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A look at the potential impact of PAMA for cardiologists
PAMA. For some, PAMA is an alcoholic beverage containing pomegranate, promoted for its healthy antioxidant properties. More importantly for cardiologists, PAMA also stands for the Protecting Access to Medicare Act, one of the many provisions of the Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, which replaced the longstanding but unenforceable SGR as a means of controlling the steep rise in Medicare spending.
MACRA was passed with bipartisan congressional support as part of a broad-reaching effort to reshape Medicare. The principles of PAMA and MACRA may offer insight into the future of health care reform as alternatives to traditional fee-for-service payment systems are explored in the name of cost control by both governmental and private payers.
Background on PAMA
The essence of PAMA is the required use of electronic clinical decision support (CDS) tools when ordering outpatient advanced imaging procedures — CT, MRI or nuclear imaging. These CDS tools are to be based on appropriate use criteria (AUC) developed by professional organizations composed primarily of providers actively engaged in the practice and delivery of health care, such as the American College of Cardiology and the American College of Radiology. They use multidisciplinary autonomous teams for rigorous, systematic review of published literature and consensus guidelines to construct detailed, explicit AUCs graded on their evidentiary strength, with public transparency of the methodology supporting determination of appropriate use and full disclosure of potential conflicts of interest. Radiology benefits management programs and insurance companies are specifically excluded from this process. CDS tools based on these AUCs are expected to be embedded into the electronic health record (EHR) for seamless integration into the decision process at the point of ordering.
On first impression, this sounds like the government is here to help us, using information technology and big data to assist physicians in delivering more cost-effective personalized medicine to our patients.
Of note, these tools are not for the use of those performing or interpreting these tests, but are the responsibility of the ordering professional. An obvious weakness of CDS as proposed is their reactive nature, failing to proactively identify patients who may benefit from an imaging procedure before it has been requested by an ordering professional. Perhaps future CDS iterations will not be focused exclusively on curtailing overuse of advanced imaging, but also give unprompted suggestions for tests not under consideration, based on intelligent data mining of an individual’s EHR. Although the target of PAMA is high-cost, advanced imaging procedures (note echocardiography is excluded from PAMA), the process of CDS has wide application under CMS’ mandate, and is being applied to clinical laboratory testing and many other areas of perceived overutilization.
At least initially, these CDS tools will not be used for denial or approval of individual services, but rather as educational tools directed to the ordering professional. However, after a period of data collection, perhaps in 2020 if implementation of the program proceeds on schedule, which seems unlikely, ordering professionals who are identified by CMS as “outliers” with low rates of adherence to AUCs relative to their peers, will be required to obtain prior authorization before advanced imaging orders will be payable by CMS. Congress mandated that CMS specify which AUCs will be used by Nov. 15, 2015; publish a list of qualified CDS mechanisms by April 1, 2016; and on Jan. 1, 2017, stop paying claims for advanced imaging services unless the ordering physician has used CDS before making an order; and require “outliers” to obtain prior authorization from CMS on Jan. 1, 2020. This aggressive timeline will likely need to be modified, as suggested by a wide alliance of professional organizations.
Much work remains to clarify how CMS will reconcile inevitable differences between AUCs submitted by various independent professional organizations; which CDS mechanisms developed by various IT providers will be approved and how EHR vendors will incorporate which of many CDS tools into their many different EHR products; and how data from different EHR vendors, who are notorious for their incompatibility with one another, will be integrated to “grade” individual physicians and determine who is really an outlier. The likelihood of error is high in such a complex system of definitions and data collection.
Many professional organizations, including the ACC, the American College of Radiology and various subspecialty professional organizations as well as large integrated health care providers, have considerable experience in creating authoritative practice guidelines and implementing practical appropriate use tools, employing a well-developed, rigorous process for scientific evidence review and critical assessment of best clinical practices by panels of expert clinicians. As clinical medicine is inherently an inexact science, translation of these AUCs into a system of CDS that actually helps ordering professionals select the right tests that benefit patients as well as reduce utilization of unnecessary, expensive services is a complex undertaking. This can result in concern over details of the process CMS will employ to select AUCs and approve CDS tools that achieve the goals of reducing costs while increasing quality without painful disruption of the clinical workflow.
Future impact
PAMA is only one of many components of MACRA, which contains several provisions accelerating development of alternative payment models to replace traditional fee-for-service payments to physicians. MACRA is a very complex initiative, which is intended to control Medicare costs while improving the quality and increasing the value of medical care. The additional administrative burden placed on practitioners in complying with these regulations will be significant. Advanced CV imaging services will rightly be under continued close scrutiny as PAMA is developed.
Appropriately utilized, advanced imaging is a very valuable, essential element of good medical care. Early iterations of PAMA are clearly focused on costs; measuring value is a much more difficult but more meaningful goal. Time will tell if CMS’ version of PAMA is more beneficial to our health than PAMA the pomegranate liqueur.
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- L. Samuel Wann, MD, MACC, FESC, is a cardiologist at Columbia-St. Mary’s Healthcare in Milwaukee. He is also Section Editor of the Practice Management and Quality Care section of the Cardiology Today Editorial Board. He can be reached at Wisconsin Cardiovascular Group, 2350 N. Lake Drive, Milwaukee, WI 53211; email: samuelwann@gmail.com.
Disclosure: Wann reports no relevant financial disclosures.