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CMS Announces $10 Million Imaging DSS Demo

 |  By cclark@healthleadersmedia.com  
   July 27, 2010

The Centers for Medicare & Medicaid Services proposes to fund a $10 million demonstration of software packages with "appropriateness criteria" or "decision support systems" to help physicians decide whether a patient needs a CT, MRI, or other scan.

“There have been a lot of press and a lot of reports about overutilization of imaging services, and the potential for harm, and I’m sure that had something to do with this,” says Joshua Cooper, senior director of government relations for the American College of Radiology.

“This is something the ACR has been advocating for awhile—the right test at the right time—so we’re pleased to see that this (project) one was chosen out of many right out of the gate.”

To reign in all this expensive and dangerous exposure, the Centers for Medicare & Medicaid Services proposes to fund a $10 million demonstration of software packages with “appropriateness criteria” or “decision support systems” (DSS). There are about five on the market today that guide physicians who aren’t sure what tests they should order for a given patient.

“Unfortunately physicians, primarily primary care doctors, don’t know what the test should be,” Cooper says.  “They’ll order a CT because that’s been their habit," when perhaps an ultrasound or simple X-ray would do just fine.

Some doctors start out with an X-ray, and if that doesn’t find anything, go to an ultrasound, and then a CT, then an MR, then with contrast and so forth on the series, Cooper says.  A sound DSS would get the patient the right test a lot faster. Sometimes, the most expensive test is the right test, and when it is, it should be the first test, he says.

The 11 advanced imaging procedures to be reviewed under the grant include MRI of the brain, lumbar spine, knee and shoulder, CT of the brain, thorax, sinus, abdomen, pelvis and lumbar spine, and Spect MPI, tests associated with high expenditures and utilization in the Medicare fee-for-service population, and the availability of relevant medical specialty appropriateness guidelines, according to CMS. 

The two-year project will start in January, and include payments to physicians and practices that report complete data, to be used to determine appropriateness of the test. According to www.auntminnie.com, CMS seeks 2,500 to 3,000 physicians from 500 to 650 practices that vary in size, geography, and specialty mix. The doctors must submit the data electronically.

Estimates vary over what percentage of imaging tests which are unnecessary, but some studies suggest the number is as many as half.

“It depends on your definition of necessary or appropriate,” Cooper says.

But it’s clear that an even bigger and increasingly looming concern deals with the amount of ionizing radiation many of these expensive tests accumulate.

According to several recent reports, per capita dose of radiation from medical imaging has increased by a factor of nearly six since the early 1980s, an increase associated with undetermined cases of cancer that would otherwise not develop, or develop slower.

Federal agencies are increasingly calling out problems with the way doctors order expensive imaging tests.

A Medicare Payment Advisory Commission (MedPAC) report in June “Aligning Incentives in Medicare,” devoted a chapter to a critique of the growth of physician office-based ancillary services including imaging. It summarized the growing evidence that many imaging tests are overprescribed because that’s one way physicians can increase their revenue.

While “the ability to provide tests and other services during an office visit may help physicians initiate treatment more quickly,” the MedPAC report said, “on the other hand, physician investment in ancillary services could lead to higher volume through greater overall capacity and financial incentives for physicians to order additional services.”

MedPAC referred to a report earlier this year that found 14% of imaging procedures performed at a sample of six physician practices were inappropriate, “based on criteria developed by the American College of Cardiology Foundation and the American Society of Nuclear Cardiology.”

Even the Mayo Clinic was faulted in a similar report, which found between 14% and 18% of tests were inappropriate.

Especially problematic are cardiology CTs. According to an article last year in the New England Journal of Medicine, 30% of the radiation exposure associated with diagnostic imaging comes from cardiac imaging.

It’s not just heart imaging studies that are at issue.  A 2010 analysis “reviewed imaging orders from primary care physicians at a large urban hospital and found that 26% did not meet appropriateness criteria developed by a radiology benefit management program,” the MedPAC report says.

Inappropriate orders included CT for chronic headache, spine MRI for acute back pain and knee or shoulder MRI for osteoarthritis, MedPAC says.

Another study in 2008 “that estimated that each additional MRI scanner in a market is associated with 733 additional MRI scans among Medicare beneficiaries, and each additional computed tomography (CT) machine is associated with 2,224 additional CT scans.

“It is unclear whether the growth in scans is driven by changes in demand for medically necessary care, or change in the supply of machines,” the MedPAC report states.

Additionally, the MEDPAC report points to studies that found that when physicians furnish imaging services in their offices, they “refer patients for more imaging than other physicians.”

Imaging accounted for 38% of cardiology’s Part B revenue in 2008, up from 35% in 2003, and it represented 23% of vascular surgery’s Part B payments in 2008, compared with 20% in 2003.

Many believe that such decision-making software—the kind the demonstration project may test—can avoid unnecessary patient exposures. A March editorial in the New England Journal of Medicine, says that between 31% and 50% of expensive, CT tests could be avoided when trying to diagnose mild traumatic brain injury if a decision guideline system was followed.

The demonstration project is just one effort underway to curb radiation exposure and safety in imaging.

In February, the U.S. Food and Drug Administration said it plans a three-pronged effort targeting CT, nuclear medicine and fluoroscopy, which result in much higher dosages than X-rays and mammography.

It plans to issue requirements for manufacturers to design CT and fluoroscopic devices in ways that avoid mishaps resulting in patient overexposure, will work to develop better certification processes for imaging facilities and hospitals and will work to educate patients and develop a system so they can track their own medical imaging history. All vendors who sell imaging equipment that uses ionizing radiation must provide a way for dose exposure to be recorded in the patient’s electronic medical record.

Can a demonstration project lead to a good “appropriateness criteria” software test that will limit overutilization of expensive imaging, and greatly reduce unnecessary radiation exposure? 

That’s the hope, Cooper says.  “This is a more artful approach, and gets at the problem better and faster, with a scalpel rather than a hatchet.”

The demonstration project was specified in the Medicare Improvements for Patients and Providers Act of 2008.

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