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CMS plans to implement appropriate use mandate for imaging procedures in 2018

When ordering advanced imaging procedures, such as radionuclide imaging, MRI and CT, physicians will soon be required to consult appropriate use criteria using CMS-approved computer-based clinical decision support mechanisms, due to an impending provision by CMS in the Protecting Access to Medicare Act, according to a commentary published in Annals of Internal Medicine.

“In response to rapid and unsustainable growth in the use of cardiac imaging procedures, various professional medical organizations have developed appropriate use criteria (AUC) to guide physicians and payers on effective use of these procedures,” Rami Doukky, MD, MSc, of Cook County Health and Hospitals System in Chicago, and colleagues wrote. “The AUC serve as a guide for physicians to incorporate symptoms, risk factors, and clinical history in selecting the patients for whom testing is most appropriate based on the best available evidence or expert consensus; further, the AUC can help physicians steer other patients to alternative tests or no testing at all.”

AUC maximizes the value of care, minimizes unnecessary imaging and invasive materials, helps to avoid excess costs, enhances the value of imaging in risk stratification and decision making, reduces radiation risk and is widely accepted by payers, physicians and patients, they added. Although use of some imaging procedures has declined, Doukky and colleagues argued that “more work needs to be done,” as there has not been a decrease in the use of rarely appropriate testing in various types of imaging.

Many electronic order entry systems are now equipped with computer-based clinical decision-support mechanisms to offer immediate assistance, according to Doukky and colleagues. Such supportive mechanisms significantly reduced inappropriate use of all cardiac imaging modalities from 22% to 6% and significantly increased medical therapy use from 11% to 32%. They noted that currently available computer-based clinical decision-support mechanisms are often disjointed from the care process and their effect on patient outcomes has not been assessed. However, understanding the potential value or lack of value of each imaging in combination with use of computer-based clinical decision support mechanisms can lead to optimal success.

Under the new provision by CMS, providers will be required to verify that they consulted computer-based clinical decision-support mechanism criteria when ordering advanced imaging procedures. After 2 years of data collection, CMS will subject “outlier” physicians to prior authorization which potentially will limit access to advanced imaging procedures for both patients and physicians, according to Doukky and colleagues.

CMS finalized eight “priority clinical areas” that will be subject to the initiation of the new mandate, including suspected or diagnosed coronary artery disease, suspected pulmonary embolism, headache, hip pain, low back pain, shoulder pain, suspected or diagnosed lung cancer and neck pain.

According to Doukky and colleagues, a fundamental shift will occur from payers to providers in the burden of reducing inappropriate use.

“Most physicians are unprepared for this paradigm shift,” they wrote. “Close collaboration between professional societies representing referring providers and imaging specialists is necessary to raise awareness among all stakeholders of the expectations under [Protecting Access to Medicare Act].”

“It takes a village to move us toward appropriate utilization of health care resources. Critical to the success of this effort is the involvement of all stakeholders — from imaging specialists to primary care providers, training programs, payers, health systems, and patients — to fully realize the benefits of AUC and extend them to other areas of medicine,” Doukky and colleagues concluded. – by Alaina Tedesco

Disclosure: Doukky reports receiving grants from Astellas Pharma. Please see full commentary for complete list of all other authors’ relevant financial disclosures.