This article was originally published July, 2017. Interested persons should check for updates on PAMA and AUC at CMS.gov website.
PAMA and the AUC for Radiology
The Protecting Access to Medicare Act of 2014 (PAMA) will take affect on January 1, 2018. It requires clinical decision support systems to confirm Appropriate Use Criteria (AUCs) on ambulatory (outpatient), non-emergent advanced imaging studies such as MRI, CT and PET scans. This page provides an overview of PAMA AUC for Radiology.
Why mention PAMA?
PAMA, in my opinion, the most bizarre federal regulation facing physicians. Unlike the overwhelming bipartisan vote on MACRA, the Senate passed PAMA on 3/31/2014 with a 64-35 vote. This statutory regulation impacts a large basket of providers/services from skilled nursing facilities to physicians’ ordering of imaging tests and laboratory.
For radiology, these take effect on January 1, 2018, though CMS proposed some changes in July 2017 to move implementation to January 1, 2019, eliminate penalties in 2019, and permit ordering physicians to receive incentives under MIPS (the Merit-based Incentive Payment System under QPP/MACRA). This is welcome news if they approve.
Radiology is some one of the three areas of AUC:
- Advanced imaging (outpatient radiology services)
- Advanced diagnostic laboratory tests (lab services, such as genetic testing)
- Cardiology (cardiology diagnostics)
The most controversial sections in my mind are how advanced imaging is in effect in 2018 with little alignment of incentives/penalties to the radiologist. Like the road to perdition, PAMA paves the road to AUC with good intentions.
What's AUC for Radiology?
Appropriate Use Criteria match the "right" test/study for the patient at the "right" time as determined by an authoritative source. Likewise, the goal is to avoid a test or study that is inappropriate for the patient's situation.
So for example, we can image the lower spine with either computerized tomography (CT Scan) or magnetic resonance imaging (MRI Scan). The medical literature (producing what we call "evidence-based decision-making") and expert opinion form the basis for the AUC. Over a dozen entities have authored advanced imaging AUCs, including the American College of Radiology (ACR).
Let's explain AUC with an example.
Let's say that you (as a patient) present to your primary care physician with new onset low back pain. Twenty years ago, your doctor would take a history, examine you, and possibly get an x-rays series of your lumbar spine (i.e. traditional x-rays of your lower spine). Today, we know that most low back pain needs no x-rays on the first visit if there are no signs of an urgent nature, such as a serious neurological finding or a risk of cancer or infection. So we avoid unnecessary radiation exposure, and treat you possibly with heat/ice, rest and simple analgesics (pain medications). If you don't get better we might add physical therapy, massage or manipulation.
But let's say instead, you do have findings suggestive of a more urgent complication. Perhaps you are diabetic, have a high fever, and the findings suggest that you might have an abcess around one of your vertebra. That is where we rely on AUC.
CMS has worked with several organizations to determine the evidence-based AUC for advanced imaging studies like MRI, CT and PET scans. The Act prescribes that these non-emergent ambulatory (outpatient) tests must be ordered with full clinical decision support algorithms to determine that the appropriate test has been ordered. So if an adult presents with back pain, the algorithms determine if the most appropriate test is an MRI or a CT scan of the spine. So far, so good.
The problem lies in that the ordering physician (not the radiologist who reads the study) is the person responsible for ordering the appropriate test and submitting the clinical decision support evidence that the AUC are met for that test. The consequence is that the patient presents to the imaging center for the test and Medicare will not pay for the test if the AUC are not documented.
The ordering primary care doctor or specialist bears responsibility for the appropriate test and AUC documentation. The interpreting radiologist loses reimbursement for the study if the AUC were not met.
I can imagine the chaos likely to occur in January 2018 (as originally proposed) as patients (i.e. taxpayers and citizens) present for imaging that are delayed due to lack of AUC documentation. In addition, the resultant financial hardship of radiologists not receiving payment because the ordering physicians’ failure to implement AUC in their workflow/EMR’s (with no personal consequences for compliance). Hopefully the CMS will move forward with the push of implementation to 2019.
I would have to coin the term here as “Non-payment for someone else’s non-performance.” It is interesting to note that again this is federal law of which many physicians remain oblivious of the future impact to their workflow, reimbursements and patient satisfaction.. You can keep up to date on PAMA at CMS.gov.
My Summary Analysis of PAMA (pending proposal changes):
- Evidence-based approaches to getting the appropriate tests done for the clinical situation is a good thing.
- Great application of clinical decision support (CDS) tools to avoid less needless radiation exposure and cost.
- Proposal for CMS to incentive ordering physicians through QPP MIPS is a great move.
- Delaying to 2019 also a great move if it happens.
- Misalignment of incentives
- Likely to cause hardships to patients, radiologists and for the referring physicians
- By Stakeholder:
- Patients: Delays and chaos; dissatisfaction/blame.
- Radiologists: Financial impact & patient dissatisfaction.
- Referring Physicians: Frustrations and likely some reactive last-minute solution from Congress or HHS to further complicate the issue.
- In the context of the current healthcare climate, this represents my biggest “bad boy” on my list of distractions for transforming Med Rec.
 Organizations like the American College of Radiology (ACR) and Harvard have estimated legitimate AUC for advanced imaging based on evidence. The evidence appears sound.
 I remain convinced that this is a “bizarre” regulation, even for healthcare.