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- Robert Shor, MD, FACC, Chair, ACC Board of Governors∗ ()
- ↵∗Address correspondence to:
Robert Shor, MD, FACC, American College of Cardiology, 2400 N Street NW, Washington, DC 20037.
The American College of Cardiology (ACC) started producing appropriate use criteria (AUC) in 2005 with the goal of providing a practical standard to address variability, while helping cardiovascular professionals define “when to do” and “how often to do” a given procedure in the context of expert consensus, the health care environment, a patient’s profile, and the physician’s judgment. AUC were intended to help guide physicians, not serve as the final word on care and management. Exceptions to the rules are expected given the variability in clinical situations.
At the time, third-party radiology benefits management companies (RBMs), hired by health plans, were applying their own nontransparent methods to limit use and lower costs, resulting in denials and/or lack of payment for care. AUC were a direct answer to ongoing conversations between payers, government agencies, and other stakeholders about how to address skyrocketing health care costs associated with the increase in volume of imaging procedures in a manner that preserved physician/patient decision making, while also ensuring appropriate, cost-effective care. Who better to help create AUC than the ACC?
The College has come a long way over the past 10 years with the development of AUC. Not only do data show an appropriate continued decrease in imaging growth over the last decade, but the ACC is often credited by members of Congress and other stakeholders for working to address a perceived problem and taking proactive efforts to provide value and evidence-based care. Physicians who have been provided with AUC data on their imaging use have recognized their shared responsibility for appropriate use of imaging services and have improved their practice patterns—a more effective way to reduce variation than simply cutting payment.
Despite this success, there is still room for improvement. Prior authorization and claim denials continue to be some of the top challenges facing physicians. According to a 2012 Kaiser Family Foundation study, U.S. physicians spend more than 868 million hours annually on prior authorization activities—a trend that is only likely to continue (1). In my own practice, we have continued to hire additional full-time employees to support this process. Finding ways to educate payers, lawmakers, and physicians themselves about the AUC process and how they can hold down costs, improve treatment efficacy, and ensure patient safety is key to this effort, particularly given the new AUC mandate included in the Protecting Access to Medicare Act of 2014. Although the specifics still need to be ironed out, the provision will require all ordering professionals to consult with AUC through a clinical decision support mechanism for all Medicare patients receiving advanced imaging starting in January 2017.
To facilitate greater understanding and use of AUC, several years ago the ACC changed its original rating methodology of “appropriate,” “uncertain,” and “inappropriate” to “appropriate,” “may be appropriate,” and “rarely appropriate.” These recommendations were grounded in concerns over how the AUC would be applied with respect to the care for individual patients and the potential for misunderstanding about the ethical and legal implication of the current terms.
The ACC has also continued to grow its “Imaging in FOCUS” (FOCUS) initiative to help providers better understand their imaging practices, identify areas for improvement, and incorporate AUC at the point of care. Data from physicians in 30 different practices involved in FOCUS have shown a significant decrease in the proportion of single-photon emission computed tomography myocardial perfusion imaging tests not meeting appropriate use, from 11% to 5% in a cohort of more than 1,000 studies (2). Another study of 472 patients with suspected coronary artery disease found that the use of a real-time, multimodality decision-support tool, like that used in FOCUS, led to a reduction in inappropriate testing from 22% in the first 2-month period to 6% in the last 2 months (3). Similarly, a continuous quality improvement initiative has shown a significant effect on the utilization of coronary computed tomography angiography.
As a result of these successes, the College is expanding FOCUS beyond health plans and the current case-review tool to offer an ongoing subscription service directly to hospitals and practices that integrates AUC decision support directly into electronic health records for all noninvasive cardiac imaging. Although Maintenance of Certification Part IV has been suspended, the subscription service does allow practices to track AUC on a continual basis and then use the information as part of a quality improvement module that offers Maintenance of Certification Part IV credit and meets laboratory accreditation quality review standards. There are also opportunities to help eligible providers meet Physician Quality Reporting System requirements.
Moving forward, there may be opportunities to incorporate FOCUS into alternative payment programs, such as Accountable Care Organizations and episode- or global-based payment models. The College is looking forward to results from pilot efforts in several states that use FOCUS either as an RBM alternative, or as part of an alternative payment model. If successful, these programs could lead to greater collaborations with payers, hospitals, state medical societies, and other stakeholders.
Yet, despite what appear to be reasonable and “appropriate” AUC and AUC point-of-care tools such as FOCUS, physicians continue to be subject to prior authorization policies and RBM denials of what we believe are appropriate management strategies (imaging and procedures). This creates great difficulties as we try to advocate for our patients. Understanding and addressing claims denials and pre-authorization issues is a priority for ACC.
The ACC’s Board of Governors and state chapters are working on a solution that may include creating a reporting mechanism for denial and test substitutions to better advocate on behalf of our patients and members. First, we are approaching the RBMs to help us understand what is occurring from their perspective in terms of denial rates, prior authorization processes, variation, and best practice. Understanding what is being questioned and/or denied can help frame discussions with payers about appropriate care. If we determine that an insurance denial database is the right way to address the problem, and I believe this likely, we will need your help in collecting this data. There are apparently only a handful of RBMs being used nationally by all payers, and this information could be very useful in tracking patterns of denials and test substitutions. We are also having ongoing discussions with the Centers for Medicare and Medicaid Services, other medical societies, and others around the upcoming implementation of the AUC mandate. We are urging that our ACC AUC be used and included in the mandated Centers for Medicare & Medicaid Services rules and are quite hopeful that this will occur.
With a more cost-conscious and value-driven health care system, physicians need to continue taking the lead to assess the most effective uses of imaging to diagnose and manage common cardiovascular disease. Ultimately, our primary concern is to meet the triple aim of better quality, reduced costs, and improved outcomes. A study of ACC members a few years ago showed that the majority of health care providers view improved care delivery, education, and cost reduction as the primary benefits of AUC, with nearly 55% noting improved decision making by practitioners in day-to-day clinical care to be 1 of the biggest AUC benefits (3). As the field of medicine continues to change—as new drugs and devices enter the market, new research findings shed light on treatment practices both new and old, and new policies dictate how and when care is provided—ensuring that the benefits of AUC are understood and taken advantage of is more important than ever. The AUC will continue to evolve, and your ACC will continue to lead the way and advocate for optimal and cost-effective care for our patients.
More information on AUC efforts will be communicated via your state chapter. Information on FOCUS is available at ACC.org/FOCUS.
- 2015 American College of Cardiology Foundation
- ↵Terry K, Ritchie A, Marbury D, Smith L, Pofeldt E. Top 15 challenges facing physicians in 2015. Medical Economics. December 1, 2014. Available at: http://medicaleconomics.modernmedicine.com/medical-economics/news/top-15-challenges-facing-physicians-2015?page=full. Accessed July 23, 2015.
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