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New Medicare Rules for Advanced Imaging Requests Will Require Substantial Resources

Dr. Keith Hentel. Credit: Ashley Jones

New federal regulations will dictate when and how physicians can order advanced imaging tests for Medicare patients to prevent unnecessary procedures and curb healthcare spending. These rules will achieve their goals only if providers can devote substantial resources and planning ahead of their implementation in 2020, according to a new paper published June 11 in the Annals of Internal Medicine from Weill Cornell Medicine and NewYork-Presbyterian investigators.

The Protecting Access to Medicare Act, known as PAMA and signed into law in 2014, changed the way Medicare pays for diagnostic laboratory and imaging tests. A key provision in the law established a new rubric for obtaining Medicare’s authorization for advanced imaging tests—including magnetic resonance imaging (MRI), computed tomography (CT) scans and nuclear medicine studies, such as positron emission tomography (PET) scans—before providers order them for patients in outpatient and emergency room settings.

“The objectives of the PAMA regulations are to ensure that patients covered by Medicare get the right exam the first time and to reduce unnecessary spending,” said lead author Dr. Keith Hentel, an associate professor of clinical radiology at Weill Cornell Medicine and chief operating officer for Weill Cornell Imaging at NewYork-Presbyterian. “The program starts soon, but there are still a significant number of providers who are unaware it’s coming.”

The rules will require providers to consult an authorized computer program called a clinical decision support system before they can order advanced imaging tests. The system lists specific clinical conditions and the circumstances under which it’s appropriate for physicians to prescribe imaging procedures, and generates a unique code number as proof that a consultation has occurred. The code number must be submitted at the time of ordering the test. A testing phase that begins on Jan. 1, 2020 will require providers to prove that they consulted the system; the Centers for Medicare and Medicaid Services will delay financial penalties to providers who fail to provide that proof until 2021.

In the paper, Dr. Hentel and colleagues at five other healthcare providers—Johns Hopkins Medicine, the University of California San Francisco, Memorial Sloan Kettering Cancer Center, Massachusetts General Hospital and Brigham and Women’s Hospital—highlighted the pros and cons of two strategies for implementing the new regulations: integrating the test ordering process with electronic health records or using a stand-alone platform. Integrated approaches may limit workflow interruptions as well as leverage information already present in electronic health records, but may require significant resources to implement and maintain. Stand-alone portals may be more disruptive to clinical workflow as they require more manual data entry and some duplication occurs, but they may cost less and require fewer resources to implement. Providers can ultimately decide which portal to use, so long as CMS has certified and approved it.

“Providers need to consider their full range of imaging orders when choosing an implementation approach,” Dr. Hentel said. “Those who receive a large number of paper referrals may find it beneficial to use a combined approach that includes a stand-alone portal.”

Dr. Hentel and colleagues say that robust evidence supporting the desired outcome of reducing inappropriate advanced imaging is lacking so far. However, CMS designed its new Appropriate Use Criteria Program by incorporating feedback from Weill Cornell Medicine and other organizations that participated in the Medicare Imaging Demonstration project, a large multi-center study that examined the effect of implementing clinical decision support systems for imaging using appropriate use criteria.

“CMS has made significant improvements based on lessons learned from the demonstration project,” Dr. Hentel said. “For example, healthcare providers can create their own appropriate use criteria to reflect local best practices and apply to become a ‘provider-led entity,’ a designation that stands for five years.” Weill Cornell Medicine was one of the earliest organizations to become a provider-led entity.

“Overall, I’m optimistic that the new PAMA regulations will reduce unnecessary advanced imaging tests for both patients and the healthcare system,” he added. “Healthcare providers should plan and implement a clinical support decision system as soon as possible.”

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