In 2014, a law was passed that, when implemented, is supposed to reduce unnecessary imaging tests, like MRIs, CT scans and other expensive diagnostic imaging tests. In order to achieve this goal, doctors will be required to consult a set of clinical guidelines before ordering one of these tests for Medicare patients. If the doctor fails to consult the Guidelines, he or she may not be paid for the test.
The new law will not apply to emergency patients. It will primarily require physicians to consult the Guideline for their patients with heart disease, headache, pain in the neck, shoulders, or pain in the lower back.
The law was scheduled to go into effect January 2018. At the urging of physicians, who argued the law would interfere with their normal practices of medicine, the Trump administration delayed implementation of the law until January 2020.
When the Guidelines are implemented, the 5 percent of physicians who are expected to order tests outside of the Guidelines will be required to have prior approval from the Centers for Medicaid and Medicare Services (CMS) before they can order any imaging tests for Medicare patients.
Although the implementation date is now been postponed, CMS says that 2020 will be a testing ground for the new law. Even if physicians do not follow the Guidelines, Medicare will still pay for the diagnostic procedure that was ordered. CMS also reports that it won’t decide until 2022 or 2023 whether to penalize physicians who do not follow the guidelines.
Critics of the Postponement
Critics of the postponement express concern that millions of dollars will be spent on unnecessary exams. They also fear that patients will be subjected to radiation when they do not need to be.
The critics are supported in their view by two studies. One was a study conducted by Harvard and published in 2011 limited to the evaluation of imaging tests for men on Medicare who were at low risk for prostate cancer. Harvard concluded that there was a “widespread overuse” of imaging tests for men in this category.
Another test out of the University of Washington that reviewed 459 CT and MRI exams found that 26 percent of the tests were unnecessary. This study was published in the Journal of the American College of Radiology in March 2010.
American College of Radiology
The American College of Radiology actually lobbied for the 2014 law. It is one of approximately 20 medical organizations that have been certified by CMS to publish Guidelines for doctors. Cynthia Moran, an executive vice president of the radiology group, was quoted as saying that the “college wanted to get ahead of the train and come up with a policy that was preferable to prior authorization.”
Currently, about 2,000 hospitals across the country are using the College’s Guidelines. Individual doctors can obtain copies of the Guidelines for free upon request.
Many Hospitals and Medical Groups Already Have Guidelines That Must be Consulted
There are some health systems that already have Guideline criteria in place for physicians to follow when ordering imaging tests. The University of Virginia Health System found that unnecessary imaging tests fell by between 5 percent and 11 percent when it implemented the Guideline requirement.
Virginia Mason Hospital in Seattle set up a system in 2011 requiring its physician to consult imaging Guidelines. It found a 23 percent decrease in MRIs ordered for lower back pain and headaches.
The idea behind the Guidelines is that if doctors consult the Guidelines prior to ordering tests, it will reduce their need to have prior authorization, which sometimes takes a long time to obtain and requires extensive paperwork.
Some Support of the Implementation Postponement or Repeal
The director of health information technology for the Medical Group Management Association fears the law, if implemented, will unduly burden all physicians just to identify a few who may order too many imaging tests.
A radiologist at Virginia Mason, Dr. Craig Blackmore, was quoted as saying, “My fear is that it will be huge disruption in work-flow and show no benefit.” Doctors, Blackmore said, are well-trained and know exactly what tests they need to order and when to order them.