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What Does CMS’ Delay in its Imaging Order Mandate Really Mean?

November 13, 2015
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Could CMS’s Nov. 11 announcement of a delay in the implementation of a mandate around diagnostic imaging test ordering erode provider confidence?

Yesterday, the online publication reported that the federal Centers for Medicare & Medicaid Services (CMS) had announced an indefinite delay in a deadline the agency had set for referring physicians to use clinical decision support (CDS) tools based on appropriate-use criteria (AUC) in ordering diagnostic imaging tests.

As AuntMinnie’s Erik L. Ridley noted in the report, “In an announcement included in the final rule of the Medicare Physician Fee Schedule (MPFS) on October 30, CMS indicated that it now doesn't expect to have approved CDS ‘mechanisms’ until approximately the summer of 2017. The agency said it was not yet in a position to predict the exact timing of a new deadline for when practitioners are expected to begin utilizing clinical decision support.”

As Ridley noted, the mandate was part of the Protecting Access to Medicare Act (PAMA) signed into law by President Obama in April 2014. That mandate required “that physicians utilize appropriate use criteria via clinical decision support for ordering advanced imaging studies such as diagnostic MRI, CT, and nuclear medicine (including PET). X-ray, fluoroscopy, and ultrasound exams were excluded. The appropriate use criteria requirements also only apply to outpatient settings such as physician offices, hospital outpatient departments, ambulatory surgical centers, and any provider-led outpatient setting.”

Already, many physicians in practice were beginning to gear up to meet the new mandate, as medical associations and trade publications (including this one) urged them to get ahead of the curve and start soon to implement clinical decision support systems incorporate the appropriate-use criteria.

But now, CMS officials have put the brakes on this train. And though what might perhaps be a six-month delay would be, in the larger scheme of things, not that long a delay, particularly in the context of so many federal regulatory mandates affecting healthcare providers, it nonetheless would be delay; and based on the CMS announcement this week, there clearly will be some delay.

What could be happening? The simplest explanation is that the mechanics of all this are taking longer than expected. And in fact, that is also the likeliest explanation. At the time, shouldn’t CMS officials have anticipated the dimensions of the work involved in architecting the details of this mandate?

One would think so. On the other hand, what has been demonstrated in the past few years is that time and time again, the sheer complexity of federal regulatory development in healthcare has stymied and intimidated federal officials. The classic phrase “the devil is in the details” readily comes to mind.

This situation reminds me in part of the delays around the transition to the new ICD-10 coding system (even as some of those were caused by congressional meddling, not CMS hesitations), and in part, of the challenges that have bedeviled the Pioneer ACO Program. The situations are all different, of course; yet in every case, there has been at least some level of confusion involved on the part of healthcare providers, and some level of frustration coming out of the delays—whoever or whatever caused them.

With regard to this situation specifically, it would be good to acknowledge that a complex, nuanced set of issues is involved here (as usual in such cases), and that further, it is more important in the long run to get this right rather than to move quickly. In this case in particular, one wants to incent ordering physicians to do the right things and not to do the wrong things, of course; and for that to happen, all the levers and calibrations must be precise.

But I also wonder whether this delay will add just one more little erosion of confidence to what is already a bushel basket full of such erosions, on the part of healthcare providers, and most especially on the part of physicians in practice. Physicians are already broadly resentful of so much of what federal officials are asking them to do, even when doctors agree with the broad principles involved.

In this case, there will probably be widespread relief, one must concede. At the same time, it would be good if federal officials could estimate correctly the timing involved in these mandates, so as to engender the maximum amount of confidence on the part of providers. I remember when the first of a few ICD-10 transition delays was announced, speaking with the CIO of a community hospital system in the Midwest, who expressed frustration that she and her team had hurried to prepare for the transition deadline, only to see the dawdlers rewarded by the first of what turned out to be a few delays. Let’s hope that there isn’t a similar feeling in this case (while conceding that such a feeling is likely to be less widespread here).

I applaud CMS officials for the principles involved in what they’re doing with this mandate, based on legislation passed by Congress and signed into law by the President. I just hope that this delay does not add to a sense of eroding confidence in the industry that has attended developments like this around other mandates, in the recent past. Only time will tell, particularly as we wait to find out exactly how long the delay in the imposition of the mandate will be.