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Improving Care, Lowering Costs

Improving Care, Lowering Costs

Effective Jan. 1, 2021, the Protecting Access to Medicare Act imposes new requirements for providers who want to prescribe a CT, MRI or nuclear medicine study for a Medicare fee-for-service patient.

Under the regulations adopted by the Centers for Medicare and Medicaid Services (CMS) to implement the new law, ordering providers must consult an interactive electronic tool called a clinical decision support mechanism (CDSM) to ensure that the scan or test is medically warranted. Each CDSM must be approved by CMS.

The CDSM tool, in turn, relies on a set of guidelines known as appropriate use criteria (AUC) that assess the appropriateness of the scan or test. AUC are evidence-based rules that can only be developed, modified or endorsed by qualified, provider-led entities that have demonstrated that they can meet stringent requirements specified by CMS.

“It’s a pretty complicated system, but it is designed to protect patients from expensive tests unless they are necessary,” says Pamela Johnson, a professor of radiology and radiological science and the vice president of care transformation for the Johns Hopkins Health System.

Johnson recently led an effort to see the Johns Hopkins University School of Medicine named as one of a handful of leading organizations tapped to develop AUC. Unlike many other health systems, at Johns Hopkins, the AUC are woven into diagnostic and care management guidelines that reach beyond medical imaging to include other tests and treatments. As an illustration, Johnson points to the Johns Hopkins University back pain guideline that not only guides appropriate imaging but might also help reduce the overprescription of opioid medications and guide the patient to an appropriate specialist.

“What this means in practical terms is that we don’t have to rely on criteria developed by another organization,” Johnson says. “Johns Hopkins gets to write its own rules based on high-quality evidence to decide when we think imaging or another medical procedure is appropriate.”

It was a huge effort across the enterprise, Johnson says. It took months just to get the green light from CMS to develop criteria. Then, she had to assemble a team of 40–50 doctors from multiple specialties to research and develop the evidence-based criteria, with consensus from all participating Johns Hopkins-affiliated entities. Johnson says the group met three to four times each week for the six months it took to assemble the initial set of rules.

Johnson counts it as a big win for the Johns Hopkins School of Medicine, and now that the rules are published, she says Johns Hopkins will share its best practices with other organizations. Most importantly, Johnson notes, being in the driver’s seat translates directly into better patient care.

“Having the legal authority to develop our own appropriate use criteria has had unforeseen benefits,” Johnson notes. The team is now building out the library of AUC beyond the CMS 8 Priority Clinical Areas (headache, neck pain, low back pain, shoulder pain, hip pain, coronary artery disease, pulmonary embolism and lung cancer), to other common clinical scenarios, like knee pain and abdominal pain.

The original CMS 8 Priority Clinical Areas cover about 40% of advanced imaging orders, providing a strong foundation for a data driven expansion strategy that best serves our patients and providers.

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