changing jobs can result in coverage fluctuations. MFA does not address how the government would feasibly absorb this cost from employers and risks encountering similar issues as other countries if unprepared. Several countries with highly regarded universal health care systems now struggle to finance their health care systems. Since 2010, the National Health Service budget of the United Kingdom has fallen short of its health care costs, resulting in longer wait times for patients, reduced payments to providers, and calls for tax increases.^25,-,27 Canada and Australia have faced similar issues of unsustainable rising health care costs, with consequent restrictions on services and increased reliance on private insurance.^28,29

The above is not a critique of the principle of universal health insurance but rather of how health care costs have become unsustainable despite a variety of coverage designs. In reforming health care, current politics seems to focus more on who will pay for care rather than on strategies and resources to promote healthier lifestyles. Modern challenges, such as increases in the prevalence of chronic diseases, risk overwhelming the health care system. Although MFA aims to increase access to care, any such legislation will likely have a minimal effect on the root causes of contemporary issues such as sedentary lifestyles and poor diet. While we have focused mainly on financial implications, we acknowledge that there are innumerable other factors to consider in evaluating health care systems.

In summary, implementation of a single-payer system might solve some problems but would likely introduce several others. As key stakeholders in health care, neuroradiologists should scrutinize how emerging legislation will affect their practices and patients.