H.R. 4302: Duct tape, delays and decision support

A permanent fix to the sustainable growth rate formula eluded Congress again--stunning, I know. Another year of SGR duct tape. And ICD-10 was laughably delayed for yet another year. (How many ICD-11 jokes have you heard over the last couple of weeks?)  This kind of partisan-driven politicking escalates the apathy that many physicians already have for Washington. But maybe that's their objective.

However, H.R. 4302 (the Protecting Access to Medicare Act of 2014), which was passed by Congress just last week, contained some language/mandates that should be considered major victories for imaging, patients, and anyone concerned with utilization of imaging services.

First, the bill requires providers to consult physician-developed appropriateness criteria when ordering advanced imaging studies for Medicare patients. It also directs the secretary of the U.S. Department of Health & Human Services to identify resources that providers can use to access these criteria. There are a number of reasons this is a real and rare legislative victory for the imaging community. Most importantly, this action continues radiology's long-standing commitment to appropriate resource utilization. And, the rules that are being implemented, again, are physician-developed

The American College of Radiology has, for many years, developed appropriateness criteria, which are physician-advised, evidence-based criteria intended to improve the efficacy of imaging resource utilization. At long last, this treasure-trove of information can become a front-line source for physicians from all specialties as we continue to optimize the way we use limited, expensive radiologic resources--specifically those pertaining to advanced imaging procedures, such as MRI and CT. 

Additionally, by instituting a decision-support like tool for providers to access these guidelines, it will prevent providers from being forced into the tumultuously treacherous world of pre-authorization and radiology benefit managers who, quite frankly, can approve and deny studies without justification, all the while keeping their approval/denial criteria proprietary. 

Now, I am a self-admitted fan of clinical decision support software. But, despite this legislative victory, it is important for radiologists to pause and see potential dangers of CDS. In the presence of CDS, it will be more important than ever for radiologists to embrace and excel at the role of consultant. When our clinical colleagues seek our recommendations for imaging studies for various symptoms, we must answer the call. We must be attentive and offer our expertise. If we simply refer them to the "CDS machine" for answers to their questions, it will render radiologists dangerously irrelevant and at further risk of commoditization. Just something to think about.

The second victory for the imaging community contained in H.R. 4302 is the mandate requiring the Centers for Medicare & Medicaid Services to produce data used to justify the unprecedented (and remarkably random) 25 percent multiple procedure payment reduction legislation (instituted in 2012) that reduced payment for professional work performed for the same patient, on the same day, in the same session. This reduction was substantially out-of-line with the efficiencies estimated by a real, legitimate study that examined professional efficiencies gained by providing services for the same patient on the same day.

I am not a Washington insider. I don't know anyone that works for CMS or the Government Accountability Office. But frankly, I don't think they have any data that even remotely supports the 25 percent number. This portion of the legislation is a "win" for all specialties because it will set precedent for improved accountability, transparency and scientific rigor involved in payment policy development.

Don't get me wrong, I stand by the many medical organizations that admonished Congress for "kicking the can" further down the road by missing this golden opportunity to permanently fix the flawed SGR formula.  And the additional ICD-10 delay is ... um, well--it just adds to the running joke that is ICD-10.

But there is positive language in H.R. 4302 that shouldn't be overlooked by the physician community. Our patients, our profession and the imaging community scored a rare federal legislative victory last week.

Matt Hawkins, M.D., is a vascular interventional radiology fellow at the University of Washington/Seattle Children's Hospital. Follow him on Twitter at @MattHawkinsMD.

Prior articles by the author:
Reimbursement in medicine: One radiologist's perspective
Keeping score with revenue: The 2-step-back feedback
It's time to end diagnosis fragmentation
RSNA13: Business analytics, clinical decision support take center stage for radiologists

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