The law requires that doctors consult clinical guidelines set by the medical industry before Medicare will pay for many common exams for enrollees. Healthcare providers who go way beyond clinical guidelines in ordering these scans (the 5% who order the most tests that are inappropriate) will, under the law, be required after that to get prior approval from Medicare for their diagnostic imaging.
But after physicians argued the provision would interfere with their practices, the Trump administration delayed putting the 2014 law in place until January 2020, two years later than originally planned.
Even then, the Centers for Medicare and Medicaid Services (CMS) slated next year as a "testing" period, which means even if physicians don't check the guidelines, Medicare will still pay for an exam. CMS also said it won't decide until 2022 or 2023 when physician penalties will begin.
Critics worry the delays come at a steep cost: Medicare paying for millions of unnecessary exams and patients subject to radiation for no medical benefit.
A Harvard study published in 2011 in the Journal of Urology found "widespread overuse" of imaging tests for men on Medicare who were at low risk for prostate cancer. And a University of Washington study in the Journal of the American College of Radiology that reviewed 459 CT and MRI exams at a large academic medical center found 26% of the tests were inappropriate.
"These delays mean that many more inappropriate imaging procedures will be performed, wasting financial resources and subjecting patients to services they do not need," said Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research in Boston. "If this program were implemented stringently, you would certainly reduce inappropriate imaging to some degree."
Doctors order unnecessary tests for a variety of reasons: to seize a potential financial advantage for them or their health system, to ease fears of malpractice suits, or to appease patients who insist on them.
The law applies to doctors treating patients enrolled in the traditional fee-for-service Medicare system. Health insurers, including those that operate the private Medicare Advantage plans, have for many years refused to pay for the exams unless doctors get authorization from them beforehand. That process can take days or weeks, which irks physicians and patients.
CMS Administrator Seema Verma has sought to reduce administrative burdens on doctors with her "patients over paperwork" initiative.
CMS would not make Verma or other officials available and answered questions only by email.
A spokeswoman said CMS has no idea how many unnecessary imaging tests are ordered for Medicare beneficiaries.
"CMS expects to learn more about the prevalence of imaging orders identified as ‘not appropriate' under this program when we begin to identify outlier ordering professionals," she said.
‘It takes 4 clicks on a computer'
An influential congressional advisory board in 2011 cited the rapid growth of MRIs, CT scans, and other imaging and recommended requiring doctors who order more tests than their peers to be forced to get authorization from Medicare before sending patients for such exams. In the 2014 law, Congress tried to soften the effect by asking doctors billing Medicare to follow protocols to confirm that imaging would be appropriate for the patient.
A growing number of health systems have used clinical guidelines to better manage imaging services, studies show. The University of Virginia Health System found that unnecessary testing fell by between 5% and 11% after implementing such recommendations.
Virginia Mason Health System in Seattle in 2011 set up a system requiring its physicians -- most of whom are on salary -- to consult imaging guidelines. It would deny claims for any tests that did not meet appropriate criteria, except in rare circumstances. A study found the intervention led to a 23% drop in MRIs for lower back issues and headaches.
Dr. Craig Blackmore, a radiologist at Virginia Mason, said he worries that, unlike the efforts at his hospital, many doctors could be confused by the Medicare program because they have not received the proper training about the guidelines.
"My fear is that it will be a huge disruption in workflow and show no benefit," he said.
In 2014, AtlantiCare, a large New Jersey hospital system, began grading physicians on whether they consult its guidelines.
"Some doctors see this tool as additional work, but it takes four clicks on a computer or less than a minute," said Ernesto Cerdena, director of radiology services at AtlantiCare.
Not all Medicare imaging tests will be subject to the requirements. Emergency patients are exempt, as well as patients admitted to hospitals. CMS has identified some of the most common conditions for which doctors will have to consult guidelines. Those include heart disease, headache, and pain in the lower back, neck or shoulders.
Robert Tennant, director of health information technology for the Medical Group Management Association, which represents large physician groups, said the law will unfairly affect all doctors merely to identify the few who order inappropriately.
"For the most part, doctors are well trained and know exactly what tests to perform," Tennant said.
The association is one of several medical groups pushing Congress to repeal the provision.
American College of Radiology's role
The law required the federal government to designate health societies or health systems to develop guidelines and companies that would sell software to embed that information into doctors' electronic health record systems.
Among the leaders in that effort is the American College of Radiology, which lobbied for the 2014 law and has been issuing imaging guidelines since the 1990s. It is one of about 20 medical organizations and health systems certified by CMS to publish separate guidelines for doctors.
The college wanted "to get ahead of the train and come up with a policy that was preferable to prior authorization," said Cynthia Moran, an executive vice president of the radiology group. About 2,000 hospitals use the college's licensed guidelines, more than any others, she said. And the college profits from that.
Moran said the licensing money helps the college defer the costs of developing the guidelines, which must be updated regularly based on new research. She said the college gives away the guidelines to individual doctors upon request and sells them only to large institutions, although she notes they are not as easy to access that way compared with being embedded in a doctor's medical records.
Kaiser Health News is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation, which is not affiliated with Kaiser Permanente.
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