WASHINGTON – In response to the April 7 Medicare Payment Advisory Commission (MedPAC) recommendation that medical practitioners who use substantially higher levels of advanced diagnostic imaging services receive Centers for Medicare and Medicaid Services (CMS) approval before being able to provide those services, the Imaging e-Ordering Coalition encourages Medicare officials to instead look to existing clinical decision support tools to reduce costs, increase efficiency, support appropriate use, and improve quality of care in diagnostic imaging.

"By referencing proven imaging clinical decision support systems, physicians are able to quickly and effectively recommend the most appropriate course of treatment for their patient at the point of order, rather than having to rely upon prior authorization in advance of treatment," said Liz Quam, co-founder of the Imaging e-Ordering Coalition, representing leading healthcare providers, technology companies, and diagnostic imaging vendors. "Not only is this approach more efficient for patient care delivery, its provision of immediate clinical feedback and alternative imaging suggestions based on established medical professional society appropriateness guidelines encourages informed decision-making and significantly lowers administrative costs."

MedPAC's recommendation – which targets the top 10 percent of providers who account for more than half of imaging services – was opposed by Commissioner Ronald Castellanos, M.D., who represents physician specialists on the panel. In his dissent, Castellanos noted that CMS does not have a structure in place to implement prior authorization, and that MedPAC should not institute such a policy that would be burdensome to both physicians and beneficiaries.

With the use of clinical decision support systems, once a physician requests an imaging procedure, specific clinical indicators are identified within the patient's electronic medical record (EMR) or the computerized physician order entry (CPOE). From there, an appropriateness score is generated, and if deemed medically appropriate, the diagnostic order is placed and the procedure is conducted. Following the procedure, advanced analytics are captured and returned to the physician along with ordering feedback, thereby helping to build data on what tests are worthwhile in certain patient situations and deliver input to affect future physician behavior.

Following a three-year pilot program on the use of clinical decision support tools in medical imaging involving four large health systems and four large payers in Minnesota, all participating medical groups reported that use of the point-of-order decision support systems was more efficient than calling in for prior authorization, had greater capacity for shared decision-making with patients, and could serve as a useful patient and provider education tool. In addition, the use of clinical decision support systems over prior authorization was found to generate monthly administrative savings of 303 hours or annual savings of $18,000 - $24,000 in salary/benefits.

"Rather than relying on prior authorization of care – which some physicians have reported as being inconsistent, resulting in unnecessary delays in treatment, and requiring justification of medical decisions to outside parties not familiar with the patient at hand – we urge MedPAC to take another look at smart technology systems such as clinical decision support tools that are already capable of supporting more efficient, cost-effective and appropriate imaging care," said Quam. "As shown in real-world settings, these systems provide reliable, immediate decision-making support and maintain medical decisions where they belong – between patients and their physicians."