What?s Appropriate?

Five Providers Step Up to Participate in CMS Demo

David Fisher, executive director, MITA

Dose reduction has unquestionably become one of the hot topics in the medical imaging industry, alongside more controversial ones like teleradiology. But unlike the latter, dose reduction is something that all parties?from physicians to patients to manufacturers?agree on: the less radiation a patient is exposed to, the better. And as David Fisher, executive director, Medical Imaging and Technology Alliance (MITA), said, ?The best way to reduce dose is not to give someone a dose.?

That is the motivation behind the Centers for Medicare and Medicaid Services? Medicare Imaging Demonstration (MID). The 2-year program is designed to promote appropriate utilization of advanced imaging services, while diminishing unnecessary overutilization and harmful radiation exposure. According to CMS, ?The program will assess the impact that decision support systems used by physician practices have on the appropriateness and utilization of advanced medical imaging services.?

?Back in MIPPA [Medicare Improvements for Patients and Providers Act of 2008], we worked on the finance committee to include language in that bill to allow us to test the application of appropriateness criteria as a means to ensure that imaging procedures are appropriate,? said Fisher. ?The announcement of the CMS program is the beginning of that legislative language.?

According to a press release on the CMS Web site, ?The demonstration includes only advanced diagnostic imaging services (specifically, the 11 modalities identified) provided to Medicare fee-for-service beneficiaries paid under Part B. Inpatient (Part A) and emergency department imaging services are excluded. Services provided by an outpatient clinic (Part B) are included in the demonstration.?

Five different locations?Brigham & Women?s Hospital, Henry Ford Health System, Maine Medical Center-Physician Hospital Organization, University of Wisconsin-Madison, and National Imaging Associates?have agreed to take part in the demonstration. Each facility will use appropriateness criteria and, after the 2-year demonstration is complete, will deliver the data to CMS to report the findings.

The appropriateness criteria used in the demonstration will be medical specialty guidelines that are developed or endorsed by medical specialty societies.

The criteria, which will be installed in computerized decision support systems, are intended to give physicians immediate reference to established standards when making on-the-spot decisions about future imaging procedures for patients. Fisher guesses that the criteria will be uploaded to an existing physician ordering system, which can then alert the physician if an inappropriate test has been ordered. From there, the physician can either heed the advice of the system or disregard it if the test is necessary.

?The demonstration is designed to test whether there are any changes to the number or type of procedures that take place based on physician-specific appropriateness criteria that are included as part of health IT systems, which are installed at these different locations,? he said.

This process, as Fisher notes, was established in part because of the difficulties the imaging field is experiencing with the recent but severe decline in reimbursement, and the general perception that diagnostic imaging is being overutilized. But he urges that the system aims only to eliminate inappropriate imaging procedures.

?We want to get rid of inappropriate imaging, but we want to be sure that imaging that is appropriate for a diagnosis and gives the physician the tools they need to treat a patient shouldn?t be tossed out with the bathwater, so to speak,? said Fisher.

?We believe that rather than ratcheting down payment to try to force physicians out of particular behaviors or to use third parties as a means to artificially lower imaging levels, we can actually work with physicians to develop the appropriate criteria for different types of procedures and thereby eliminate inappropriate imaging while preserving imaging for diagnosis and treatment.

?We?ve always supported eliminating inappropriate imaging. No one should pay for inappropriate imaging. However, we don?t want to use artificial means to reduce appropriate imaging. Appropriateness criteria are the right way to do that.?

Eventually, Fisher hopes that this demonstration will provide positive results and can be the model for a program that can be more universally applied to imaging facilities. After the 2-year demonstration is complete, CMS will evaluate the findings over the course of a year and eventually release what they have uncovered.

?We would hope that if the program demonstrates a reduction in inappropriate imaging, the CMS would try to roll it out across the country,? said Fisher.

—Chris Gaerig