And it’s more like a 55-gallon drum - and slowly picking up speed.
The Protecting Access to Medicare Act of 2014 (PAMA) calls for the implementation of Clinical Decision Support Mechanisms (CDSM) which utilize Centers for Medicare and Medicaid Services (CMS) approved appropriate use criteria (AUC). These CDSMs must be consulted prior to completing an order for either CT, MRI, Nuclear Medicine, or PET studies for Medicare outpatients in any non-inpatient place of service. CMS has targeted reporting for eight clinical areas to identify outlier physicians:
- Coronary artery disease (suspected or diagnosed)
- Suspect pulmonary embolism
- Headache (traumatic or non-traumatic)
- Hip Pain
- Low Back Pain
- Shoulder Pain (to include suspect rotator cuff injury)
- Cancer of the Lung (primary or metastatic, suspected or diagnosed)
- Cervical or neck pain
Ordering providers don’t have to
abide by what was shown to be the best imaging modality; they must only
demonstrate that they consulted AUC through an approved mechanism. Failure to
consult an approved AUC will cause the professional
and technical component reimbursement to be denied- as in zero-dollar
reimbursement. That should get your attention.
The goal is admirable, reduce the number of inappropriate exams, which would improve the quality of healthcare by reducing dose where applicable. Good for the provider and good for the patient. However, as always, the devil was, and still is in the details.
Originally slated to go in effect on January 1, 2016, this initiative has been delayed time and time again, and thankfully so. Neither CMS, nor the providers, nor the industry was prepared to implement these standards. Like peeling away the layers of an onion, the deeper reasonable interests investigated the topic, the more challenges became apparent. Available space to devote to the resultant coding is an issue, for example.
Moreover, what about those providers who still use the fax machine or paper orders? How are we going to get all providers, regardless of their specialty or size, to do this? These are real-world challenges.
A more significant challenge is that not everyone knows enough about the AUC consultation requirement, the approved mechanisms, and all of the other details, and are nowhere close to implementing a workable solution. Plus, there is no funding mechanism provided externally to help you to comply with the mandate. Assuming you have addressed this, I am quite sure that this was a pleasant conversation for radiology managers to have with their CFO’s (I sincerely hope you’ve had these conversations, right?).
Apparently, many are not.
In a recent survey conducted by the Association fro Medical Imaging Management (AHRA), among the 291 total responses who responded to the question “Have you implemented or begun implementing Clinical Decision Support (CDS)?”, 35% responded Yes, 61% responded No, and 3% were not sure what CDS is (Source: Regulatory Affairs: Clinical Decision Support (CDS) 05/2018 Survey, released on July 5,2018).
The good news is that since the passing of PAMA 2014, healthcare entities have far more choices available today as to which CDSM they would like to consider. The list of qualified provider-led entities (qPLE) who have been approved to “develop, modify, or endorse” Appropriate Use Criteria (AUC) are growing as well (see the list at the end of this blog). Newly approved qPLE’s are announced each June. The industry around Clinical Decision Support for Medical Imaging is growing. More choices allow for more informed decisions. More options will enable the marketplace to reward those who succeed and punish those whose products don’t pass muster.
What is a more significant concern, now that the mandate has been pushed back to January 1, 2020, is- will the industry STILL be ready? The first year will, in effect be an educational and operations testing period, but full compliance will be the standard for the second year. It is my concern that this reality has not become real. According to Sheila M. Sferrella, MAS, RT(R), CRA, FAHRA, Chair of the AHRA Regulatory Affairs Committee and President of Regents Health Resources, “it typically takes 12-18 months to implement a program like AUC in a hospital setting. Budgeting, funding, IT interfaces, RFP or vendor selection, and then implementation. This regulation is the most challenging one we have had to implement on the hospital side because we have to make sure we capture the AUC code from the referring physician so that the hospital gets paid and then somehow transfer that information to the radiologist’s professional group for payment. It includes hospital bling forms and physician billing forms where codes do not necessarily populate in the same place. The AHRA (The Association for Medical Imaging Management) is working with a group of industry leaders to find a solution that is electronic and not manual. We are trying to help our members prepare for implementation.”
The AHRA has been at the forefront of working with the CMS and their members to find a solution. I count myself as a member of this organization, and I applaud their actions on this front. It will be a very hot topic at their Annual Meeting in Orlando in July.
It is vitally important that the radiology industry examine, explore, and make their voices heard on the selection of the best CDSM for their facility. They should lead the charge on selection because it is their world that bears the responsibility for it to work. Moreover, they will be the ones penalized if they do not implement the change.
The can that was kicked is now rolling back. According to Ms. Sferrella, the likelihood that this initiative will be again kicked down the road is “almost none.” While some may have hoped this would happen, or the initiative will die and go away, that is not going to happen.
In summary, it is always a better outcome to plan and prepare before a crisis hits. Acting at the last minute, deciding and implementing a CDSM to make the deadline usually results in panic buying and a whole lot of stress. There is still time, but it is running out faster than you think.
January 1, 2020, is now just 18 months away.
Approved qPLE’s approved as of this writing:
- American College of Cardiology Foundation
- American College of Radiology
- Banner University Medical Group-Tucson University of Arizona
- CDI Quality Institute
- Cedars-Sinai Health System
- Intermountain Healthcare
- Massachusetts General Hospital, Department of Radiology
- Medical Guidelines Institute
- Memorial Sloan Kettering Cancer Center
- National Comprehensive Cancer Network
- Sage Evidence-based Medicine & Practice Institute
- Society for Nuclear Medicine and Molecular Imaging
- University of California Medical Campuses
- University of Utah Health
- University of Washington School of Medicine
- Virginia Mason Medical Center
- Weill Cornell Medicine Physicians Organization