ACR offers an alternative to fix prior authorization and affirm the position of clinical guidelines approved by radiologists.
FROM THE CHAIR OF THE COMMISSION ON ECONOMICS
Gregory N. Nicola, MD, FACR
Benjamin E. Northrup, MD, President-Elect, Missouri Radiological Society, Contractor Advisory Committee Network Representative, Missouri, Diagnostic and Interventional Radiology, Alternate CPT® Advisor, American Roentgen Ray Society, Guest Columnist
Physicians have seen the burden of prior authorization grow prodigiously in recent years. While insurers purport that these policies are important measures of cost and quality control, there has been a rising clamor from physicians and patients, decrying the burnout, administrative waste and avoidable patient harm associated with prior authorization. Professional societies and advocacy groups, including ACR and the AMA, have become increasingly concerned with the administrative burden and patient harm resulting from prior authorization. Former AMA President Jack Resneck Jr., MD, summarized the feelings of many when he said, “Health plans continue to inappropriately impose bureaucratic prior-authorization policies that conflict with evidence-based clinical practices, waste vital resources, jeopardize quality care and harm patients. The byzantine system of authorization controls is rife with opportunities for reform…”
Traditional Medicare has historically required prior authorization much less frequently than Medicare Advantage and other private insurance plans. However, as the current administration strives to combat fraud, waste and abuse, a new proposal seeks to expand the reach of prior authorization with a new program targeting several procedures commonly performed by radiologists. On June 27, CMS announced a new Innovation Center model called the Wasteful and Inappropriate Service Reduction (WISeR) Model. CMS will use this model to partner with IT companies to provide a new, expedited prior-authorization process that uses artificial intelligence to target specific services that CMS deems low-value and prone to fraud, waste and abuse.
WISeR Explained
The WISeR model will focus on a specific subset of 17 items and services that CMS views as having “little to no clinical benefit for certain patients,” may result in harm to Medicare beneficiaries and “that historically have had a higher risk of waste, fraud and abuse.” The press release specifically names skin and tissue substitutes, electrical nerve stimulator implants and knee arthroscopy for knee osteoarthritis as items that could be targeted. In addition to these services, several procedures performed by radiologists were named: image-guided decompression of the spine, epidural steroid injections for pain management and percutaneous vertebral augmentation.
As the current administration strives to combat fraud, waste and abuse, a new proposal seeks to expand the reach of prior authorization with a new program targeting several procedures commonly performed by radiologists.
CMS cites a report from the Medicare Payment Advisory Commission to support the creation of this model. It estimates that up to $5.8 billion in Medicare spending in 2022 was spent on services with minimal benefit. In addition, an estimate from a Special Communication in JAMA estimated that waste accounts for up to 25% of healthcare spending in the United States.
The WISeR model will begin on Jan. 1, 2026, and continue through Dec. 31, 2031. It applies to traditional Medicare and requires the application of existing coverage policy in statutes, regulations, National Coverage Determinations and Local Coverage Determinations to make coverage decisions on the services. The model will require providers in six states (Ohio, Arizona, New Jersey, Oklahoma, Texas and Washington) to submit a prior-authorization request to a WISeR model participant and/or Medicare Administrative Contractor or undergo a post-service/pre-payment medical review.
The Burden of Prior Authorization
Physicians are familiar with the deleterious effects of prior authorization, as this cost-control tool is used frequently by private insurers. Accordingly, the AMA has commissioned an annual survey to better define the impact that prior authorization has on patients, physicians, hospitals and healthcare spending. The most recent survey results were alarming, demonstrating negative effects on patient outcomes, burnout and employee productivity. The survey also found that this cost-control tool paradoxically increases the cost of care. Specifically, denials in prior authorization were found to lead to higher overall use of healthcare resources in 88% of cases, with 47% necessitating immediate care (ER visits) and 33% leading to hospitalization.
The Risks to Medicare Beneficiaries
In light of these findings, widening the application of prior-authorization processes to new groups of Medicare beneficiaries puts our seniors at increased risk of adverse outcomes. WISeR mandates partnership with IT companies to develop AI-mediated prior-authorization processes. Without input from professional societies, it is unlikely these companies will account for the clinical nuances that are vital in determining whether one of the 17 targeted services is clinically appropriate.
Decreased access to the procedures targeted by WISeR (image-guided spinal decompression, epidural steroid injections, and vertebroplasty and balloon kyphoplasty) will result in increased morbidity and mortality among Medicare patients. The Society of Interventional Radiology recently wrote a comment letter to CMS in which they quantified the mortality consequences of the proposed prior-authorization changes with respect to vertebroplasty and balloon kyphoplasty. Based on a large study that analyzed over two million Medicare beneficiaries using Number Needed to Treat metrics, it is estimated that prior authorization leading to denial or delay of care would lead to an additional 47–96 deaths at one year and an additional 71–87 deaths at five years for every 1,000 Medicare beneficiaries who would have otherwise been treated with vertebroplasty or balloon kyphoplasty.
A Wiser Solution
Although the WISeR model is fraught with shortcomings, ACR recognizes the need to reduce unnecessary services to decrease Medicare spending and the risk of patient harm. Medicare spending exceeded $1 trillion in 2023 and, per the Congressional Budget Office, is expected to exceed $1.7 trillion by 2034. Conveniently, criteria to determine whether an imaging service or image-guided procedure is clinically appropriate – namely the ACR Appropriateness Criteria® - already exist. The implementation of these evidence-based appropriate-use criteria, developed and reviewed by expert panels, form the foundation of clinical decision support systems and represent an alternative to prior authorization. In contrast to WISeR, the ACR Appropriateness Criteria® can be thought of as “prior authorization done right.” The use of these clinical decision support systems was already codified in the Protecting Access to Medicare Act (PAMA) of 2014, but implementation has been indefinitely paused. To revive this important provision, the ACR-supported Radiology Outpatient Ordering Transmission (ROOT) Act has been introduced in the Senate (S.1692) and the House (H.R. 5737). The ROOT Act would amend PAMA, easing implementation by replacing the problematic “real time” claims processing requirement with a provider attestation of qualified appropriate-use-criteria consultation.
In the face of increasing practice overhead and administrative burdens, ACR will continue to advocate for responsible prior-authorization reform that preserves patient access and affirms the use of guidelines approved by radiologists with input from physicians in other specialties as needed when determining the clinical appropriateness of radiology services.
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