ACR Bulletin

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AUC: A Brief History

With PAMA, the radiologist’s challenge now centers on implementation.
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PAMA is the law, and it is not going away. Our challenge now centers on implementation.

—Ezequiel Silva III, MD, FACR
April 01, 2019

The congressional mandate for CMS to require Appropriate Use Criteria (AUC) consultation during the ordering of advanced diagnostic imaging is upon us. This year is a voluntary reporting period, 2020 is an educational and operations testing period, and 2021 is the formal start date with payments at risk. This program is a major policy change, requiring significant effort by our profession. For many radiology professionals, the new law has prompted a first introduction into AUC and clinical decision support (CDS) for practices. In this column, I discuss the origins of AUC, how it has evolved, and how it became a component of payment policy.

Former President Bill Clinton made healthcare reform a major focus of his 1992 presidential campaign. Early in his first term, he created a task force chaired by then-First Lady Hillary R. Clinton. In 1993, former ACR BOC Chair, K. K. Wallace, Jr., MD, proposed a way in which radiology could contribute meaningfully to healthcare reform. During testimony before the House Committee on Ways and Means on the 1994 Medicare budget, he pledged that the ACR would take a leadership role in defining the most cost-effective and beneficial ways of utilizing radiologic services. He stated that the ACR stood ready to design a system of patient care guidelines to eliminate inappropriate utilization of imaging services, which “could lead to significant savings for our healthcare system.”

Clinton’s healthcare reform never passed, but the groundwork for AUC was established by Wallace’s congressional testimony. To satisfy Wallace’s pledge, the ACR Task Force on Appropriateness Criteria was created, and by early 1994 deliberations had begun. The Task Force incorporated attributes from the Agency for Healthcare Research and Quality, as designed by the Institute of Medicine for developing acceptable medical practice guidelines. Since its inception, the AUC methodology has relied on a combination of evidence and expert consensus (when data from scientific outcome and technology assessment studies are insufficient). Additionally, the AUC process has relied on the input of professionals from other medical specialties — both within and outside the house of radiology.

By the late 2000s, the ACR had created a comprehensive set of AUC with input from hundreds of clinical experts and thousands of scientific references. The criteria were fully transparent, widely available, and continually updated. One important challenge, however, was that these criteria were essentially in a paper format — that is, they could be downloaded from the ACR website or printed out as a PDF. But integration into clinical care pathways was limited, particularly as information systems became more digital. The ACR established a licensing agreement with National Decision Support Company to enable our AUC content to be digitized into a format more easily integrated into health IT solutions. This change could also allow for the digital capture of these consultations for such purposes as registry reporting, end-user feedback, and compliance reporting.

At the same time as our AUC was evolving, increasing focus was being placed on the growth of imaging services compared to other services. This prompted significant payment reductions for imaging. From 2006 to 2012, imaging suffered 12 different payment reductions. Policymakers seemed committed to controlling imaging utilization through payment reductions, and the trend showed little sign of slowing. Even the Patient Protection and Affordable Care Act included payment reductions for radiology. Could radiology change this dynamic and be part of a solution that would not involve payment reductions? As in 1993, AUC once again became part of a constructive dialogue in which it could favorably influence payment policy.

We did not know it at the time of its passing, but PAMA was the last Sustainable Growth Rate (SGR) fix before MACRA passed in 2015 and replaced the SGR. Policymakers — recognizing AUC as a potential solution to control the inappropriate utilization of imaging — made CDS mandatory. And the ACR, confident in its AUC offerings, supported this policy direction.

PAMA is the law, and it is not going away. Our challenge now centers on implementation. We have the opportunity to gain experience with the new AUC mandate and build upon its origins. And we have an obligation to share our experiences and help CMS craft a meaningful, worthwhile, and workable program.

Author Ezequiel Silva III, MD, FACR  Chair of the Commission on Economics