Appropriate use criteria (AUC) have been identified as a tool to reduce “inappropriate” imaging tests without intruding on the physician–patient relationship. In 2015, the American Society of Nuclear Cardiology (ASNC) and 16 other associations convinced policymakers to delay an AUC Medicare program until its requirements can be refined.   

Since the mid-2000s, AUC for advanced diagnostic imaging procedures have been developed in response to perceived overutilization with associated increases in costs. ASNC has been at the forefront of this effort to ensure that providers are referring patients for cardiac testing, and cardiologists furnishing these tests are performing the right tests in the right patients at the right times. ASNC participated in the American Board of Internal Medicine Foundation Choosing Wisely campaign to identify the top five times when stress tests should not be performed. This activity resulted in a pathway for all cardiology stakeholders, particularly payers, to reduce the number of less “appropriate” imaging tests while avoiding intrusions on the physician–patient relationship. The approach also maintains a “patient-centered” approach to cardiac imaging.

In 2015, the potential for AUC adherence to reduce costs led Congress to mandate creation of an AUC program under Medicare. Federal law requires the Centers for Medicare & Medicaid Services (CMS) to implement an AUC program for all

advanced diagnostic imaging testing. Beginning in January 2017, CMS will track utilization; its plan is to reimburse physicians who performed and interpreted advanced diagnostic imaging studies only if the providers who ordered the imaging services documented AUC using a clinical decision support (CDS) tool. On October 30, 2015, following advocacy efforts by an ASNC-led coalition of medical societies, CMS announced that it will delay the date when test-ordering practitioners will be expected to document AUC using a CDS mechanism because the agency will miss the statutory deadlines for specifying AUC for the program and identifying qualifying CDS tools.

Use of nuclear cardiology imaging procedures in the United States has been steadily declining since 2006, when the AUC were introduced (see Figure).  In theory, mandating AUC consultation for all advanced diagnostic imaging will allow Medicare to realize and capitalize on the early successes of AUC. This would be good for patients and good for Medicare. However, as the creators, proponents and educators of AUC, nuclear cardiologists have good reason to be cautiously optimistic as CMS attempts to roll out the new Medicare AUC program. Cumbersome or costly CDS tools will ultimately lead physicians, who may need to consult AUC for a wide range of conditions from stress tests for chest pain to magnetic resonance imaging for knee pain, to abandon employing AUC altogether and refer their patients for consultations rather than appropriate imaging tests. This could ultimately drive up costs rather than producing savings.

By CMS’s own admission, the AUC program designed by Congress is complex and massive, affecting nearly every physician specialty as well as primary care providers. If the program fails to deliver intended results, physicians, especially those who offer office-based imaging services, will be at risk for unwelcomed policy interventions, including required use of radiology benefit managers and removal of the Stark self-referral in-office ancillary exception.

Given the complexity of the law that CMS has been asked to implement, ASNC is pleased that CMS has recognized that more time is needed to work through critical aspects of the program as well as to develop and disseminate educational tools and resources to test-ordering professionals.

Before embarking on this AUC program, there are lessons to be taken from the electronic health record (EHR) Meaningful Use efforts. Prior to establishment of Meaningful Use, physicians had begun to acquire and implement EHRs in their practices because they understood their potential to improve care delivery. Today, according to the American Medical Association, more than 80 percent of physicians use EHRs but only 12 percent have successfully participated in Stage 2 of Meaningful Use due to onerous program requirements. 

CMS must ensure that the AUC program is not onerous for the physicians who are expected to use it, and program components must be carefully considered and, if possible, tested so the goals of the program, as envisioned by its congressional authors, can be achieved.  

Brian Abbott, MD, is the 2016 president of the American Society of Nuclear Cardiology, an associate professor of medicine at the Warren Alpert Medical School of Brown University and co-director of cardiovascular imaging at the Cardiovascular Institute of the Miriam and Newport Hospitals in Providence, R.I.