8-Part Series for Radiologists:
Protecting your Medicare Revenue Stream in 2017-2018
Part 5: More about PAMA and Appropriate Use Criteria for Advanced Diagnostic Imaging
As I write Part 5, I'm unsure where CMS will take PAMA in 2018. In mid-July, CMS announced that they were proposing two changes to PAMA and were soliciting feedback.
- Delay implementation from January 1, 2018 to one year later, on January 1, 2019.
- Forego the radiology penalties and instead create incentives for the ordering physicians to adopt clinical decision support systems (CDSS) to leverage the appropriate use criteria (AUC) when placing a request for an advanced diagnostic imaging study.
- In this later change, CMS would consider the use of CDSS for AUC fulfillment and documentation as points under the MIPS (Merit-based Payment System) portion of the Medicare Quality Payment Program (QPP). [See Part 2 of this series.]
The comment period ended on September 11, 2017 and it may be some time before we hear the results. Hopefully you saw our earlier article and gave your feedback (July 13, 2017: Medicare Proposes Shift of PAMA AUC from Stick to Carrot). When I submitted my comments on August 30th, there had only been 14 comments on the entire list of CMS proposed changes.
In fact we are doing this 8-part series so that radiologists and their teams can be more informed about these two laws that have a potential impact to your Medicare reimbursement. There are so many communications that it is hard to keep up with the news that impacts your Medicare revenue stream. In fact, the proposed changes to PAMA where in a larger communication entitled:
- "Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program (CMS-1676-P)"
Is it any wonder that the majority of radiologists tell me they haven't even heard of MACRA and PAMA? Yet both laws could have a significant impact on your Medicare reimbursement. I guess this is why in Washington, D.C., they say, "The best place to hide something is in plain site." It is a challenge to know what has impact to the individual and what does not.
What is PAMA Really Trying to Solve?
Whether radiology dodges a bullet or not for January 1, 2018, it may be time to understand why the law was passed in the first place. Let's make a few assumptions:
- We sometimes perform an advanced diagnostic study using a modality that is not the best for the clinical situation.
- For example, doing a CT directed biopsy when an ultrasound-directed biopsy would be adequate.
- Or doing a contrast CT scan when a non-contrast CT would have provided the answer.
- There is evidence to guide us in many cases on what the most appropriate modality is preferred for the clinical presentation and diagnostic needs.
- This is not just for Medicare patients, but for all ages and payors.
- Therefore it is valid to generate AUC for many common scenarios, including pediatrics.
- Ionizing radiation and iodinated contrast dyes are not risk-free
- Therefore it is legitimate to avoid unnecessary studies involving either or both.
- Doing the wrong modality at first may delay getting to the proper diagnosis and treatment.
- Doing the wrong modality at first will increase the cost of care, especially if we need to follow up with imaging using the best modality.
So Congress acted reasonably when they passed a law intended to decrease unnecessary and duplicative testing, while reducing costs, excessive patient risks and wasteful use of resources.
Consider a More Proactive Approach to AUC
This seems like a great opportunity for the leaders in radiology to help be part of the solution. We should encourage the adoption of AUC for all ages and situations. We should avoid unnecessary studies. We should consider non-ionizing imaging (like ultrasound) whenever evidence determines it is better or "as good as" ionizing or higher cost modalities. We should encourage referring physicians to leverage CDSS before they request advanced diagnostic imaging studies. We should always be looking for ways to improve the value of the care we deliver, improve the safety of our interventions, eliminate waste/redundancy, and reduce costs.
It is important to provide input to our elected officials and the people at agencies like CMS who have to administer laws like this. PAMA has some good intentions, but the legislation initially put penalties on you, the service providers. This would have led to many unintended consequences for your business and patients. However, we can all be better stewards of the time and resources we have to provide safe and effective care.
We encourage you to ponder this and suggest innovations to solve the five problems listed above.
If you missed
Part 1: Introduction, CLICK HERE.
Part 2: Details of MACRA and the Quality Payment Program. CLICK HERE.
Part 3: How to Participate with QPP if you are a Radiologist Who Qualifies. CLICK HERE.
Part 4: Overview of PAMA and the Appropriate Use Criteria (AUC) for Advanced Diagnostic Imaging. CLICK HERE.