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Launching the CMS AUC program: why providers may need to start yesterday

Kevin McDermott

Kevin McDermott, Vice President and General Manager of Provider Strategy and Products



Scott Cowsill

Scott Cowsill, Senior Director of Integrated Preauthorization and Clinical Decision Support



As part of the Protecting Access to Medicare Act of 2014 (PAMA), CMS was directed to establish a program to promote appropriate use criteria (AUC) for outpatient advanced imaging. The goal of the program is to improve the quality of care and reduce inappropriate imaging for Medicare fee-for-service beneficiaries. The CMS AUC program requires providers to consult CMS-qualified clinical decision support tools, or mechanisms, for high-tech imaging studies. Providers must begin to comply starting January, 2020.

With the launch of the CMS AUC program imminent, Kevin McDermott and Scott Cowsill sat down to talk about the program, why some providers are arriving a bit late to the party, and the future of clinical decision support.


How do the Centers for Medicare and Medicaid Services (CMS) shape health care policy for Medicare?

Kevin: There's really two primary areas that CMS impacts: benefit coverage and reimbursement methodologies. On the benefit side, CMS manages what’s covered under Medicare. It also sets reimbursement policies for hospitals, for physicians, etc.

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“As the largest payer in the US, CMS sets the standard that is used to determine reimbursement across our entire health system” according to Kevin McDermott.

CMS also really sets the standard that is used to determine reimbursement across our entire health system. Because it’s the largest payer in the US, much of the commercial insurance market follows Medicare to determine how they structure their own benefit coverages and reimbursement methodologies, typically paying a percentage or premium on those. In turn, providers look at that in their reimbursement mix. What am I getting paid relative to Medicare? They use Medicare reimbursement as a benchmark to evaluate and negotiate commercial contracts with commercial payers.



Scott: Looking at it from a different angle, when our federal government passes a law like the PAMA legislation, they don't pass it with a written recipe for exactly how CMS is to implement it. A law is passed outlining criteria that needs to be met. CMS doesn't have free reign, but has an “artistic license” to determine how to deploy and enact the passed laws. The opinions of stakeholders in the industry like payers, clinicians, and patient, definitely help influence how they shape policy.



So, what is the CMS Appropriate Use Criteria program?

Scott: The CMS Appropriate Use Criteria (AUC) program, in my opinion, is our government's approach towards realizing the many benefits that have been demonstrated over the last several decades in the private sector with commercial payer prior authorization programs. The CMS AUC program came about to give provider’s easy online access to clinical decision support (CDS) tools that support evidence-based medicine. The requirement is for providers to consult one of the CMS-approved tools, or in CMS terms “mechanisms”, when ordering outpatient high-tech diagnostic imaging studies for Medicare fee-for-service (FFS) beneficiaries. It stops short of requiring providers to follow the recommendations of the mechanisms, however, at least for now. In many ways, the evolution of the CMS AUC program has helped the commercial prior authorization market advance and enhance the data exchange relationship that we have with providers, as we now have EMR integrated workflow solutions.

Kevin: I think at a market level, it's really CMS dipping their toes into the prior authorization water. How the program goes on many levels including financially, administratively, and the general market reaction will determine whether CMS moves to a more aggressive program three to five years from now.

How will the AUC program impact providers?

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Who will be impacted by the AUC program? “Almost every provider in the United States”, says McDermott, pointing to the 37 million lives covered.

Kevin: It will impact them tremendously. Almost every provider in the United States sees Medicare FFS patients, whether they’re hospitals, physicians, or ancillary clinical providers, and order or perform high-tech imaging in an outpatient setting, which is the scope of the AUC program. They all will have to use one of the CMS-qualified clinical decision support (CDS) mechanisms and receive a clinical decision support number in order to be compliant. They must also include the number on both technical and professional claims for payment.

Medicare covers approximately 37 million lives nationwide. Due to sheer volume, providers may need to hire additional staff to comply with this program, or they may choose a mechanism that connects into their EMR, simplifying the workflow to a large degree. The size of the organization will determine which path they take.

Of course, most often one provider orders an imaging study, and another performs it: a hospital, an imaging center, etc. The onus is on the ordering provider by law and by the CMS mandate to consult a qualified CMS AUC mechanism, receive a clinical decision support number, and pass it along to the imaging facility who ultimately will bear the financial risk if the process is not followed and the study provided is not in compliance.

Scott: I agree the program will impact providers significantly. But to the extent they choose a solution that closely parallels their current workflow, a positive impact would be high-quality patient care. The objective of the program is to make evidence-based medicine more accessible and easier to use for clinicians, so that they can provide the best possible care to their patients in the least disruptive manner.

How do clinical decision support programs like the CMS AUC program affect provider decision-making?

Kevin: It really depends on the workflow and the actors. When the preliminary rule on the CMS AUC program came out, Medicare was very clear that the actor in the program would be the ordering clinician. They would be the ones that would go into the tool, go through the appropriate use criteria, and get a determination. If implemented in that way, the CMS AUC program may have had a tremendous impact on provider decision-making. However, Medicare has now softened the rules to allow other personnel under the direction of the ordering clinician to get the determination, so the ordering clinician may not have the kind of direct involvement needed to influence decisions.

Plus, unlike payer prior authorization programs, with CDS programs there's no denial issued and no peer-to-peer consultation available when a study is found to be inappropriate. Providers can still continue to do the study. CMS' goal in its AUC program is for providers to respond to the appropriateness criteria, reducing the overall utilization, and cost curve. We'll see if that happens with this softer model.

Scott: In a perfect world, my answer would be I hope that clinical decision support would have little to no impact on provider decision-making, because then we could ascertain that providers are ordering appropriately the majority of the time. However, data shows that there's a giant delta between what medical evidence demonstrates is appropriate and what's actually being ordered.

At what point do providers need to look for a vendor to help them ensure that they're compliant with the Medicare AUC program?

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Although the date to implement it is around the corner, about half of providers remain unaware of the CMS AUC program, says Scott Cowsill.

Scott: Yesterday (laughs). I've been following this legislation a long time, and at conferences when the question was asked, "How many of you know about the PAMA mandate?", only three hands would go up out of 500 attending. Over the last two to three years, it's gone from less than ten percent to around 50 to 65 percent of people who actually know what it is. But that means about half are still not aware, and we're only a year out from the go-live date for the mandate. So there's no better time than now for providers to start looking at how they’re going to solve this for their organization.

Kevin: Most of the market hasn't moved into decision-making yet, but they should. If you think about it, especially for those that want the EMR integration, there's really only a few viable vendors. Vendors that health systems will feel confident working with--that have history, have a customer base, have financial security--will likely be in high demand. With thousands of health systems around the country needing to implement by the January 1, 2020 start date, right now is the time to align with a vendor and schedule implementation.




With that said, how is AIM helping providers comply with the Medicare AUC program?

Kevin: AIM is one of the qualified CDS mechanisms identified by CMS. With our AIM Inform product, we're bundling the CMS AUC program capability to parallel the workflow of our radiology prior authorization program for commercial payers, and we’re making the bundle available through provider EMR systems. Combining programs in this way can really reduce the time it takes to comply with both. So that's a big win. AIM is one of only a few vendors in the market that can do that. Plus, our provider satisfaction rating has been a very high 93% or greater year after year--so we’re confident that a majority of providers prefer the usability of AIM programs to those of our competitors.

For those who prefer not to integrate with their EMR, or just want to explore getting started, we offer a free CMS AUC tool live on our ProviderPortalSM. It’s live now and available to any provider in the US to begin submitting orders for the CMS program. Just in its first week, we had almost 2,500 orders processed. Since the program doesn’t start until January 1, 2020, it seems clear that providers are really curious about it and want to start getting familiar with it.

Scott: Logistically speaking, I'd say to all our AIM customers and AIM users out there that we’re here for you. This is what we do. We wanted to make this an easy program, a seamless program, and a user-friendly program for all the people that we service across the country right now.



With the CMS AUC program in effect, do you see health plan prior authorization programs going away?

Kevin: No. First of all, this program is focused only on the Medicare fee-for-service population. It doesn’t apply to the Medicare Advantage population that’s serviced by commercial payers. Therefore, the program doesn't impact payer cost of care.

Second, there's very little evidence in the market that demonstrates that the use of CDS tools like those the CMS AUC program requires actually bends the cost curve. CDS tools give feedback, and tell doctors whether clinicians’ orders are appropriate or not, but it doesn't necessarily reduce the volume of inappropriate studies ultimately being scheduled and ordered. Thus far, the CDS market has been highly fragmented, and as a result, there’s been no national scale to show these kinds of programs work to reduce costs or eliminate inappropriate care. So health plans will likely stay with their tried and true prior authorization programs for the foreseeable future.

The only area that I've seen health plans look to ease prior authorization requirements is for providers that are taking on the financial risk of their patients. Like ACOs, for example.

You’ve probably got things to add to that, right Scott?

Scott: Definitely. One thing is there's obviously distinct differences between clinical decision support tools and prior authorization programs. And one of the things that prior authorization programs do in the commercial space, that clinical decision support tools do not do, is combine clinical appropriateness review with a check against the medical policies of the payers that we serve.

So I don't see prior authorization programs going away because these programs are able to manage clinical appropriateness and medical policy. In the future, I can imagine the CMS AUC becoming more like commercial prior authorization programs in this way while utilizing the more streamlined, integrated, technical platform delivery approach.

What does the future of clinical decision support and prior authorization look like?

Scott: This one is easy for me and I think it would resonate with anyone that's affiliated with clinical decision support or prior authorization, and that is that I haven't met many, if any, clinicians that would argue against practicing evidence-based medicine. Providers may prefer not to do payer prior authorizations for a variety of reasons, however, nobody is arguing that the clinical algorithms that support these programs are leading them down some bad path of practicing medicine.

So what I've come to learn is that it's not the practice of evidence-based medicine that's a burden, but the means by which providers access the evidence can be cumbersome. And so in the future, what I see is a hybrid that takes seamless integration efficiencies of many available clinical decision support tools, and brings it to payer prior authorization. If we make the process that much easier, integrating it into provider workflows, putting it right at the point of care, then all of a sudden there really isn't that perceived burden. That’s what we've done with AIM Inform by streamlining both the clinical decision support for the CMS AUC program and payer prior authorization.

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In the future, “we’re going to see multiple stakeholders align into a more common experience and workflow” according to McDermott. “Here at AIM, we've put CMS AUC and payer prior authorization right in front of physicians in their EMRs, so they can get determination at point of care,” offered Cowsill as an example of this more streamline approach to provider workflow.

Kevin: I really think what we're going to see in the future is multiple stakeholders align into a more common experience and workflow. This will probably be driven by the large EMR vendors. Payer prior authorization workflow is one of the top three issues that they're trying to solve for their client base. They are looking to make it easier to process prior authorizations within the EMR workflow. Eventually they will figure out how to make a streamlined data integration workflow and get the right data in between all the interoperability standards and interfaces that are out in the market. Then the payers and the vendors, like AIM, will align to those standards more commonly. Ultimately, it will be much easier to plug into the workflow regardless of vendor or health plan. Integrating into the clinician and facilities workflow will make it easy for providers to comply.

Scott: That makes me think of something else that I say all the time, and I think this is the key differentiating factor for the future, and that is that clinical decision support needs to be three things: consumable, timely, and actionable. By changing its place in the workflow, it becomes those things.

So regarding consumable, there's a lot of sources of evidence-based medicine content out there. But if it's not all codified into one unit or platform where it can be consumed by a user then what good is it? You have to be able to access it.

It also has to be timely. Currently, the patient and the physician aren't together when the payer prior authorization process takes place. Here at AIM, to make it timely, we've put CMS AUC and payer prior authorization right in front of them in the EMR, so they can get determination at the point of care.

The last thing is it has to be actionable. It certainly doesn’t help a clinician to find out whether a test or procedure is appropriate or not if it's four days after they’ve seen the patient. Our platform provides immediate feedback to the ordering clinician and offers them the opportunity to modify their clinical decision at the point in the delivery continuum where it has the most impact. They can take action right then, and choose to change, withdraw, or continue based on the response provided.

What advice would you give to the providers and health systems out there that are seeking to comply with this mandate, other than start now? What should they do next? How do they start?

Kevin: We recently developed a starter guide. It’s a step-by-step approach on how to find the right fit for your organization to identify and select a CDS mechanism vendor for the AUC program. We'll also be releasing our Provider's Handbook to the CMS Appropriate Use Criteria Program in the upcoming weeks.

Scott: This mandate isn't going away, no matter what other things you have on your plate. The sooner you can get started, the better. You can't be afraid of it, you have to embrace it. If you don't know anything about it, find out as much as you can. So, start now would be number one. And number two would be you'll need to find a solution, whatever that solution may be, and it must fit your organization's culture and logistical workflows.

Learn more about AIM Inform and the CMS AUC Program:

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Contact Scott Cowsill directly

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Sign up to receive our Provider’s Handbook to the CMS Appropriate Use Criteria Program

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Gain payment clarity at the point of care with AIM Inform Integrated into the EMR systems that your clinicians use every day, AIM Inform enables completion of health plan prior authorizations for outpatient advanced imaging and compliance with the CMS Appropriate Use Criteria Program from a single source. As a result, your patients receive quality care at the right time, and you achieve real-time payment clarity and clinical determination.