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Complying with the Protecting Access to Medicare Act can be Easy

Did you know that 80-90 percent of U.S. healthcare costs are the direct result of a provider decision? By and large, in their efforts to best care for their patients, it has been shown that some clinicians have a tendency to overtreat. This overtreatment has resulted in as much as $200 billion in annual waste.

Studies estimate that patient care is 112-times more effective when guidance is included in the provider workflow through a clinical decision support (CDS) solution. That’s why the Protecting Access to Medicare Act (PAMA) aims to address waste and ensure high quality care for patients. CDS is ultimately about changing provider behavior in an attempt to help guide them to better care. In the case of PAMA, this guidance should result in lower costs and better care quality.

But, like any policy meant to be followed, PAMA comes with reimbursement penalties for non-compliance starting in 2021.

CMS requires providers to be PAMA-compliant in 2020.

The Centers for Medicare & Medicaid Services (CMS) expects providers to use 2020 to prepare to have an effective PAMA-compliant CDS solution in place that aids in ordering appropriate advanced diagnostic imaging services for Medicare patients. Accordingly, it is critical for providers to actively work toward implementing a CDS solution during this time and take advantage of a penalty-free period to put a plan in place for implementation. On January 1, 2021, CMS will withhold payment if proof of a CDS solution is not in place when ordering these services.

So, what exactly is PAMA, why is it important and what do providers need to do to be compliant with it?

PAMA is designed to increase the rate of appropriate advanced diagnostic imaging services provided to Medicare beneficiaries. This type of imaging includes:

  • Computed tomography (CT)
  • Positron emission tomography (PET)
  • Nuclear medicine
  • Magnetic resonance imaging (MRI)

The program requires that healthcare providers consult a CDS tool when ordering advanced diagnostic imaging services for Medicare fee-for-service (FFS) patients. CDS tools help determine if orders are applicable to appropriate use criteria (AUC) and that adhere to the guidelines.

There are eight priority clinical areas that AUC aim to address:

  • Coronary artery disease (suspected or diagnosed)
  • Suspected pulmonary embolism
  • Headache (traumatic and nontraumatic)
  • Hip pain
  • Low back pain
  • Shoulder pain (to include suspected rotator cuff injury)
  • Cancer of the lung (primary or metastatic, suspected or diagnosed)
  • Cervical or neck pain

What should providers look for in a CDS solution?

Providers need a qualified CDS mechanism (qCDSM) that delivers the mandated guidance at the point of order entry to improve appropriate imaging use. This is done by eliminating studies without strong evidence-based indications while delivering important clinical information to the radiologist for evaluating the studies. In fact, Stanson Health, the CDS solution Premier® acquired in 2018, directly integrates into the EHR workflow and provides recommendations to the clinician.

The goals of a successful PAMA deployment include:

  • Improving the overall quality of care
  • Reducing unnecessary radiation and/or contrast exposure
  • Providing higher quality clinical histories for the radiologists
  • Avoiding overdiagnosis/overtreatment

Radiologists often claim they rarely have accurate and complete clinical information available when they read a study. This information is critical at the time of interpretation and can leverage data already available in the EHR. Premier’s CDS solution is striving to reduce the use of imaging studies that lack strong evidence-based indications while simultaneously delivering important clinical information to radiologists.

All of this is nice, but let’s take a look at what compliance looks like in the real world.

Imagine a patient – let’s say a 68-year-old man – who presents with lower back pain. During the initial consult he describes his level of physical activity. He spends most days hunched over a desk typing away on a computer. On weekends, he coaches a youth basketball team at the local community center.

Many providers – though not as many who would care to admit – would order a CT of the lower back to rule out a host of possible conditions. Even though most know the culprit is likely overuse on the basketball court or underuse in the office. That abundance of caution adds an additional layer of cost to the system, causes undue anxiety for the patient and his family, and exposes him to unnecessary radiation. All of this when logic, odds and medical studies overwhelmingly suggest the appropriate treatment would consist of rest, an anti-inflammatory medication and perhaps an adjustment in ergonomics at work.

The goal here is straightforward. And with the right tools in place, it should not be burdensome for physicians to reach it.

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