July 20, 2022, 12:15 p.m. News Staff — In a win for the Academy’s fight against administrative complexity, CMS this month announced an indefinite suspension of the Appropriate Use Criteria program’s impending penalty phase.
The program, established by the Protecting Access to Medicare Act of 2014 and designed to reduce unnecessary orders for diagnostic imaging, commenced an “educational and operations testing” phase in 2020 after years of rule-making and delay. It was set to go into full effect Jan. 1, 2023, or the first of the year following the end of the COVID-19 public health emergency.
On July 7, however, CMS added this note to its AUC program page: “The payment penalty phase will not begin January 1, 2023, even if the PHE for COVID-19 ends in 2022. Until further notice, the educational and operations testing period will continue. CMS is unable to forecast when the payment penalty phase will begin.”
The move signals acknowledgement of the AAFP’s steady advocacy to delay implementation of the AUC program and affords lawmakers time to repeal it, as the Academy also has urged.
In a 2020 letter to CMS, for example, the Academy and 15 other medical organizations called the program “void of integration with patient quality, outcomes and satisfaction metrics” and cautioned that it would cost “$75,000 or more for a practice to implement a clinical decision support mechanism to comply” with its rules, citing data published in 2017 by the Association for Medical Imaging Management.
Most recently, the Academy objected to the program’s administrative burdens by co-signing a May 18 letter to CMS from a coalition of medical professional and other groups.
“The AUC program mandate as structured would take away the flexibility of how physicians and other health care professionals consult AUC and, in some cases, make it difficult, if not impossible, to rely on the specialty-specific AUC developed by their professional societies or their continued use of nationally recognized independent care guidelines,” the groups said.
The Academy and its 43 co-signatories (including the AMA, the American Society for Radiation Oncology and the American Society of Nuclear Cardiology) were responding to a request from Congress that CMS, in consultation with health care stakeholders, report on the AUC program’s implementation, challenges and successes. The letter urged “a thoughtful re-examination of the program and action by Congress to address the complexity and prescriptiveness of the program, as well as the burden and cost it will impose among the vast majority of physicians in this country when it is layered, not integrated, upon existing CMS quality programs.”
CMS had set the 2023 start date for the AUC penalty phase in the 2022 Medicare physician fee schedule and Quality Payment Program final rule. In MPFS guidance sent to the agency last year, the Academy said the AUC program was “overly burdensome, complex and … does not consider quality, patient outcomes or other important factors, which are more appropriately addressed in alternative payment models.”
“According to an AAFP survey, more than half of our members report participating in an APM,” the Academy added. “These physicians are already accountable for the quality and cost of their care, including strong incentives to reduce unnecessary utilization of costly imaging services, rendering the AUC program unnecessary.”