The Centers for Medicare & Medicaid (CMS) has adjusted its plans to enforce compliance with the Protecting Access to Medicare Act (PAMA), originally intended to go into effect Jan. 1, 2021. As a result of COVID-19, CMS recently announced the extension of its PAMA compliance requirement to Jan. 1, 2022, giving providers the duration of 2020 and calendar year 2021 to prepare.
The Protecting Access to Medicare Act (PAMA) aims to address waste and ensure high-quality care for patients by mandating the use of a clinical decision support (CDS) tool when ordering advanced imaging services.
With the deadline extension, there are no payment consequences associated with PAMA compliance during calendar years 2020 and 2021. On Jan. 1, 2022, CMS will begin to withhold payment if proof of a CDS solution is not in place when ordering advanced imaging services.
CMS expects providers to use this additional time to prepare for an effective PAMA-compliant CDS solution that aids in ordering appropriate advanced diagnostic imaging services for Medicare fee-for-service 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.
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 guidelines known as appropriate use criteria (AUC) and if they adhere to the guidelines.
There are eight priority clinical areas that AUC aims 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 makes one CDS solution different than the rest?
Providers need a qualified CDS mechanism (qCDSM) that delivers the mandated guidance at the point of order entry. The qCDSM achieves this by recommending the cancellation of studies without strong evidence-based indications for the specific clinical scenario, while also delivering important clinical information to the radiologist for evaluating the studies.
Stanson Health has developed an innovative, artificial intelligence (AI)-enabled PAMA solution that directly integrates into the EHR workflow and provides clinician recommendations as well as an easy and intuitive user experience.
Radiologists often claim that it is rare for them to have accurate and complete clinical information available when they read a study. This information is critical at the time of interpretation. Stanson, Premier’s PAMA-compliant CDS solution, is able to leverage data already available in the EHR. Currently in use with more than 200,000 clinicians, Stanson is designed to deliver this important, clinically relevant information to radiologists with few interruptive alerts.
What does compliance look 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 would order a CT of the lower back to rule out a host of possible conditions, even though most know the culprit is likely overactivity on the basketball court or poor posture 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: support providers to ensure delivery of evidence-based care. And with the right tools in place, it should not be burdensome for physicians to reach it.
Simply put, providers and their IT teams should look for a solution that’s helpful—not just required.
It has been documented that 90% 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, some clinicians have a tendency to overtreat, according to studies. This overtreatment has resulted in as much as $200 billion in annual waste.
Now more than ever, providers need a reliable PAMA solution that helps guide care in the EHR workflow, enabling providers to improve quality and cost of care via an easy and intuitive user experience.
Frustrated with your current PAMA solution?
We want to help during these tough financial times, so we are waiving all fees for the first year when you transition from a legacy solution. Our innovative solution is helpful… not just required.
Connect with Premier’s PAMA experts today to talk about your transition.