Appropriate Use of CV Diagnostic Imaging: Bridging the Past, Present and Future

Illustration: Lee Sauer

Introduction | The Genesis of AUC | Medicare and AUC | Medicare Drops the AUC Requirement | Why Stick With AUC? | Conclusion | Related Resources

Introduction

In the dynamic field of cardiovascular care, the concept of appropriate use criteria (AUC) has been a beacon guiding the judicious use of diagnostic testing. AUC are developed to provide guidance to clinicians deciding when it's most beneficial to use certain diagnostic tests. This blog dives into the world of AUC, exploring its history, its connection to Medicare requirements, the recent Medicare changes, and why, despite these changes, AUC remain a critical tools in the decision-making toolkit of cardiology programs.

The Genesis of AUC

The inception of AUC marked a pivotal moment in the effort to address a growing concern within the healthcare system: the overutilization of diagnostic tests. Unnecessary diagnostic testing not only imposed financial strains on the healthcare system but also subjected patients to potential risks without corresponding benefits. Recognizing the urgency of this issue, leading cardiology societies, including the American College of Cardiology (ACC), spearheaded the development of AUC with the objective of establishing evidence-based guidance to inform clinical decision-making about cardiovascular diagnostic testing.

AUC were designed to answer critical questions regarding “when” and “how often” specific diagnostic tests should be employed, considering the individual patient's condition, the healthcare environment and the clinician's judgment. This approach aimed to ensure that each patient received the right test at the right time, optimizing patient care by eliminating unnecessary procedures.

The development of AUC was a detailed and collaborative process, involving experts from the ACC and other cardiovascular specialty societies. These experts reviewed the latest scientific evidence and combined it with their clinical experience to create practical and grounded guidance for clinicians, based on the most current knowledge. AUC were structured to be comprehensive, covering a broad spectrum of cardiovascular conditions and diagnostic tests, including echocardiography, nuclear imaging, stress tests and more. This breadth ensured that the AUC could be a valuable resource, applied to a wide range of clinical scenarios across cardiovascular care.

Over the years, AUC have undergone continuous refinement and expansion to keep pace with the advances in medical science and changes in clinical practice. New evidence and technologies have been incorporated into the documentation, ensuring relevance and effectiveness. This ongoing process of review and update has been critical to writing committees' successful response to the progressive nature of cardiovascular medicine.

The AUC's impact on outpatient care and healthcare efficiency has been significant. By promoting the appropriate use of diagnostic tests, the AUC have helped to improve the accuracy of diagnosis, enhance patient safety and reduce healthcare costs. They have also served as a framework for evaluating care patterns and helping identify areas where improvements can be made. The adoption of AUC has not only improved quality of individual patient care but also enhanced the overall outcomes of cardiovascular healthcare.

Medicare and AUC: A Tangled Tale

The complex relationship between Medicare and AUC underscores the challenges of integrating evidence-based clinical documents into the fabric of the national healthcare system. The Protecting Access to Medicare Act (PAMA) of 2014 marked a significant milestone in this journey, introducing a mandate to align the use of advanced diagnostic imaging with the principles of the AUC. This legislation required clinicians to consult AUC through a clinical decision support mechanism (CDSM) when ordering advanced diagnostic imaging services, such as CT, MRI and PET, for Medicare beneficiaries.

The rationale behind this mandate was multifaceted. Primarily, it sought to enhance the quality of care provided to patients by ensuring that diagnostic imaging was used judiciously and appropriately based on the latest clinical evidence and guidelines. Additionally, by promoting the use of AUC, the mandate aimed to optimize healthcare resources, reducing unnecessary testing and associated costs. This approach was seen as a critical step towards fostering a more efficient and effective healthcare system and prioritizing patient outcomes and value-based care.

However, the path to implementing the PAMA mandate has been fraught with challenges. One of the initial hurdles was developing and integrating CDSMs into the clinical workflow. CDSMs are sophisticated tools that provide clinicians with access to AUC information at the point of care, enabling them to make informed decisions about diagnostic imaging. The requirement to use CDSMs represents a significant change in practice for many healthcare providers, necessitating adjustments to electronic health records systems, clinicians' training and administrative processes.

Moreover, the timeline for implementing the AUC mandate has been subject to multiple delays and extensions. These delays were attributed to various factors, including the need for additional time to develop and test CDSMs, challenges in integrating these systems into existing healthcare IT infrastructure, and the need for extensive education and outreach to ensure clinicians were prepared to comply with the new requirements. The educational and operational testing period, initially envisioned as a phase to familiarize clinicians with the AUC and CDSM requirements, was extended several times due to the complexities involved in implementing such a significant change across the healthcare system.

Despite these challenges, the intent behind the Medicare AUC mandate remains clear: to leverage evidence-based clinical documents like guidelines and AUC to improve the quality and efficiency of care for Medicare beneficiaries. The journey toward fully implementing the AUC mandate illustrates the integrated balance between advancing healthcare policy and navigating the practical realities of changing clinical practice period. As the healthcare community continues to work towards the full realization of this mandate, the lessons learned from this experience will undoubtedly inform future efforts to integrate evidence-based clinical documents into decision-making on a national scale.

The Plot Twist: Medicare Drops the AUC Requirement

The journey of integrating AUC and two Medicare frameworks took an unexpected turn when the Centers for Medicare & Medicaid Services (CMS) decided to pause the AUC program for advanced diagnostic imaging. This decision, announced in late 2023, marked a significant shift in the trajectory of AUC implementation within the Medicare system. CMS cited multiple challenges that led to this decision, primarily focusing on the difficulties associated with the current claims system in the administrative burdens placed on the healthcare providers.

Challenges With the Claims System

One of the critical issues that precipitated the passing of the AUC program was the inadequacy of the existing claims processing system to support the integration of AUC. The system, which was designed to handle vast amounts of data and complex billing processes, struggled to incorporate the additional layer of AUC verification. This integration was crucial for ensuring that diagnostic imaging orders complied with the AUC guidelines before approval and reimbursement. The claims system's inability to adapt effectively meant that it could not reliably verify compliance with AUC, leading to potential issues with billing accuracy and increased administrative workload.

Administrative and Financial Burden

Implementing the AUC program also imposed a significant administrative and financial burden on healthcare providers. Providers were required to use CDSMs to consult AUC when ordering advanced imaging test. This process necessitated changes to electronic health record (EHR) systems, training for clinical staff, and ongoing management to ensure compliance. For many healthcare providers, especially smaller practices, these requirements represented a substantial strain on resources. The financial implications of updating technological systems and the time investment in training and compliance monitoring contributed to a growing concern about the feasibility and sustainability of the AUC program under the existing framework.

Reaction to the Pause

The decision to pause the AUC program elicited mixed reactions from various stakeholders in the healthcare community. Some applauded the move, viewing it as a necessary step back to evaluate and possibly redesign the approach to integrating AUC into Medicare. These stakeholders argued that reassessing the program could lead to a more streamlined and effective system that minimizes burdens on providers while still achieving the goals of improving care quality and reducing unnecessary testing.

Conversely, others expressed concern that pausing the AUC program might slow down the progress toward more evidence-based, rational use of diagnostic imaging. They feared that without the regulatory push for Medicare, some providers might revert to less judicious use of imaging tests, potentially leading to increased healthcare costs and patient exposure to unnecessary procedures.

Looking Forward

The pause of the AUC program by CMS is not necessarily the end of the road for using AUC in Medicare. Instead, it provides an opportunity for CMS, healthcare providers and other stakeholders to revisit the program's implementation strategy. This time can be used to address the technical and administrative challenges that have hindered the program's success. By re-evaluating the integration of AUC into the claims system and considering the feedback from the healthcare community, CMS can work towards a solution that balances the need for evidence-based practice with the practical realities of healthcare administration.

Why Stick With AUC?

Given this backdrop, one might wonder why a cardiology program would continue to embrace AUC in their decision-making processes. The answer lies in the intrinsic value of AUC, which transcends regulatory mandates.

1. Enhancing Patient Care: At its core, AUC are designed to ensure patients receive the most appropriate care. By adhering to these criteria, clinicians can make informed decisions that not only improve patient outcomes but also minimize exposure to unnecessary risks. This patient-centric approach is fundamental to the ethos of any cardiology program committed to delivering high-quality care.
2. Promoting Cost-Effectiveness: In an era where healthcare costs are continually scrutinized, AUC serve as a tool for promoting cost-effective care. Implementing AUC can lead to significant cost savings by reducing the number of unnecessary diagnostic tests performed. This helps manage healthcare costs and allows for reallocation of resources to other critical areas within the healthcare system.
3. Standardization of Care: AUC provide a standardized framework that helps reduce variability in clinical practice. This standardization ensures that all patients receive care that is consistent with the best available evidence, regardless of where they receive their treatment. For cardiology programs, this can improve overall treatment quality and patient satisfaction, which are crucial for maintaining the program's reputation and effectiveness.
4. Regulatory and Legal Protection: While Medicare has paused the AUC requirement, adhering to these criteria can still provide a layer of legal and regulatory protection. By following established guidelines, cardiology programs can defend their clinical decisions more effectively in the face of potential legal challenges or audits.
5. Fostering Continuous Improvement: AUC are not static; they evolve based on the latest scientific evidence and clinical practice experience. Cardiology programs commit to a culture of continuous improvement and learning by integrating AUC into their decision-making processes. This commitment to staying abreast of the latest guidelines and evidence ensures that patient care strategies are always aligned with the best available knowledge.
6. Quality Improvement and Performance Metrics: Many cardiology programs use performance metrics of quality improvement benchmarks to evaluate and enhance their services. AUC can serve as an effective tool in these efforts by providing clear standards against which to measure the appropriateness of care. This can be particularly valuable in environments emphasizing value-based care, where reimbursement is tied to the quality of outcomes rather than the volume of services provided.
7. Building Trust and Transparency: Adhering to AUC can also enhance trust and transparency between patients and healthcare providers. When patients understand that their care decisions are based on widely accepted guidelines developed by experts in the field, it can increase their confidence in the care they receive.
8. Education and Training Benefits: AUC serve as an excellent educational tool for trainees and new clinicians. They provide concrete examples of best practices and cardiology to train a new generation of healthcare providers who are well-versed in evidence-based medicine.

Conclusion

AUC have played a pivotal role in guiding the use of cardiovascular diagnostic tests, ensuring that such procedures will enhance patient care, reduce unnecessary medical expenses, and standardize practices across healthcare settings. Despite the CMS's recent decision to pause the AUC program, the fundamental principles of AUC remain highly relevant. They continue to offer a framework for clinicians to make informed decisions that balance the benefits and risks of diagnostic tests, thereby fostering a patient-centered approach to healthcare. The ongoing refinement and adaptation of AUC, driven by emerging medical evidence and technological advancements, underscore their enduring value to cardiovascular medicine.

The pause in the AUC program presents an opportunity for a comprehensive review and possible redesign that addresses the practical challenges faced during implementation. This reassessment period could lead to more streamlined and effective applications of AUC in clinical practice, potentially reintroducing the program with enhanced mechanisms for integration into healthcare systems. Moreover, healthcare providers' continued voluntary use of AUC underscores the intrinsic benefits in promoting high-quality, cost-effective patient care. As the healthcare community bridges the gap between quality of care and outcomes, the lessons learned from the AUC initiative will likely inform future policies and practices, ensuring that the use of diagnostic imaging remains aligned with the best interests of patients and the overall efficiency of healthcare delivery.

Related Resources:  

• ACC AUC Program
• Imaging in FOCUS AUC Brochure Update
• Singh A, Parker Ward R. Appropriate use criteria for echocardiography: Evolving applications in the era of value-based healthcare. Curr Cardiol Rep. 2016;18(9):93.
• American Society of Nuclear Cardiology. Appropriate Use Criteria Mandate (Section 218 PAMA)
• CMS Pauses AUC Program for Advanced Diagnostic Imaging, Rescinds Current Regulations
• Stainback RF. Overview of quality in cardiovascular imaging and procedures for clinicians: Focus on appropriate-use-criteria guidelines. Methodist Debakey Cardiovasc J. 2014;10(3):178-184: 
• Appropriate Use Criteria (AUC) Program for Advanced Diagnostic Imaging Services
• Reporting Appropriate Use Criteria in Claims for Medicare Patients
• Is Medicare’s Appropriate-Use Criteria Program Doomed? ACR Chief Discusses What Went Wrong and How It Can Get Back on Track
• Spertus J, Chan P. The need to improve the appropriate use of coronary revascularization: Challenges and opportunities. J Am Coll Cardiol. 2012;59(21):1877-1880.
• CMS.gov Appropriate Use Criteria
• AUC for Advanced Diagnostic Imaging - Educational and Operations Testing Period - Claims Processing Requirements
• Billing and Coding: Cardiovascular Stress Testing, Including Exercise and/or Pharmacological Stress and Stress Echocardiography
• Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; and Basic Health Program
• Hendel RC, Lindsay BD, Allen JM, et al. ACC appropriate use criteria methodology: 2018 Update: A report of the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol. 2018;71(8):935-948. 
• Dehmer GJ, Patel MR. Use of appropriate use criteria is increasing, but what are their effects on medical care? Circulation. 2015;132:4-6.
• Hammer M, Mian M, Elhadad L, Li M, Roifamn I. Appropriate utilization of cardiac computed tomography for the assessment of stable coronary artery disease. BMC Cardiovasc Discord. 2021;21:154. 
• AUC ACC Updates AUC Methodology
• Iskandrian AE, Hage FG, Christian TF. Nuclear cardiology guidelines and appropriate use criteria: American College of Cardiology, American Heart Association, and European Society of Cardiology. In: Iskandrian AE, Hage FG, eds. Nuclear Cardiac Imaging: Principles and Applications, 6th ed. Oxford Academic; 2024.
• Back to the Basics - History of the AUC