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Congress Passes Legislation Linking Physician Payments to Appropriate Use Criteria

March 31, 2014

On March 31, 2014, the Senate voted to pass H.R. 4302, the Protecting Access to Medicare Act of 2014. The House of Representatives had previously passed the bill by voice vote on March 27. This legislation makes permanent changes to how physicians who perform advanced imaging services are paid by connecting it to appropriate use criteria. These permanent changes were included as part of the temporary one year patch to the Sustainable Growth Rate system.

These changes state that Secretary of Health and Human Services must launch (by 2017) a program that encourages the use of AUCs for advanced diagnostic imaging services (ADIS). Additionally, no later than November 15, 2015, the Secretary, in consultation with stakeholders, will choose which AUCs will be included in the program.

The main objective of an AUC is to identify patients who will most appropriately benefit from a procedure, thus resulting in a more effective and equitable allocation of healthcare resources. AUCs, which must be created or endorsed by national medical specialty societies or other provider-led entities, must also have stakeholder consensus; be scientifically valid and evidence-based; and be based on publicly available studies that are published and reviewable by stakeholders. Additionally, advanced diagnostic imaging services are defined as diagnostic magnetic resonance imaging, computed tomography, nuclear medicine (including positron emission tomography), and other diagnostic imaging services specified by the Secretary in consultation with physician specialty organizations and other stakeholders.

Earlier in the day, the Senate failed to pass Senator Ron Wyden’s (D-OR) bill, S.2157, the Commonsense Medicare SGR Repeal and Beneficiary Access Improvement Act of 2014. Senator Wyden’s bill would have permanently repealed the Medicare Sustainable Growth Rate system and would have used Overseas Contingency Operations (OCO) funds as a payment offset. In February, the House Ways & Means Committee, House Energy & Commerce Committee, and Senate Finance Committee introduced a bipartisan, bicameral bill known as the SGR Repeal and Medicare Provider Payment Modernization Act of 2014. However, disagreements over pay-fors stalled progress on the bill.