By Jenny Lower

Congress doesn’t always succeed in implementing forward-thinking policy changes. But the recent passage of the Protecting Access to Medicare Act of 2014 not only addresses overutilization and rising costs with careful, evidence-based reform, it puts power back in the hands of radiologists.

Passed by the Senate on March 31 and signed into law on April 1, the bill—also known as the latest Sustainable Growth Rate (SGR) “patch”—requires referring physicians to consult appropriateness criteria before prescribing advanced imaging procedures for Medicare patients. The requirements apply to CT, MRI, nuclear medicine, and PET; ultrasound and x-ray are not affected.

Cindy Moran, American College of Radiology

Cindy Moran, American College of Radiology

The bill offers a 12-month reprieve from the 24% payment cuts originally scheduled to go into effect on January 1 of this year. Congress has passed similar payment patches more than a dozen times in the last 12 years, typically without introducing new policies. This version marks a distinct shift.

By requiring physicians to consult appropriateness criteria such as ACR Select, the legislation reverses the trend toward marginalization many radiologists have experienced as a result of the current volume-driven, fee-for-service model, said Cindy Moran, executive vice president for government relations, economics, and health policy at the American College of Radiology (ACR). “It reinserts radiologists as the managers of diagnostic imaging studies and reinserts them as consultants to the ordering physician.”

The unusual departure is due to Congress’ failure to pass a more comprehensive SGR reform bill in 2013. Despite widespread support in the House and Senate among both Republicans and Democrats, policy makers failed to agree on how to manage the package’s $180 billion price tag. Sensing an opportunity for incremental reform, the ACR convinced Congress to incorporate the appropriateness criteria into the patch as a “downpayment” on broader changes down the road.

Embracing decision support also largely precludes radiology benefits managers (RBMs) from becoming entrenched in the fee-for-service model, and instead enables appropriateness criteria to serve as an educational tool, Moran said. “It allows for a discussion between the ordering physician and the rendering physician—unlike the black box of an RBM, which just makes a payment decision. When it’s part of a larger communication tool, the appropriateness criteria process allows more interaction.”

Policy makers hope those discussions will help rein in rising healthcare costs due to overutilization, which may arise from ignorance on the part of the referring physician. But there are other legitimate concerns that lead to overimaging, such as the threat of malpractice suits and pressure from patients themselves. Appropriateness criteria can provide a framework to help combat those issues.

The appropriateness criteria portion of the bill rolls out January 1, 2017, but some benchmarks take effect before then. The Secretary of Health and Human Services will have to determine by April 2015 which sets of appropriateness criteria to sanction. The Secretary then has until April 2016 to designate a clinical decision support system to manage the criteria. The ACR is hopeful that ACR Select will pass muster. The criteria have been continually updated over the past two decades and the organization believes it offers the most comprehensive, evidence-based solution available.

“The bill is a fundamental reorientation of how Medicare has been run and how Medicare has been paying for services,” Moran said. “We think it’s a very positive change. But it needs to be correctly built, so we’re going to have to work with the system to make sure that it meets those criteria.”

Jenny Lower is the associate editor for Axis Imaging News.