Within a year, the Centers for Medicare & Medicaid Services (CMS) will implement a provision in the Protecting Access to Medicare Act (PAMA) that requires physicians to consult appropriate use criteria (AUC) using CMS-approved computer-based clinical decision support mechanisms when ordering advanced imaging procedures. Under PAMA, providers will have to submit proof that applicable AUC were consulted to have their claims processed. After the CMS collects 2 years of data, "outlier" physicians will subject to prior authorization, thus possibly limiting patients' and physicians' access to advanced imaging procedures. Because coronary artery disease evaluation is a priority clinical area, most cardiac imaging procedures will be subject to the initial rollout of the mandate.
Once PAMA is implemented, the burden of reducing inappropriate use will move largely from payers to providers. In preparation for this shift, physicians will need to be educated about expectations under PAMA, which should include increasing their understanding of appropriate use. This will require close collaboration between professional societies representing referring providers and imaging specialists and involvement of all stakeholders.
Article: Promoting Appropriate Use of Cardiac Imaging: No Longer an Academic Exercise, Rami Doukky, MD, MSc; Gretchen Diemer, MD; Andria Medina, MD, PhD; David E. Winchester, MD, MS; Venkatesh L. Murthy, MD, PhD; Lawrence M. Phillips, MD; Kathleen Flood, BS; Linda Giering, PhD; Georgia Hearn, JD; Ronald G. Schwartz, MD, MS; Raymond Russell, MD, PhD; David Wolinsky, MD, Annals of Internal Medicine, published 28 February 2017.