TIMOTHY L. SWAN, MD, FACR, FSIR SPEAKER, ACR …wsrs.org/2017meeting/handouts/swan_support.pdf · speaker, acr council ... 8 10 12 14 16 18 1980 1983 1986 1989 1992 1995 1998 2001

C L I N I C A L D E C I S I O N S U P P O R T

T I M O T H Y L . S W A N , M D , FA C R , F S I R S P E A K E R , A C R C O U N C I L

American College of Radiology

F I N A N C I A L D I S C L O S U R E S

None


C L I N I C A L D E C I S I O N S U P P O RTH I S T O R Y


C D S H I S T O R Y


“The U.S. health care delivery system does not provide consistent, high

quality care to all people”


•Definition • “…process for enhancing health-related decisions and actions with

pertinent, organized clinical knowledge and patient information to improve healthcare and healthcare delivery.”

• Less of an electronic filing cabinet and more of an indispensable tool for better health care


Osheroff, J.A., Teich, J.A., D. Levick et al. Improving Outcomes with Clinical Decision Support: An Implementer’s Guide. 2nd Edition. Chicago, IL: HIMSS, 2012: p. 15


•With the advent of the “meaningful use” EHR Incentive Program, healthcare organizations, along with healthcare providers, are required to integrate clinical decision support (CDS) into their federally certified EHR systems.


C D S B U C K E T S

•Data entry • Smart forms • Order sets

•Data review • Virtual ICUs

•Assessment & understanding • Links in EHR to detailed information about disease

•User task trigger • Alerts


L E G I S L AT I O N

•Health Care Act 2006

•MIPPA 2008

•HI-TECH Act of 2009

•PPACA 2009 — PQRS and Value Modifier

•PAMA 2014


C L I N I C A L D E C I S I O N S U P P O RT

I M A G I N G


H E A LT H C A R E S P E N D I N G — % O F G D P, 1 9 8 0 – 2 0 1 3


0

2

4

6

8

10

12

14

16

18

1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

US (17.1%)

FR (11.6%)

SWE (11.5%)

GER (11.2%)

NETH (11.1%)SWIZ (11.1%)

DEN (11.1%)

NZ (11.0%)

CAN (10.7%)

JAP (10.2%)

Source: OECD Health Data 2015.

O V E R A L L R A N K I N G — $ / C A P I TA


11/11

A D VA N C E D D I A G N O S T I C I M A G I N G S E R V I C E S ( A D I S )


MAGNETIC RESONANCE IMAGING COMPUTED TOMOGRAPHY POSITRON EMISSION TOMOGRAPHY

MRI MACHINES PER MILLION POP. MRI EXAMS PER 1,000 POP. CT SCANNERS PER MILLION POP. CT EXAMS PER 1,000 POP.

PET SCANNERS PER MILLION

POP.

PET EXAMS PER 1,000

POP.

AUSTRALIA 13.4 27.6 53.7 110 2.0 2.0

CANADA 8.8 52.8 14.7 132 1.2 2.0

DENMARK — 60.3 37.8 142 6.1 6.3

FRANCE 9.4 90.9 14.5 193 1.4 —

JAPAN 46.9 — 101.3 — 3.7 —

NETHERLANDS 11.5 50.0 11.5 71B 3.2 2.5

NEW ZEALAND 11.2 — 16.6 — 1.1 —

SWITZERLAND — — 36.6 — 3.5 —

UNITED KINGDOM 6.1 — 7.9 — — —

UNITED STATES 35.5 106.9 43.5 240 5.0 5.0

OECD MEDIAN 11.4 50.6 17.6 136 1.5 —

Source: OECD Health Data 2015.

C L I N I C A L D E C I S I O N S U P P O R T — I M A G I N G

•Rapid imaging growth and inappropriate utilization of imaging services

•Medicare Payment Advisory Committee (MEDPAC) stressed over-utilization

•ACR developed appropriate use criteria to ensure appropriate imaging in a way that does not delay necessary care, interfere in doctor-patient decisions, or arbitrarily penalize radiologists via arbitrary cuts.


I M A G I N G A P P R O P R I AT E N E S S C R I T E R I A

•Helps health care providers choose most appropriate medical imaging exam or radiation therapy

•2017 AC Updates ― ACR releases new set of AC •Represents national standard for more than 875 clinical variants •12 revised topics •8 new criteria •208 clinical conditions

•Access criteria at acr.org/AC



•The ACR’s Appropriateness Criteria (AC) represent the combined knowledge of hundreds of physicians, diverse medical societies, and covers 90% of the known clinical scenarios in imaging

•The AC represent a national standard for imaging appropriateness.

•ACR’s role is to curate clinical content based on market feedback, development of new imaging procedures and member feedback



Use of AUC-based CDS ensures that the patient gets the right scan for the right indication and has been shown to improve quality, reduce low-value scans, and lower imaging costs.


I N S T I T U T E F O R C L I N I C A L S Y S T E M S I M P R O V E M E N T


C D S A L E R T S


P R O T E C T I N G A C C E S S T O M E D I C A R E A C T O F 2 0 1 4 ( PA M A )

•With ACR’s active support, legislators codified AUCs and ultimately CDS as an alternative to RBMs

• Defined AUC • Criteria are evidence-based • Assist professionals to make the most appropriate treatment decisions for a

specific clinical condition

• PAMA required CMS to implement by January 2017


•CDS must be used for Medicare fee-for-service patients • CDS expects to reduce unnecessary imaging and waste

•Risks/Benefits • Replace onerous payer-led preauthorization programs • If poorly executed, CDS becomes cumbersome for ordering

physicians with little or no effect on imaging appropriateness

•Need local strategy for the implementation of imaging CDS


P R O T E C T I N G A C C E S S T O M E D I C A R E A C T O F 2 0 1 4 ( PA M A )

C D S I M P L E M E N TAT I O N


PA M A E F F E C T O N A U C

•Goals for AUC • promote evidence-based advanced diagnostic imaging

• improve quality of care • reduce inappropriate imaging

•CMS established requirements for AUC development •PAMA gives preference to AUCs developed by “Provider-Led”

entities


Q U A L I F I E D P R O V I D E R - L E D E N T I T I E S


Q P L E O R G A N I Z AT I O N S


PA M A — S E C T I O N 2 1 8 ( B )

•CDS must be used for Medicare fee-for-service patients • CDS expects to reduce unnecessary imaging and waste

•Risks/Benefits • Replace onerous payer-led preauthorization programs • If poorly executed, CDS becomes cumbersome for ordering

physicians with little or no effect on imaging appropriateness

•Need local strategy for the implementation of imaging CDS


PA M A E F F E C T O N R A D I O L O G Y

•Radiology has not had additional broad reimbursement cuts

•Despite millions of new Medicare enrollees every day, MEDPAC and scholarly journal data peg imaging as one of the slowest-growing Medicare components


•2016 final rule • Delayed implementation to January 2017

•2017 final rule • requirements for CDSMs • Delayed implementation to January 2018

•ACR Select - qualified CDSM in July 2017 •2018 proposed rule

• Establishes implementation date of Jan. 1, 2019 • One year “educational and operations testing period” without

penalties for incorrect reporting



•CMS work still to do: • Proposed claims processing instructions • Development of G-codes to indicate what CDSM was used • Use of modifiers to indicate whether the ordered service adhered to

the appropriate use criteria



•ACR comments on CDS in 2018 proposed rule: • ACR supports comprehensive implementation Jan. 1, 2019 • ACR prepared to execute its AUC program • ACR Select® free web portal provides access to ACR Appropriateness

Criteria® • ACR supports educational and operations testing period • All orders for advanced diagnostic imaging services should include a

unique consultation identifier (UCI) • ACR offered comments on the use of the UCI on the claims form

rather than G-codes and modifiers



•By promoting CDS/AUC use, radiologists can position themselves as a resource to hospital/health system administrators as medicine transitions from volume- to value-based care.



C L I N I C A L D E C I S I O N S U P P O R T Q & AAmerican College of Radiology

W H Y H A S N ’ T I M A G I N G C D S B E E N A D O P T E D Y E T ?

• Fee-for-service inertia • Complexity of integration and increased workload for use • Unrealistic expectations????? • Real risk of non-payment to radiologists when CDS is not

used by referring provider • CMS recognized early implementation would likely require

implementation of non-integrated CDS solutions that increase workload of referring provider

• Hardship exemption provisions will be used frequently


W H AT D O E S A J A N U A R Y 2 0 1 9 C D S I M P L E M E N TAT I O N D AT E M E A N ?

•Prepare now! • Radiology practices should carefully assess PAMA’s requirements to:

• determine whether to to become a QPLE; or • implement existing CDS tools

• Optimal implementation of imaging CDS will help practices avoid penalties and take full advantage of the one-year learning curve


W H AT S H O U L D I B E D O I N G T O P R E PA R E ?

• Communicate with referring physicians • Referring physicians should become familiar with the

available CDS options


W H AT A R E P R I O R I T Y C L I N I C A L A R E A S ?

•Clinical areas believed to have the most imaging utilization abuse

•PAMA requires the identification of outlier ordering professionals, who will be subject to a prior authorization requirement beginning on January 1, 2020.


W H AT C O N D I T I O N S M A K E U P T H E P R I O R I T Y C L I N I C A L A R E A S ?

•The final list: • Coronary artery disease (suspected or diagnosed) • Suspected pulmonary embolism • Headache (traumatic and non-traumatic) • Hip pain • Low back pain • Shoulder pain (to include suspected rotator cuff injury) • Cancer of the lung (primary or metastatic, suspected or diagnosed) • Cervical or neck pain


W I L L A U C C O N S U LTAT I O N B E R E Q U I R E D F O R A L L A D VA N C E D D I A G N O S T I C I M A G I N G O R J U S T T H E P R I O R I T Y C L I N I C A L A R E A S ?

•PAMA mandates that AUC be consulted for all advanced diagnostic imaging services provided to Medicare patients

•CMS (2017 MPFS final rule) does not have statutory authority to limit the consultation requirement to priority clinical areas.


A R E E M E R G E N C Y D E PA R T M E N T S E X E M P T F R O M T H E A U C R E Q U I R E M E N T A N D A R E T H E R E A N Y O T H E R E X E M P T I O N S ?

•Exemptions (2017 MPFS): •Emergency services when provided to individuals with emergency

medical conditions •Inpatients where services are paid under Medicare Part A. •Ordering professionals who have a significant hardship exception in the

EHR Incentive Program


W H Y I S T H E C D S S O L U T I O N A B E T T E R O P T I O N F O R R A D I O L O G I S T S A N D R E F E R R I N G P H Y S I C I A N S ?

•Optimization of Advanced Diagnostic Imaging Services (ADIS) and provider education

• Modification of this requirement (e.g., for limited clinical indications, for only selected patients or by radiology facilities assuming part or all of that duty) will create confusion, prolong implementation and decrease the value of the CDS process.

•The differences between prior authorization and CDS/AUC are: •Prior authorization is binary (Yes or No)

• There is no educational component to the provider

•There is no discussion between referring provider and radiologist


H O W A R E R A D I O L O G I S T S P R O T E C T E D U N D E R A U C /C D S P R O G R A M S ?

•Imaging providers will not be competitively disadvantaged by this federal requirement:

• All radiology providers may refuse Medicare referrals without this documentation • To receive Medicare payment for ADIS a “decision support number (DSN)”

• Imaging providers cannot perform AUC administrative duties for referrers • There is no facility “exempt” from PAMA

• These factors should quickly result in integration of CDS in referring practices


Documents

TIMOTHY L. SWAN, MD, FACR, FSIR SPEAKER, ACR …wsrs.org/2017meeting/handouts/swan_support.pdf · speaker, acr council ... 8 10 12 14 16 18 1980 1983 1986 1989 1992 1995 1998 2001