A Computer Program Could Determine Your Medicare Coverage Beginning This Year

Trump standing in front of MRI; halts plan to reduce unneeded diagnostic imaging

This article was updated on January 10, 2020. The update can be found at the bottom of the article. 

Diagnostic imaging (like MRI and CT scans) are notoriously expensive, ranging between $400 and $3,500. For this reason, Congress passed a law in 2014 that aimed to reduce the number of unnecessary scans and other expensive diagnostic tests that could harm patients and waste money. Trump pushed pause on implementing the protocol, but it will go into effect in 2020 as a trial run, with full implementation in 2021. 

The protocol 

The Protecting Access to Medicare Act (PAMA) of 2014 states that patients are required to receive prior authorization for imaging services like CT, PET, and MRI scans before Medicare will provide coverage. However, a computer program called a Clinical Decision Support Mechanism (CDSM) determines if the scan will be approved for coverage. According to the Centers for Medicare and Medicaid Services (CMS), a CDSM “assists [doctors] in making the most appropriate treatment decision for a patient’s specific clinical condition.”

If a doctor does not follow this protocol, they could be penalized. The penalty amount will not be determined until 2022 or 2023. 

In defense of the protocol, Seema Verma, administrator for CMS said in an email to Kaiser Health News, “It takes four clicks on a computer.” 

Once initiated, this new law will only apply to beneficiaries with Original Medicare (Part A and Part B). Medicare Advantage plans provided by private insurers have long required prior authorization before a patient receives expensive diagnostic imaging. This protocol can be risky for patients, though, as it can often delay diagnosis and treatment for several weeks or months. 

How common is unnecessary diagnostic imaging?

Doctors may order unnecessary tests for several reasons, like:

  • Increasing the price of their services,
  • Minimizing the possibility of malpractice suits, and
  • Appeasing insistent patients. 

One 2011 study from Harvard found “widespread overuse” of diagnostic imaging for men who were at very low risk of developing prostate cancer. 

Another study from the University of Washington reviewed 459 MRI and CT scans at an academic medical center. The researchers found that 26 percent of the scans were deemed unnecessary. 

In 2011, Seattle instituted a similar protocol at Virginia Mason Health System in which fellow doctors consulted on necessary imaging. The protocol dropped MRIs for common complaints like lower back pain and headaches by 23 percent. 

What are the downsides?

Dr. Craig Blackmore, a radiologist with Virginia Mason Health System, said he fears doctors will avoid ordering necessary diagnostic imaging because they have not received proper training in the new protocol and do not understand it. 

“My fear is that it will be a huge disruption in workflow and show no benefit,” he said. 

The American College of Radiology lobbied for the law in 2014 and has been trying to pass imaging guidelines since the 1990s. 

UPDATE

CMS has released a statement on its website noting that the protocol will go into effect in 2020, but it will only be a trial year. During this time, doctors are encouraged to learn, test, and prepare to use the protocol. During the trial period, doctors will not be fined if they do not use the protocol or use it improperly. The protocol will be fully implemented and mandatory beginning January 1, 2021.


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