November 6, 2013 — The American College of Radiology (ACR) applauded a joint Senate Finance and House Committee on Ways and Means’ proposal to require ordering physicians to consult appropriateness criteria for advanced imaging services provided to Medicare patients. The provision, included in a draft policy to replace the sustainable growth rate (SGR) formula, would deny Medicare payment for the exam if appropriateness criteria were not consulted by the ordering physician and require prior authorization for outlier providers whose ordering is inconsistent with that of their peers.
“This landmark step by Congress is a validation of a cornerstone of the College’s Imaging 3.0 initiative that increases quality of imaging care and preserves health care resources. We strongly urge Congress to follow this approach which helps medicine transition from volume-based to quality-based care without interfering in the doctor-patient relationship,” said Paul Ellenbogen, M.D., FACR, chair, ACR Board of Chancellors.
The policy draft would require the Secretary of the Department of Health and Human Services to specify appropriateness criteria from among those developed/endorsed by national professional medical specialty societies (such as the ACR) or other entities. The secretary must also identify mechanisms, such as clinical decision support (CDS) tools, by which ordering professionals could consult these appropriate use criteria. CDS systems in Minnesota and at Massachusetts General Hospital have been shown to cut down on duplicate and/or unnecessary scanning and their associated costs.
“We look forward to continuing our work with Congress, the Centers for Medicare and Medicaid Services and other stakeholders to arrive at medical imaging policies that make sense in terms of quality, access and appropriateness,” said Ellenbogen. “The provisions in this congressional policy draft are a strong first step in that process,”
Studies show that imaging exams reduce unnecessary hospital admissions, shorten length of stay and are directly linked to greater life expectancy. A recent Neiman Institute Report, a study in Journal of the American College of Radiology (JACR) and a Moran Company report show Medicare imaging use and imaging costs are down significantly. Medicare spending on scans today is the same as it was in 2003, and the Health Care Cost Institute reports that imaging is the slowest growing of all physician services among the privately insured. Use of appropriateness criteria can help streamline the ordering of these services.
“Use of appropriateness criteria in the ordering of exams can educate providers regarding which scan is best for the patient’s given condition and even when no exam is warranted at all,” said Ellenbogen. “This can help ensure that every patient who needs imaging care gets the right exam at the right time for the right indication and avoids care that they may not need. This is what modern imaging care is all about. We look forward to working with Congress to help move this process forward.”
In addition to the provisions associated with appropriateness criteria, there are many provisions in the policy draft related to an SGR replacement. ACR will review those additional provisions in the days to come and provide feedback to Congress, CMS and other stakeholders.