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Appropriate use criteria key to reining in health costs


Thoughtful policies-with the input of physicians and physician specialty expertise-should be enacted to successfully address inappropriate utilization and ensure more efficient pathways.

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Dr. Shore is medical director of Carolina Urologic Research Center, Myrtle Beach, SC.

Overutilization of diagnostic, prognostic, and therapeutic services not only contributes to excess costs within our constrained health care budget but, even more important, may also contribute to unnecessary patient morbidities.

Unfortunately, special interest groups with significant influence-including certain specialty societies, institutional health care entities, and proponents of nationalizing health care-are staunchly dedicated to marginalizing the independent practice of medicine. As important, practice-changing diagnostic and therapeutic services have emerged, physicians must be able to continue to have shared decision making and discussion directly with the patients they serve. Ideally, all health care decisions would be made between physician and patient and should be both clinically appropriate and cost effective.

Unfortunately, in an era of diminishing resources and economic constraints, policymakers and actuaries from the Centers for Medicare & Medicaid Services, spurred on by the aforementioned interest groups, have answered these challenges with blunt policy instruments, such as reimbursement cuts to medical imaging and the proposed elimination of the in-office ancillary services exception (IOASE).

Eliminating the IOASE will assuredly lead to a dramatic loss of patient access to care as well as a “hobbling” of the medical profession. Thoughtful policies-with the input of physicians and physician specialty expertise-should be enacted to successfully address inappropriate utilization and ensure more efficient pathways. Appropriate use criteria (AUC) is one such pathway policymakers should fully embrace.

As 2013 end-of-year budget negotiations concluded, it was encouraging that policymakers considered using evidence-based AUC as a vehicle for sustainable growth rate (SGR) reform. This provision would require ordering physicians to consult appropriateness criteria for advanced imaging services provided to Medicare patients in order to be reimbursed for that service. Well-constructed AUC will benefit patient care and avoid systemic waste and abuse of services, and must be designed and reviewed by community and academic clinician experts, patient advocates, and policymakers.

Implementation of clinical guidelines would not only guard against inappropriate over- or under-utilization of specific services, it would also restore medical decision making to expert physicians, rather than leaving it to Congress and actuaries to determine the best course of treatment for a particular patient. Moreover, the AUC readily emerges as a more balanced and efficient option when compared to proposals that would levy heavy operational burdens on doctors and concomitantly restrict patient access, such as eliminating the IOASE provision (thus preventing physicians from offering certain diagnostic and therapeutic services in their office) or the purely cost-based decisions issued by the narrowed representation of the Independent Payment Advisory Board.

Repeal of the IOASE would prohibit cancer treatment services from being provided by integrated medical practices, which allows a team of physicians to establish coordinate patient care. Appropriateness criteria would empower physicians and their patients to plan a course of treatment that is uniquely suited to the individual needs of that patient through shared discussion. Thus, the independent doctor-patient relationship is not only preserved but also enhanced.

While there is no one-size-fits-all solution to containing rising health care costs, Congress should pursue policy fixes that enhance patient access to coordinated care, encourage appropriate utilization of the most innovative health care technologies, and preserve the patient-physician relationship of independence. Inclusion of evidence-based AUC in SGR reform is a step in the right direction: a common-sense approach that both addresses concerns regarding utilization of services and preserves patients’ ability to seek care at their own doctor’s office, promoting the most convenient and affordable site of service for patients.

Policymakers should reject any modification or elimination of the IOASE in an SGR reform package, and instead advocate for inclusion of appropriateness criteria with broad clinician and patient representation.

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