When we start the conversation about imaging decision support one topic always jumps to the forefront – “PAMA”. The sections of 2017 MPFS proposed rule that relate to the implementation of decision support for compliance with the Protecting Access to Medicare Act of 2014 (PAMA) have a lot of nuances. From what we’ve heard out in the market, interpreting these nuances can be a daunting and confusing task.
What We Know
When diving in to the CMS proposed rule, four basics for PAMA compliant CDS implementation appear to be clear:
- The proposed rule mandates that a compliant decision support solution must start reporting by January 1st, 2018.
- Every imaging order placed must consult (e.g. ask a question of) a Clinical Decision Support Mechanism (CDSM) that leverages Appropriate Use Criteria (AUC) published by one or more qualified Provider Led Entities (qPLE).
- At a minimum a CMS qualified CDSM must return one of at least three answers:
- Complies with an Appropriate Use Criteria (AUC)
- Does Not comply with an AUC
- No Applicable AUC Available
- Priority Clinical Areas (PCA) will be used by CMS to “identify outlier ordering professionals”. PCA are a list of broadly defined clinical conditions, E.g.: abdominal pain, that create a measurement baseline by defining “required” AUC coverage for a CDSM. Today, PCA cover clinical scenarios indicated for approximately 40% of all high cost exam orders. PCA will expand to cover more clinical scenarios each year.
What We Don’t
The access and claims reporting requirements remain undefined. These processes are part of the future rule-making process and will not be addressed in the final rule due out this November. Two main requirements remain unclear:
- The reporting requirements, including how to submit claims in order to ensure compliance is “measured”, at least minimally linked to the PCA, and ideally ensure that the program “works”.
- The algorithm by which providers will be defined as “outliers” and the additional authorization hurdles that they will be subject to.
A Real World PAMA consultation
In the real world, a PAMA consultation is an order placed in the EMR for Medicare Part B advanced imaging.
During the ordering process the user asks the CDSM a “question” via a structured, coded indication or reason for exam.
To comply with PAMA, the CDSM must reference AUC and return an answer of ‘Complies’, ‘Does Not Comply’ or ‘No AUC Apply’. It is important to note that the CDSM must respond for every exam ordered.
Priority Clinical Areas
PCAs do one thing – define areas for provider measurement. It can be tempting to think that your organization might get away with a solution that only covers the PCAs with a supposedly simpler CDSM interaction. This however is not the case.
By limiting CDSM AUC coverage to only select clinical areas, PCAs only constrain the number of useful responses a CDSM can provide. The answer of ‘No AUC Apply’ does not ensure the correct order is being placed, merely that the system “Does Not Know”. Additionally, as PCAs define outlier measurement, the ordering user needs to know if an AUC applies (is within a PCA) for the indication they are placing the order for to avoid becoming an outlier.
When other CDSM developers talk about AUC, it is critical to understand that there is a lot of catch up that non-medical society qPLEs have to do to “re-invent the wheel.” This can lead to significant gaps in coverage and a high percentage of ‘No AUC Apply’ answers. CareSelect Imaging leverages AUC from all qPLE medical societies. These societies have invested tens of thousands of hours to develop evidence-based AUC that help doctors use the right imaging test to answer their clinical question.
As these clinical questions (a specific description of the patient condition) are the best way to get an answer through imaging (the most appropriate imaging test), you can imagine that providers seek both specificity and coverage. PCAs really don’t limit the questions in any way especially as the claims process is as yet unknown. A complete payable claim requires both evidence of CDSM consultation and to be coded with enough clinical specificity to ensure that outlier status is avoided. When AUC coverage is limited only to the scope defined by the PCAs this becomes impossible.
Beyond Compliance
A specific clinical question transcends compliance. A clear, concise indication informs the ordering, protocoling and interpretation of imaging and results in less re-work for furnishing services.1 When a CDSM, like CareSelect Imaging, allows you to properly frame questions and gives useful answers, interaction becomes routine and helpful vs. punitive and “fatiguing”. This enables the CDSM to provide useful guidance to the user for every imaging order.
A shorter list of “questions”, organized around the PCA, would force the provider to ask questions that will ensure the “right answer”. This effectively creates an environment where providers game the system, and the furnishing site is forced to verify the question truly matches to the answer to ensure there is a valid, payable claim.
Next Steps
Based on our analysis of the published claims data in the proposed rule, the 8 clinical areas in the proposed rule still cover well over 450 clinical indications, ranging from diagnostic to cancer and cardiac imaging.
The known claims data, released by CMS2, indicates that far more than 8 questions will be necessary, with a further expansion in next year’s rule. If you limit the questions, you will end up with an incomplete system and the answers and evidence will not be clear enough to generate a payable claim (aka comply).
So then, does the rulemaking cycle even matter when deciding how to implement? Whether it is 8 or 80 priority clinical areas, we already know what we need to know about implementation of the provider side and how to prepare for compliance on the claims side: comprehensive coverage.
Every single day another health system adopts our imaging solutions or brings our solutions online within their EMR. Over the last 12 months, we have provided over 20 million AUC consultations at over 1000 acute care facilities with over 100,000 physicians accessing our solution. We know how to do this.
Consult with your EMR vendor about implementing PAMA compliant imaging decision support with ACR Select or our CareSelect Imaging solution. In this case, the answer is clear.
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Rockford Health System, “HIMMS Analytics Stage 7 Case Study,” http://www.himssanalytics.org/system/files_force/Rockford%20Health.pdf?download=1
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“Data Analysis – Centers for Medicare and Medicaid Services,” https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Appropriate-Use-Criteria-Program/data.html
