Appropriate Use Criteria Timelines Unrealistic, Says Coalition

Physicians, Patients Rely on Diagnostic Imaging Services

October 15, 2015 02:45 pm News Staff
[CT laboratory Observation room in an office with a computer tomograph]

The AAFP recently added its voice to that of other physician organizations that put their collective weight behind an attempt to persuade Congress to delay the timeline for implementation of the Medicare appropriate use criteria (AUC) program.

The 17 organizations sent the same message in nearly identical letters to the chairs and ranking members of the House Ways and Means Committee, the House Energy and Commerce Committee and the Senate Finance Committee.

In addition to the AAFP, signatories included the American Society of Nuclear Cardiology, the American Academy of Neurology, the American College of Cardiology, the American College of Physicians and the American Osteopathic Association.

In the letter(2 page PDF) to Senate Finance Committee Chair Orrin Hatch, R-Utah, and Sen. Ron Wyden, D-Ore., the committee's ranking member, the organizations recognized the importance of the AUC program's purpose -- to encourage physicians and other health care professionals to utilize high-cost imaging services appropriately.

Story Highlights
  • The AAFP recently joined 16 other medical organizations in asking members of three powerful congressional committees to delay implementation of the Medicare appropriate use criteria program.
  • In letters to the committees, the organizations said primary care physicians would bear a disproportionate burden during the program's implementation.
  • Congress set a Jan. 1, 2017, implementation date for the program, which requires physicians to document that they have consulted appropriate use criteria before they order certain advanced diagnostic imaging services for patients.

However, "As medical societies whose members frequently order and rely on advanced diagnostic imaging for the diagnosis and treatment of their patients, we are deeply concerned with the timeline for implementation" of the program, as required by the Protecting Access to Medicare Act of 2014, said the organizations.

Furthermore, they expressed great concern that primary care physicians would bear a "disproportionate burden" during implementation of the program.

The groups reminded lawmakers that it was Congress that set the Jan. 1, 2017, implementation deadline by which physicians have to begin documenting that they have consulted appropriate use criteria before they order certain advanced diagnostic imaging services.

If physicians fail to do so, the health care professionals who provide those imaging services won't get paid.

According to the letter, a delay in implementing the program would allow CMS to continue developing program requirements and, at the same time, would give physicians, hospitals and health IT vendors additional time to prepare to implement program requirements.

Most concerning, said the organizations, was CMS' acknowledgement that it likely could not meet the April 1, 2016, statutory deadline by which it is supposed to make clear to physicians the mechanics of exactly how they are to consult -- and verify their compliance with -- the AUC program.

If the current timeline is maintained, physician practices would have just a few weeks -- from the time the final rule is published in November 2016 until Jan. 1, 2017 -- to incorporate the new tasks required by the AUC program into their workflow, an effort that would be "virtually impossible for many practices, especially small practices," concluded the organizations.

For the AUC program to work as intended, clinical decision support mechanisms must be "integrated into a practice's clinical workflow and should facilitate -- not obstruct -- evidence-based care delivery," said the letter.

The organizations agreed with CMS' assessment that the best approach to implementing the program is one that is "diligent, maximizes the opportunity for public comment and stakeholder engagement, and allows for adequate advance notice" to physicians, practitioners and beneficiaries.

In addition, the professionals who are tasked with developing appropriate use criteria and clinical decision support mechanisms also need time to do their work and deserve advance notice as to how the program is expected to function.

"We do not believe the current timeline under which CMS is being required to act supports this 'best approach' to implementation," which will fall at the same time that physicians are expected to meet new requirements of the Medicare Access and CHIP (Children's Health Insurance Plan) Reauthorization Act of 2015, said the letter.

This was not the first time the AAFP has spoken out on the issue of appropriate use criteria for certain diagnostic imaging services -- and the burden that a rushed rollout would put on family physicians. In its response to the proposed 2016 Medicare physician fee schedule, the Academy called on CMS to use a "phased-in" approach and focus initially on a limited number of clinical conditions and related criteria.