Robert T. Eberhardt, MD

As major debates continue regarding local and national health care legislation, including the Affordable Health Care for America Act, several issues affecting vascular imaging have arisen. As a medical community, we continue to “tighten our belts” as a result of the declining reimbursement from the Center for Medicare and Medicaid Services (CMS) for medical imaging— a consequence of the Balanced Budget Act of 1997. Vascular imagining has been particularly affected by dramatic reductions in reimbursement. In the face of these declining reimbursements, there continues to be more stringent requirements for payment for services provided. One such requirement is the need for laboratory accreditation (or technologist certification) for reimbursement in more than 30 states. The potential benefits of these requirements on the quality of care are readily acknowledged (and I support them, as a member of the board of directors for the Intersocietal Commission for the Accreditation for Vascular Laboratories). However, the primary motivating force for such requirements may be far less altruistic.

In contrast with these increasing constraints on reimbursement, there has been some optimism in the arena of vascular screening. These include a proposal to expand the benefits of abdominal aortic aneurysm screening for Medicare beneficiaries and a seemingly curious Texas law mandating coverage for select cardiovascular screening imaging modalities. These two legislative matters provide disparity on the legislative process and the potential impact of keeping health care providers involved in the process.

The original SAAAVE (Screening Abdominal Aortic Aneurysms Very Efficiently) Act provided benefits for screening for abdominal aortic aneurysms. This was supported by studies demonstrating a ∼50% reduction in mortality by screening at-risk men for abdominal aortic aneurysms. In the SAAAVE Act, a one-time screening was made available for males with histories of smoking, and males and females with family histories of abdominal aortic aneurysm, as part of the Welcome to Medicare Physical Exam. However, access to services is restrictive, as this was only available during the first year of Medicare eligibility, and as a consequence severely underutilized (with < 10,000 beneficiaries being screened in 2007). An attempt to expand these benefits in the SAAAVE Act of 2009 was introduced. This act would extend the one-time benefit to 65–75 year old Medicare beneficiaries at risk (including male smokers and those with family histories). This approach would be in line with the high level of recommendation provided by the U.S. Preventive Services Task Force (USPSTF). Despite the acknowledged benefit, the possibility of such a change is being closely scrutinized due to its potential financial impact. While no formal cost estimates are available from the Congressional Budget Office, it has been suggested that this modification may cost up to $4 billion over 10 years. As a consequence, further movement on this act has been delayed. Currently the Secretary of Health and Human Services will provide a report to Congress on Medicare beneficiary barriers, and education on the benefits has been made a priority.

In seeming polar contrast to the SAAAVE Act, a Texas law has been passed that mandates that health insurance companies cover two screening imaging tests for heart disease— a CT scan for coronary calcium and a carotid duplex for plaque and intimal medial thickness. Insurance companies are required to cover the test for males between 45 and 76 years of age, females between 55 and 76 years of age, and others at risk. The screening is intended to reduce the burden of heart disease and improve health care. However, this law has been passed before health professionals have even determined their proper role or demonstrated improved outcomes. This legislation was strongly supported by a vocal group in the Society for Heart Attack Prevention and Education (SHAPE). In contrast, such widespread screenings have not been endorsed by the American College of Cardiology or the American Heart Association.

It is my perspective that one act dealing the vascular imaging, with potential profound impact and acknowledged improvement in outcomes, seems unlikely to move forward. In contrast, a state law has extended imaging benefits to many recipients with limited data to support its utility (or widespread professional society endorsement). Despite (or due to) this apparent paradox in an environment of ever-increasing government regulation, we as cardiac and vascular providers need to stay involved in the political process. It is important to participate in the process and help “SHAPE” decisions by policy makers that will impact our ability to provide quality patient care and vascular imaging services.