ASNC Continues to Cast Doubt on Medicare AUC Program

On Sept. 6, 2016, ASNC submitted comments to the Centers for Medicare and Medicaid Services (CMS) on its latest round of proposals for implementing the Medicare Appropriate Use Criteria (AUC) Program for advanced diagnostic imaging, including those related to priority clinical areas and requirements for clinical decision support mechanisms (CDSMs) that must be used for consulting AUC. In its comments, ASNC continued to question the need for a stand-alone AUC Program as CMS transitions to a new value-based payment system under which physicians will be assessed on resource use. 

“The AUC Program is an excellent concept that ASNC fully supports, but the mandate has gone awry,” said ASNC CEO Kathy Flood. “This law is based on sound principles but the implementation requirements, as they currently stand, are unnecessarily complex and would be unduly onerous and costly for referring providers and imaging physicians.” 

ASNC emphasized in the letter that AUC, when effectively applied, ensure that the right patients get the right test first. Ms. Flood added, “ASNC is committed to effective implementation of the AUC Program. Our priority is to arrive at a process that, first, protects patients' access to appropriate testing and, second, curtails undue burdens and cost on referring providers.”

CMS has proposed chest pain among eight clinical priorities that will be used to identify outlier ordering professionals. The priority areas were selected based on volume. Last year, CMS stated that it believed the goal of the AUC program was to “promote the evidence-based use of advanced diagnostic imaging to improve quality of care and reduce inappropriate imaging services.” However, as ASNC pointed out to CMS in its letter, in the majority of chest pain cases, providing an advanced imaging test to a symptomatic patient in the Medicare population would be an appropriate test. Instead, ASNC pointed CMS to the Choosing Wisely recommendations, which better correlate with low-value testing.

In September, ASNC met with CMS staff to further share concerns with chest pain as a priority clinical area. During the conversation ASNC Health Policy Committee member David Winchester, MD, MS, emphasized that chest pain is a low-yield area for identifying inappropriate outliers and the identification of outliers would be complicated by the inability to identify pre-test probability of suspected coronary artery disease from administrative claims data. Dr. Winchester suggested testing for asymptomatic and pre-operative patients as two areas that more readily allow for the identification of inappropriate testing. “High volume testing does not naturally lead to a high yield of inappropriate tests,” said Dr. Winchester. “I believe CMS understands this; the question ultimately is whether the Agency is willing to take the highest volume indication for advanced imaging testing off the table as a priority clinical area and start with a more focused approach.”

The other significant component of CMS's proposed rule is requirements CDMS would need meet to become qualified under the AUC Program. Most notably, CMS is proposing that qualified CDSMs must make available to ordering professionals, at a minimum, specified applicable AUC that encompass all priority clinical areas. Furthermore, CMS is proposing that CDSMs would not be required to incorporate specified applicable AUC from more than one qualified provider-led entity. This means, for example, that while the American College of Cardiology is a provider-led entity with applicable AUC, CDSMs would not be required to include the ACC AUC.   

By November 1 CMS will release the Medicare Physician Fee Schedule Final Rule, which will finalize the priority clinical areas and requirements for CDSMs. In 2017, CMS is expected to undertake rulemaking on final implementation components of the AUC Program, including reporting and billing requirements.

Additional information about the AUC Program