Medicaid/Medicare Medicare Quality

Appropriate Use Criteria, or how I learned to love CMS telling doctors what to do

As part of Section 218(b) of the Protecting Access to Medicare Act, CMS instituted the appropriate use criteria (AUC) for the use of advanced diagnostic imaging.  In order to be reimbursed for these diagnostic imaging services, physicians must consult with and document that they used AUC software before recommending advanced diagnostic imaging.  Failing to document use of clinical decision support (CDS) with AUC criteria would lead to the claim being rejected (i.e., not paid).

At first glance, this seems like a great idea. AUCs are evidence based guidelines that can ostensibly help physicians use diagnostic imaging appropriately.  However, are top-down mandates helpful for improving care?  Aren’t there already clinical guidelines in place to assist practitioners?

Although AUC are evidence-based, my guess is that they will be ineffective in practice and physicians will see them as an administrative burden.

Even Atul Gawande–one of the strongest advocates of checklists–recognized that purely top-down approaches typically do not work. He strongly advocates for the clinical team taking the lead in adopting checklists.  However, that does not always happen:

…the most extreme example, they turned [our 19-item checklist] into an 81-item checklist. It was impossible to use. We’d specifically designed it to be something you could run through in 60 seconds or less at each pause point, so you weren’t distracted from the main operation. And you could see that the administration in the hospital had got hold of it, and they were using it to try to impose their ideas. And essentially, the clinical team was not the team that were designing and controlling the checklist. Invariably, you look at that and you know that everybody is completely ignoring it, and it has become just a tick box effort instead of an enabler of greater capability.

This is a key concern with AUC.  Will it actually be a tool to improve care or will doctors not take it seriously and just consider it another paperwork task that takes them away from patient care?

Although initially the AUC provisions were going to go into effect on January 1, 2018, the implementation of AUC for diagnostic imaging is being delayed until January 1, 2019.  This will give providers more time to implement the necessary software, but I am skeptical that CMS dictates on practicing medicine will be taken to heart by real-world providers.


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