Law to reduce unneeded Medicare CT, MR exams delayed by Trump administration

August 14, 2019
by Thomas Dworetzky, Contributing Reporter
The Protecting Access to Medicare Act, law since 2014, is being delayed by the Trump administration, according to a Kaiser Health News report via NPR.

Federal officials “have yet to implement” the law, which covers such diagnostic procedures as CT, PET, nuclear medicine and MR, according to Kaiser Health News (KHN). They have now pushed the start date to January 2020 — from 2018 — and the Centers for Medicare & Medicaid Services is making the first year one of "testing," so the agency will still cover scans even if doctors don't check the guidelines first. Plans now call for determining overuse penalties sometime in the 2022-2023 range, said the news service.

The law requires practitioners ordering “advanced diagnostic imaging service” for a Medicare patient to consult with a qualified Clinical Decision Support Mechanism — or guidelines — with the aim of cutting down on unneeded tests that can waste money and harm patients. Those who over-order could face penalties.

Critics worry such delays will mean Medicare pays millions for unneeded tests and patients get hit with unnecessary radiation.

"These delays mean that many more inappropriate imaging procedures will be performed, wasting financial resources and subjecting patients to services they do not need," Gary Young, director of the Northeastern University Center for Health Policy and Healthcare Research in Boston, told the news service, noting that, "If this program were implemented stringently, you would certainly reduce inappropriate imaging to some degree."

The law zeros in on testing with fee-for-service Medicare patients — health insurers have already been balking at paying for such tests without some form of preauthorization.

"CMS expects to learn more about the prevalence of imaging orders identified as 'not appropriate' under this program when we begin to identify outlier ordering professionals," a CMS spokeswoman told KHN.

The focus of the use of guidelines is on non-workflow disrupting tests, so patients in the emergency room and hospital aren't part of the program. CMS is focusing guideline-use on situations typically involving less time-critical testing, such as for headaches, heart disease, and back, neck, and shoulder pain.

Some complain that the law is overreaching and burdensome.

"For the most part, doctors are well trained and know exactly what tests to perform," Robert Tennant, director of health information technology for the Medical Group Management Association, told KHN. The group, which represents physician groups, has been urging Congress to repeal the provision.

The American College of Radiology, one of the medical organizations and health systems with CMS approval to create guidelines, hopes “to get ahead of the train and come up with a policy that was preferable to prior authorization,” its Executive Vice President Cynthia Moran told the news agency.

While clear guidelines are one approach to cutting down on unneeded scanning, technology may provide other paths as well.

In July, a new study showed that over 30 percent of head CT scans could be avoided with the use of the FDA-cleared BrainScope One medical device.

“Greater than 80 percent of patients who arrive at the emergency department with a mild traumatic brain injury (mTBI) will be scheduled for a CT scan to rule out a structural injury. On average, mTBI patients who receive a CT scan spend approximately 6.6 hours in the ED, including a 2.5 hour waiting period for the scan to be performed and assessed by a radiologist,” BrainScope CEO Michael Singer told HCB News. “Ninety-one percent of these scans are negative, exposing the patient to unnecessary radiation. Additionally, a CT scan does not indicate the presence or severity of concussion, resulting in many concussed patients being discharged with little or no follow-up.”

The handheld system uses AI to triage head-injured patients between those likely CT positive and those CT negative for structural brain injury.

“BrainScope One may be used in the future to help identify those patients who may need advanced neuroimaging (for example MR), who might be found to be CT-, but who have suffered a brain injury,” noted Singer, adding, “this would help to better, cost-effectively determine who needs imaging and what type of imaging, which could help ensure clinically appropriate scanning decisions.”