Skip to main content

04.11.2019 | Editor's Page

PAMA implementation: The road ahead

verfasst von: Rami Doukky, MD, MSc, FASNC

Erschienen in: Journal of Nuclear Cardiology

Einloggen, um Zugang zu erhalten

Excerpt

As of January 1, 2020, the Centers for Medicare and Medicaid Services (CMS) has implemented §218(b) of the Protecting Access to Medicare Act (PAMA) of 2014. The law was enacted by Congress to minimize the use of rarely appropriate advanced diagnostic imaging studies (radionuclide imaging, magnetic resonance imaging, and computed tomography) provided to Medicare beneficiaries.1 Under this program, at the time a practitioner orders an advanced diagnostic imaging study for a Medicare beneficiary, he/she will be required to consult a qualified Clinical Decision Support Mechanism (CDSM). CDSMs are electronic portals through which appropriate use criteria (AUC) are accessed. The CDSM provides a determination of whether the order adheres to AUC, or if the clinical scenario was not addressed by AUC. A consultation must take place at the time of the order for imaging services to be paid by Medicare. Ultimately, practitioners whose ordering patterns are considered “outliers” will be subject to prior authorization. Definition of “outliers” and methodology of prior authorization have not yet been established. This program impacts all practitioners who order advanced diagnostic imaging studies, regardless of specialty, as well as physicians and facilities that furnish advanced diagnostic imaging services in any setting, whether their claims are paid under the physician fee schedule or Hospital Outpatient Prospective Payment System (HOPPS).1 Since July 1, 2018, this program has been operating under a voluntary participation period. As of January 1, 2020, the program has entered an “Education and Operations Testing Period,” during which claims will not be denied for failing to include proper AUC consultation information. The program is set to be fully implemented on January 1, 2021, which means AUC consultations using qualified CDSMs are required, along with reporting of this information on the professional and technical claims for the advanced diagnostic imaging service. Claims that fail to comply will not be paid. CMS finalized 8 “Priority Clinical Areas” which will be used to benchmark providers according to their utilization of rarely appropriate imaging studies.1 Since known or suspected coronary artery disease evaluation is a priority clinical area, the vast majority of cardiac imaging studies will be subject to the initial roll-out of the AUC mandate. Furthermore, CMS has identified qualified “Provider Led Entities” (professional organizations) which have developed or endorsed applicable AUC.1 The AUC developed by the American College of Cardiology (ACC), the American Society of Nuclear Cardiology (ASNC), and many other professional societies are among those approved by CMS.2 As a result of PAMA implementation, there will be a massive shift wherein the burden of reducing inappropriate use will move largely from payers to providers. Most physicians are unprepared for this paradigm shift. …
Literatur
2.
Zurück zum Zitat Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;63:380–406.CrossRef Wolk MJ, Bailey SR, Doherty JU, Douglas PS, Hendel RC, Kramer CM, et al. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2014;63:380–406.CrossRef
3.
Zurück zum Zitat Brindis RG, Douglas PS, Hendel RC, Peterson ED, Wolk MJ, Allen JM, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005;46:1587–605.CrossRef Brindis RG, Douglas PS, Hendel RC, Peterson ED, Wolk MJ, Allen JM, et al. ACCF/ASNC appropriateness criteria for single-photon emission computed tomography myocardial perfusion imaging (SPECT MPI): A report of the American College of Cardiology Foundation Quality Strategic Directions Committee Appropriateness Criteria Working Group and the American Society of Nuclear Cardiology endorsed by the American Heart Association. J Am Coll Cardiol. 2005;46:1587–605.CrossRef
4.
Zurück zum Zitat Doukky R, Hayes K, Frogge N. Are cardiologists truly better at appropriately selecting patients for stress myocardial perfusion imaging? Int J Cardiol. 2014;176:285–6.CrossRef Doukky R, Hayes K, Frogge N. Are cardiologists truly better at appropriately selecting patients for stress myocardial perfusion imaging? Int J Cardiol. 2014;176:285–6.CrossRef
5.
Zurück zum Zitat Doukky R, Hayes K, Frogge N, Nazir NT, Collado FM, Williams KA. Impact of insurance carrier, prior authorization, and socioeconomic status on appropriate use of SPECT myocardial perfusion imaging in private community-based office practice. Clin Cardiol. 2015;38:267–73.CrossRef Doukky R, Hayes K, Frogge N, Nazir NT, Collado FM, Williams KA. Impact of insurance carrier, prior authorization, and socioeconomic status on appropriate use of SPECT myocardial perfusion imaging in private community-based office practice. Clin Cardiol. 2015;38:267–73.CrossRef
6.
Zurück zum Zitat Doukky R, Frogge N, Appis A, Hayes K, Khoudary G, Fogg L, et al. Impact of appropriate use on the estimated radiation risk to men and women undergoing radionuclide myocardial perfusion imaging. J Nucl Med. 2016;57:1251–7.CrossRef Doukky R, Frogge N, Appis A, Hayes K, Khoudary G, Fogg L, et al. Impact of appropriate use on the estimated radiation risk to men and women undergoing radionuclide myocardial perfusion imaging. J Nucl Med. 2016;57:1251–7.CrossRef
7.
Zurück zum Zitat Doukky R, Hayes K, Frogge N. Appropriate use criteria for SPECT myocardial perfusion imaging: Are they appropriate for women? J Nucl Cardiol. 2016;23:695–705.CrossRef Doukky R, Hayes K, Frogge N. Appropriate use criteria for SPECT myocardial perfusion imaging: Are they appropriate for women? J Nucl Cardiol. 2016;23:695–705.CrossRef
8.
Zurück zum Zitat Doukky R, Hayes K, Frogge N, Balakrishnan G, Dontaraju VS, Rangel MO, et al. Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging. Circulation. 2013;128:1634–43.CrossRef Doukky R, Hayes K, Frogge N, Balakrishnan G, Dontaraju VS, Rangel MO, et al. Impact of appropriate use on the prognostic value of single-photon emission computed tomography myocardial perfusion imaging. Circulation. 2013;128:1634–43.CrossRef
9.
Zurück zum Zitat Elgendy IY, Mahmoud A, Shuster JJ, Doukky R, Winchester DE. Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis. J Nucl Cardiol. 2016;23:680–9.CrossRef Elgendy IY, Mahmoud A, Shuster JJ, Doukky R, Winchester DE. Outcomes after inappropriate nuclear myocardial perfusion imaging: A meta-analysis. J Nucl Cardiol. 2016;23:680–9.CrossRef
10.
Zurück zum Zitat Hayes-Brown K, Frogge N, Doukky R. The impact of appropriate use on the cost effectiveness of SPECT myocardial perfusion imaging in the community setting. J Am Coll Cardiol. 2014;63(12 Supplement):A1222.CrossRef Hayes-Brown K, Frogge N, Doukky R. The impact of appropriate use on the cost effectiveness of SPECT myocardial perfusion imaging in the community setting. J Am Coll Cardiol. 2014;63(12 Supplement):A1222.CrossRef
11.
Zurück zum Zitat Malhotra S, Doukky R. Differential impact of appropriate use criteria on the association between age and an abnormal stress myocardial perfusion SPECT. Cardiovasc Innov Appl. 2019;4:63–9.PubMedPubMedCentral Malhotra S, Doukky R. Differential impact of appropriate use criteria on the association between age and an abnormal stress myocardial perfusion SPECT. Cardiovasc Innov Appl. 2019;4:63–9.PubMedPubMedCentral
12.
Zurück zum Zitat Hendel RC. The value and appropriateness of positron emission tomography: An evolving tale. J Nucl Cardiol. 2014;22(1):16–21.CrossRef Hendel RC. The value and appropriateness of positron emission tomography: An evolving tale. J Nucl Cardiol. 2014;22(1):16–21.CrossRef
13.
Zurück zum Zitat Lin FY, Dunning AM, Narula J, Shaw LJ, Gransar H, Berman DS, et al. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: A prospective multicenter study. J Am Coll Cardiol. 2013;62:308–16.CrossRef Lin FY, Dunning AM, Narula J, Shaw LJ, Gransar H, Berman DS, et al. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: A prospective multicenter study. J Am Coll Cardiol. 2013;62:308–16.CrossRef
14.
Zurück zum Zitat Tilkemeier PL, Bourque J, Doukky R, Sanghani R, Weinberg RL. ASNC imaging guidelines for nuclear cardiology procedures: Standardized reporting of nuclear cardiology procedures. J Nucl Cardiol. 2017;24:2064–128.CrossRef Tilkemeier PL, Bourque J, Doukky R, Sanghani R, Weinberg RL. ASNC imaging guidelines for nuclear cardiology procedures: Standardized reporting of nuclear cardiology procedures. J Nucl Cardiol. 2017;24:2064–128.CrossRef
16.
Zurück zum Zitat Doukky R, Diemer G, Medina A, Winchester DE, Murthy VL, Phillips LM, et al. Promoting appropriate use of cardiac imaging: No longer an academic exercise. Ann Intern Med. 2017;166(6):438–40.CrossRef Doukky R, Diemer G, Medina A, Winchester DE, Murthy VL, Phillips LM, et al. Promoting appropriate use of cardiac imaging: No longer an academic exercise. Ann Intern Med. 2017;166(6):438–40.CrossRef
17.
Zurück zum Zitat Winchester DE, Wolinsky D, Beyth RJ, Shaw LJ. Discordance between appropriate use criteria for nuclear myocardial perfusion imaging from different specialty societies: A potential concern for health policy. JAMA Cardiol. 2016;1:207–10.CrossRef Winchester DE, Wolinsky D, Beyth RJ, Shaw LJ. Discordance between appropriate use criteria for nuclear myocardial perfusion imaging from different specialty societies: A potential concern for health policy. JAMA Cardiol. 2016;1:207–10.CrossRef
Metadaten
Titel
PAMA implementation: The road ahead
verfasst von
Rami Doukky, MD, MSc, FASNC
Publikationsdatum
04.11.2019
Verlag
Springer International Publishing
Erschienen in
Journal of Nuclear Cardiology
Print ISSN: 1071-3581
Elektronische ISSN: 1532-6551
DOI
https://doi.org/10.1007/s12350-019-01942-2

Herzstillstand nach Energy-Drinks

18.06.2024 Plötzlicher Herztod Nachrichten

Energy-Drinks können sich in Kombination mit anderen Risikofaktoren offenbar zu einem „perfekten Sturm“ zusammenbrauen, der schlimmstenfalls in einen plötzlichen Herzstillstand mündet. Sieben solcher Fälle schildert ein auf Rhythmusstörungen spezialisiertes US-Team.

Schleifendiuretikum ohne Herzinsuffizienz? Verordnung hinterfragen!

18.06.2024 Diuretika Nachrichten

Werden Schleifendiuretika häufig ohne sorgfältige Diagnostik verschrieben? Eine Kohortenstudie aus Schottland scheint darauf hinzudeuten.

Was eine zu kleine Klappe für die Langzeitprognose bedeutet

18.06.2024 Aortenklappenersatz Nachrichten

Stellt sich nach der Implantation eines biologischen Aortenklappenersatzes die Prothese als zu klein für den Patienten heraus, hat das offenbar nur geringe Auswirkungen auf Langzeitüberleben und Reoperationsrisiko; zumindest solange die effektive Öffnungsfläche über 0,65 cm2/m2 liegt.

Vorteile für Blutdruckselbstmanagement

18.06.2024 Hypertonie Nachrichten

Kontrollieren Hypertoniker ihren Blutdruck regelmäßig selbst, und passen sie entsprechend eigenständig ihre Antihypertensivadosis an, wird der Blutdruck um etwa 3 mmHg stärker gesenkt als unter dem üblichen ärztlichen Therapieplan.

Update Kardiologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.