On Wednesday, October 30, the House Ways and Means and Senate Finance Committees jointly released a draft version of policy to replace the sustainable growth rate formula (SGR), and language regarding the use of appropriateness criteria in ordering of advanced medical imaging was included.
The bill would financially penalize providers who fail to consult appropriateness criteria when ordering advanced imaging, and would also mandate prior authorization for providers whose imaging ordering patterns are outliers when compared against their peers. It asks the Secretary of HHS to identify appropriateness criteria to use and mechanisms through which it could be disseminated, like clinical decision support (CDS).
An alternate framework was introduced at the end of July, when the House Energy and Commerce Committee voted 51-0 in favor of HR 2810, to which multiple procedure payment reduction (MPPR) and CDS language had been added as part of a 32-page amendment. That legislation asked that the secretary of the Department of Health and Human Services (HHS) make publicly available the data upon which the MPPR mandate was based; it also requested a report from HHS on the extent to which CDS and other provider support tools could help lower costs and improve quality.
The Ways and Means/Senate Finance draft and the Energy and Commerce draft will be reconciled to create a full SGR repeal package, and with CDS mentioned in both, it is more likely than not to make it into the final version. “Having CDS language in both versions of this package is very positive,” said Ted Burnes, director of RADPAC. He adds that there’s still hope for the MPPR language from the Energy and Commerce version: “There is still the chance that when they put all these things together, the MPPR language will make it.”
The two committees did not identify pay-fors for the mandates in the policy draft. Comments are due to the committees by November 12.