CMS decides to apply AUC for imaging procedures in 2018

According to a commentary released in Annals of Internal Medicine, when ordering advanced imaging procedures, like radionuclide imaging, MRI and CT, physicians will soon be needed to consult appropriate use mandate using the CMS-approved computer-based clinical decision support mechanisms, because of an impending provision by CMS (Centers for Medicare & Medicaid Services) in the Protecting Access to Medicare Act.

Rami Doukky, MD, MSc, of Cook County Health and Hospitals System in Chicago, and colleagues wrote, “In response to quick and unsustainable growth in the utilization of cardiac imaging procedures, various professional medical agencies have developed appropriate use criteria (AUC) to instruct physicians and payers on effective use of these procedures. The AUC serve as a guide for physicians to incorporate risk factors, symptoms and clinical history in opting the patients for whom testing is most suitable based on the best available evidence or expert consensus; further, the AUC can assist physicians to steer other patients to alternative tests or no testing at all.”
They added, AUC enhances the value of care, minimizes unimportant imaging and invasive materials, assists to ignore excess costs, maximizes the value of imaging in risk stratification and decision making, decreases the radiation risk and is highly accepted by payers, physicians and patients. However use of certain imaging procedures has declined, Doukky and colleagues explained that “more work requires being done,” as there hasn’t been a decrease in the use of rarely appropriate testing in several types of imaging.
In accordance to Doukky and colleagues, several electronic order entry systems are now equipped with computer-based clinical decision-support mechanisms to give immediate assistance. Such supportive mechanisms significantly decreased the inappropriate use of all cardiac imaging modalities from 22 percent to 6 percent and significantly increased medical therapy use from 11 percent to 32 percent. They pointed out that presently available computer-based clinical decision-support mechanisms are mostly disjointed from the care process and their effect on patient outcomes hasn’t been assessed. Although, understanding the potential value or deficiency of value of each imaging in combination with utilization of computer-based clinical decision support mechanisms can lead to optimal victory.
Providers will be needed to verify under the new provision by CMS that they consulted computer-based clinical decision-support mechanism criteria when ordering advanced imaging procedures. According to Doukky and colleagues, after two years of data collection, CMS will subject “outlier” physicians to prior authorization which probably will restrict access to advanced imaging procedures for both sufferers and physicians.
Eight “priority clinical areas” has been finalized by CMS that will be subject to the initiation of the latest mandate, involving suspected or diagnosed coronary artery disease, suspected pulmonary embolism, shoulder pain, hip pain, low back pain, headache, suspected or diagnosed lung cancer and neck pain.
A fundamental shift will occur from payers to providers in the burden of decreasing inappropriate use, according to Doukky and colleagues.
They wrote, “Most physicians are unprepared for this paradigm shift. Close collaboration between professional societies representing referring providers and imaging specialists is important to raise awareness among all stakeholders of the expectations under [Protecting Access to Medicare Act].”
Doukky and colleagues concluded, “It takes a village to move us toward suitable utilization of health care resources. Critical to the victory of this effort is the involvement of all stakeholders — from imaging specialists to primary care providers, payers, training programs, health systems, and patients — to completely realize the benefits of AUC and extend them to other components of medicine.”