A permanent fix to the unpopular sustainable growth rate formula or "doc fix" is making its way through Congress and physicians might be surprised to find out that a provision tucked away in the proposed law would require them to consult "appropriateness criteria" when referring Medicare patients for advanced imaging tests.

The policy, which the American College of Radiology helped lead, is essentially a decision-support tool that will be used by physicians and overseen by the Centers for Medicare and Medicaid Services and the secretary of Health and Human Services.

"Most providers will consult this and it will guide them," Cynthia Moran, assistant executive director of government relations at ACR, told DOTmed News.

The appropriateness criteria, which is evidence-based, will be embedded in an electronic health record and will notify the provider automatically if the ordering test is appropriate or not. Providers can log onto a secure page on CMS' website to consult the criteria as well. This feedback will also be compiled and used to evaluate the ordering habits of doctors. By 2020, "outlying" doctors will be subject to prior authorization when ordering tests for their patients. The treating physicians will have to make sure the information follows the patient to the imaging exam and they will also be responsible for submitting the information that the test conforms to the appropriateness criteria in order to get reimbursed by Medicare.

Moran said that the ACR has been working on this approach since the Affordable Care Act legislation was debated. The policy was not well formulated then, so it only received mention in a clause of the law pertaining to an area of development for the newly formed CMS Innovation Center to consider.

For the past two years, the ACR has been working to get all physician groups as well as vendors to support the policy, not fight it.

"It's been our highest legislative priority," said Moran.

But a recent Wall Street Journal op-ed from Dr. Scott Gottlieb from the American Enterprise Institute gives a different representation of the physician-developed appropriateness criteria.

Gottlieb writes: "Radiologists (and other medical specialists) struck a bargain with legislators to give them input into the development of these criteria — one reason doctor groups have rolled over. They see it as a better alternative to price cuts, or more direct controls over their medical practice. The bill does have language to give these groups a say over the criteria, but a fair reading of the bill shows these are weak and give enormous discretion to the Centers for Medicare and Medicaid Services and "the Secretary of Health and Human Services."

Either way, ACR and other imaging stakeholders see it as a way to be directly involved with payment reform — which is transitioning from reimbursing providers based on volume to rewarding them for value.

The bipartisan bill, called the Excellence in Diagnostic Imaging Utilization Act of 2013 (H.R. 3705), passed the House Ways and Means and Senate Finance Committees last week and now awaits consideration by the full House of Representatives and Senate in early 2014.

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