RADPAC - Federal_UpdateQ124

Federal Legislative Update

ACR Proposes Administrative Simplification of the Imaging Appropriate Use Criteria Program

Through Section 218(b) of the Protecting Access to Medicare Act of 2014 (PAMA), Congress required the consultation of appropriate use criteria (AUC) by providers ordering advanced diagnostic imaging exams (AUC program) for Medicare beneficiaries. AUC is an effective and evidence-based program, founded on physician-developed guidelines intended to optimize patient care by guiding providers as to whether an advanced imaging study is appropriate and, if so, which is the most appropriate. The AUC program is housed within an Electronic Medical Record via clinical decision support technology and has demonstrated improvement in the ordering of the correct imaging study in hundreds of institutions over several years. Entities using AUC have shown reductions in unnecessary utilization of imaging studies resulting in savings to both the institutions and copayment costs to patients.

The use of imaging AUC was mandated by Congress to be implemented on January 1, 2017. Regrettably, statutory requirements in the 2014 legislation have resulted in numerous implementation problems and delays. Specifically, CMS has identified certain claims processing challenges that cannot be resolved without corrections to the underlying statutory language and proposed and subsequently finalized in the CY 2023 Medicare Physician Fee Schedule (MPFS) Rule, to “pause” the implementation of the PAMA AUC program. Despite the “pause,” CMS has acknowledged the benefits of AUC to Medicare and indicated significant estimated savings ($700,000,000 per year) associated with its eventual implementation.

Proposed language to address the current law’s administrative hurdles has been drafted and, a study by The Moran Company modeling the Congressional Budget Office’s (CBO) scoring process estimates the draft amendments would provide savings to Medicare in the range of $2 billion over ten years. The Moran Company also estimated that Medicare beneficiaries would save about $1.4 billion over the current budget window via reduced cost-sharing.

ACR supports retaining the basic structure and intent of the PAMA Imaging AUC program. However, the proposed amending language would remove the unimplementable point-of-care “real-time” claims processing obligation and replace it with an ordering provider’s attestation of “conferring/reviewing” qualified AUC for the ordering of advanced imaging studies. This ordering data would be collected and subject to annual, retrospective reviews and audits by CMS. To help manage utilization within their facility and act as an important educational tool for ordering providers, compliance or non-compliance data would be collected and reviewed by hospitals or health systems

Congress must revisit the PAMA AUC program and make significant changes to the existing statute to make the program implementable. Enacting proposed amendments to the underlying statutory language will address the CMS-identified challenges and address administratively burdensome requirements identified by stakeholders during the implementation process.

For more information contact Rebecca Spangler, ACR Senior Government Affairs Director.

Physician Workforce Crisis & Proposed Policy Solutions

Ensuring an adequate supply of physicians is integral to the future of our nation’s healthcare infrastructure. Unfortunately, the need for physicians continues to grow faster than supply. The United States could see an estimated shortage of between 13,500 and 86,000 physicians by 2036, including in most specialties. These shortages are driven by the need for more doctors as the population ages out it creates vacancies by retirements.

Within radiology, physician shortages are especially problematic because of the central role that imaging and minimally invasive image-guided therapies play in virtually every significant episode of care. If the number of radiologists continues to decrease while the amount and complexity of exams and procedures increase, the benefit to the patient of reduced surgical intervention and the savings associated with that reduction will be obviated.

Congress can help stop the current and impending crisis in the physician workforce through several short and long-term policy solutions.

- Implement PAMA-established AUC programs based on physician-developed guidelines. This will promote appropriate imaging, reduce the over-ordering of low-value tests, help manage wait times and backlogs, and ensure that radiologists in shortage areas will only interpret necessary imaging tests. ACR supports amending Section 218(b) of the Protecting Access to Medicare Act (PAMA)

- Increase the number of Medicare-supported graduate medical education (GME) positions. As medical school enrollment continues to grow (up 30% since 2022), an artificial cap placed on Medicare support of GME nearly three decades ago has made it difficult for medical resident training to keep pace. While the 1,200 positions recently provided by Congress over the last three years are an important start to training more physicians, additional support is needed.

- To continue addressing the growing physician shortage issue and strengthen the nation’s health care system, Congress should enact the Resident Physician Shortage Reduction Act of 2023 (H.R. 2389/ S. 1302). This bipartisan legislation, supported by ACR, would increase the number of federally supported medical residency positions by 2,000 annually for seven years. The Resident Physician Shortage Reduction Act is crucial to expanding the physician workforce and ensuring that patients can access quality care from providers.

- Reauthorize and strengthen the Conrad 30 program. Currently, resident physicians from other countries training in the U.S. on J-1 visas must return to their home country for two years after residency ends before they can apply for a work visa or green card. Supported by ACR, the Conrad 30 program allows 30 qualified residents per state to remain in the U.S. if they agree to practice in a medically underserved area for three years. This Congress, the Conrad State 30 and Physician Access Reauthorization Act was reintroduced in both chambers (H.R. 4942/S. 665) to reauthorize the program and make minor improvements to its functioning—allowing the waivers to expand beyond 30 (up to 45) if certain nationwide thresholds are met.

- Enact the Healthcare Workforce Resilience Act. Legislation has been introduced to expedite the visa authorization process, impacting both physicians stuck overseas due to backlogs, and international physicians currently working in the U.S. on temporary visas with approved immigrant petitions. Supported by ACR, the Healthcare Workforce Resilience Act (H.R. 6205/S. 3211) would initiate a one-time recapture of up to 40,000 unused employment-based visas – 25,000 for foreign-born nurses and 15,000 for foreign-born physicians.

For more information, contact Ashley Walton, ACR Government Affairs Director.

Medicare Payment Reform Update

Since December 2020, Congress has acted annually to mitigate statutorily required reductions to the MPFS by applying a positive adjustment to the conversion factor (CF) ¬¬- the basic starting point for calculating Medicare reimbursement. Most recently, the Consolidated Appropriations Act of 2024 increased the congressional bump to the MPFS CF by 1.68% beginning March 9 for the remainder of 2024. Combined with the already existing 1.25% CF bump that Congress passed at the end of 2022, the result is a 2.93% increase over what the CF would have been without congressional action.

This bipartisan Congressional effort, a result of intense advocacy from an ACR-led coalition of physician and non-physician organizations, mitigated impending overall payment reductions by roughly 50% for 2024 granting short-term stability for providers to ensure beneficiaries continue to have access to high-quality care. In addition, the increase to the CF from the recent funding bill is estimated to “reclaim” almost $86 million for ACR specialties (DR, RO, IR) for the remainder of 2024, for a total of roughly $1.7 billion “reclaimed” since 2020.

These year-over-year reductions demonstrate that the current Medicare physician payment system is broken. Systemic issues such as the negative impact of the MPFS’s budget neutrality requirements are amplified by the lack of a Medicare Economic Index (MEI)-based inflationary update, which would allow Medicare reimbursement to keep pace with the true cost of practice. As one of the only fee schedules without an inflationary update, physicians are particularly vulnerable to compounding financial factors that generate significant instability for healthcare professionals and threaten beneficiaries’ timely access to essential healthcare services.

Earlier this year, Reps. Raul Ruiz, MD (D-CA), Larry Bucshon, MD (R-IN), Ami Bera, MD (D-CA), and Mariannette Miller-Meeks, MD (R-IA), introduced H.R. 2474, the Strengthening Medicare for Patients and Providers Act. Supported by ACR, the legislation would add a permanent, MEI-based inflationary update to the MPFS. Long-term reforms to mitigate major shifts within the MPFS must be considered, such as adjustments to budget neutrality requirements.

For more information, contact Ashley Walton, ACR Government Affairs Director.