CMS is seeking participants for a just-announced $10 million demonstration pilot that will test the effectiveness of decision-support systems (DSSs) in curbing the utilization of 11 CT, MRI, and nuclear medicine imaging studies associated with 32 different CPT codes (Exhibit 1).
The agency anticipates eligible applicants, which it is calling conveners, to include medical specialty societies, physician groups, integrated health care delivery systems, independent practice associations, IT vendors, and radiology benefits managers. The law prohibits the use of prior authorization in the project.
“There were hundreds of demonstration projects peppered throughout the health care bill and we are pleased that CMS thinks enough of this project to make it one of the first out of the gate, says Josh Cooper, JD, senior director of government relations, the ACR. “We advocated for the provision in the health care bill under the CMS innovation section.”
Conveners will be selected based on their ability to provide a panel of physicians willing to use imaging DDS for the purposes of the Medicare Imaging Demonstration (MID) as well as their ability to provide DDS software to the panel. The ultimate goal is to include 2,500 to 3,500 physicians from 500 to 600 physician practices representing the full range of practice specialties, settings, and type. Interested physician practices must apply through a convener.
CMS anticipates engaging up to six conveners for the two-year project, and in the event that the relationships that result raise questions about the anti-kickback statute and physician self-referral laws, CMS has the authority to waive the application of such laws.
When asked whether the ACR will submit an application to participate as a convener, Cooper says that is under consideration. “I think it’s too early to tell,” he says. “We are reviewing it right now to determine what if any role we can play in this, and hopefully we’ll have a better idea at end of the next week.”
Incentives and Underwriting
Funding of $10 million will underwrite incentives of up to $20,000 per participating ordering physician practice, based on a tiered system that accounts for volume (Exhibit 2). Payments will be made through conveners. Entities that apply to be conveners are required to submit a bid price for the operational requirements of the program, such as reporting and payment distribution costs.
The project is authorized by the Medicare Improvements for Patients and Providers Act of 2008, which requires that the appropriateness criteria used be developed by a medical professional society. The conveners will acquire DDS for advanced diagnostic imaging services that are current with medical specialty guidelines, make the DDS available to physician panels, and collect data on physician ordering patterns as they relate to appropriateness criteria.
For the purposed of the demonstration project, relationship between conveners and physician practices must be exclusive. In other words, physicians cannot participate with more than one convener.
Applications must be submitted by September 21, 2010. Visit the CMS web site for RFP, application, and other details.