A recent review of Medicare billing claims from 1991 through 2011 has verified what many of us anecdotally know to be true. While the data only account for fee-for-service Medicare patients, the analysis by Kroll and colleagues found a substantial increase in the proportion of lumbar punctures performed by Radiologists, from 11% in 1991 to 46.6% in 2011 (while the overall number of lumbar punctures remained essentially unchanged). Diagnostic lumbar punctures performed by Radiologists increased by 325% while those performed by neurologists, neurosurgeons, and primary care physicians decreased by 67-83%. The only other provider groups who have done an increasing number of lumbar punctures are emergency medicine physicians and mid level providers, though the overall proportion of the procedures skews highly toward Radiologists.
This raises questions and some potentially problematic issues.
While imaging-guided lumbar punctures may have greater safety or efficacy, another potential motivator of this shift in distribution is their unfavorable reimbursement. The authors highlight an excellent example of this noting that in 2011, the average Medicare reimbursement for diagnostic lumbar puncture was $78.14, compared to $118.24 for interpretation of a brain MRI with and without contrast. With such a reimbursement paradigm, there are very real financial concerns as to the viability of Radiologists continuing to perform such a large proportion of the procedures. The self-perpetuating nature of such a trend (clinicians becoming less able to perform their own lumbar punctures and thus relying more and more upon Radiologists for such procedures) is an additive concern.
Nonetheless, there does remain some silver lining to this news. It’s important to remember that these data are derived from only Medicare patients, who are less likely to be affected by the (likely minor) radiation risks. Additionally, this excludes younger patients for whom imaging-guidance may not be necessary due to lower incidence of degenerative changes. Finally, despite the current disincentives in reimbursement, the authors highlight that the increasing importance of Radiologists in such an important diagnostic procedure is likely to have favorable economic impacts in emerging non-fee-for-service reimbursement models.
As the authors note, different practices have varying requirements to determine which lumbar punctures will be performed by the Radiology department, with some locations requiring an initial failed bedside attempt, and with others willing to perform any lumbar puncture as long as not contraindicated.
Please let us know your view on this trend and your practice’s approach in the comments section below.
