Medicare Imaging Demonstration Final Evaluation

Medicare Imaging Demonstration Final Evaluation: Report to Congress

Justin W. Timbie
Peter S. Hussey
Lane F. Burgette
Neil S. Wenger
Afshin Rastegar
Ian Brantley
Dmitry Khodyakov
Kristin J. Leuschner
Beverly A. Weidmer
Katherine L. Kahn
Copyright Date: 2014
Published by: RAND Corporation
Pages: 202
https://www.jstor.org/stable/10.7249/j.ctt14bs4fw
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  • Book Info
    Medicare Imaging Demonstration Final Evaluation
    Book Description:

    In 2011, the Medicare Imaging Demonstration from the Centers for Medicare & Medicaid Services began testing whether exposing ordering clinicians to appropriateness guidelines for advanced imaging would reduce ordering inappropriate images. Small changes in ordering patterns were noted, but decision support systems were unable to assign appropriateness ratings to many orders, limiting the potential effectiveness of decision support.

    eISBN: 978-0-8330-8965-6
    Subjects: Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-ii)
  2. Preface
    (pp. iii-iv)
  3. Table of Contents
    (pp. v-x)
  4. Figures
    (pp. xi-xii)
  5. Tables
    (pp. xiii-xiv)
  6. Medicare Imaging Demonstration Evaluation Executive Summary
    (pp. xv-xxiv)
  7. Abbreviations
    (pp. xxv-xxvi)
  8. Section I: Report Overview

    • 1. Background and Description of the Demonstration and Its Evaluation
      (pp. 3-22)

      Increasing use of advanced medical imaging is often cited as a key driver of medical spending growth, including a fourfold increase in Medicare program spending between 1995 and 2005. Although recent trends show a decline in utilization rates for advanced imaging, several studies have found that many imaging requests are inappropriate, risking harm to patients through radiation exposure and increasing health care costs. Inappropriate medical imaging also imposes other, less commonly considered risks, including downstream tests and procedures resulting from misdiagnosis or from findings that are otherwise benign. These downstream effects have little value at best, and can be harmful...

  9. Section II: Convener-Level Results Associated with Advanced Image Ordering with Decision Support Systems for Practices Associated with the Medicare Imaging Demonstration

    • 2. Analysis of DSS Data
      (pp. 25-58)

      This chapter addresses the research question:

      What were the rates of appropriate, uncertain, and inappropriate advanced imaging orders over the course of the demonstration?

      We begin with a description of the sample of beneficiaries for whom advanced imaging orders were placed using DSSs during the two-year demonstration period, and the clinicians who participated in the demonstration. We summarize the diverse specialties of these clinicians, as well as the relative volume and type of imaging procedures they ordered through DSSs—drawing contrasts between conveners and specialties where appropriate. We then present the results of three sets of unadjusted analyses; all results...

    • 3. Analysis of the Impact of the MID Demonstration on the Appropriateness of Advanced Imaging Orders
      (pp. 59-68)

      This chapter addresses the research question:

      Were any patterns or trends evident in the appropriateness or inappropriateness of advanced imaging procedure orders?

      This component of the analysis of demonstration DSS data evaluates changes with time in the distribution of advanced imaging orders being rated, as compared with not being rated, by (linked to) national specialty guidelines—and, if rated, the distribution of advanced imaging orders across three appropriateness categories (appropriate, equivocal, and inappropriate). We first build models to quantify changes in clinician ordering behavior with respect to therated/not rateddichotomy over the study period, and separately with models of...

    • 4. Relationships Between the Appropriateness of Advanced Imaging Procedure Orders and Imaging Results
      (pp. 69-74)

      This chapter will discuss the question:

      Is there a relationship between the appropriateness of advanced imaging procedure orders and imaging results?

      (Specifically, we examine whether receipt of particular patterns of appropriateness feedback affects the subsequent volume of advanced image orders.)

      While CMS and the evaluation team initially hoped the results of advanced imaging studies would be available for analysis, this was not feasible from the perspective of conveners. Without the opportunity to access data describing image test results, we elected to examine whether receipt of patterns of appropriateness feedback affects the subsequent volume of advanced image orders.

      To examine whether...

  10. Section III: Convener-Level Analyses of Advanced Image Utilization Before and After the Medicare Imaging Demonstration Was Introduced in Practices Associated with the Demonstration Compared with Comparable Control Practices

    • 5. Trends in Imaging Utilization in the Medicare Imaging Demonstration
      (pp. 77-84)

      This chapter discusses the statute question:

      Were any national or regional patterns or trends evident in utilization of advanced imaging procedures? (Chapter 5)

      To examine national and regional trends in advanced imaging utilization, we compared trends in imaging utilization over time between demonstration group ordering clinicians and a matched set of control ordering clinicians who were not exposed to DSS (see Appendix A). We measured utilization between January 2009 and November 2013, a period that includes the predemonstration period and the demonstration baseline and intervention periods. The predemonstration period represents 21 months (January 2009 through September 2011) prior to the...

  11. Section IV: Physician and Patient Experience with Appropriateness Criteria for Advanced Imaging

    • 6. Physician Satisfaction with Exposure to Advanced Imaging Appropriateness Criteria in the Demonstration
      (pp. 87-98)

      This chapter discusses the question:

      How satisfied were physicians in the demonstration with being exposed to advanced imaging appropriateness criteria?

      Clinician focus group participants reported that they were variably satisfied with the demonstration project, with some describing their support for the “idea” behind the demonstration. (See Appendix B for methods associated with clinician and staff focus groups.) However, most were not convinced that the DSS in its current form would have a significant positive impact on patient experiences or quality of care. For example, Convener A generalists and specialists noted that they liked the idea behind the demonstration, but were...

    • 7. Medicare Patient Satisfaction in the Demonstration with Receiving an Advanced Imaging Procedure after Physicians Were Exposed to Appropriateness Criteria
      (pp. 99-108)

      How satisfied were Medicare patients in the demonstration with receiving an advanced imaging procedure after a physician was exposed to appropriateness criteria?

      In Chapter 6, we provided results on physician satisfaction with the demonstration, drawing upon results from clinician focus groups held with several conveners. In this chapter, we shift the focus to patient satisfaction, reporting on results from both the physician focus groups and from two patient focus groups. Participants in the patient groups were adult Medicare beneficiaries who had one of the 12 MID advanced images during the previous three to six months. A total of 13 patients...

  12. Section V: Six Statute Questions That Can Inform Future Recommendations About Decision Support

    • 8. Recommendations About the Acceptability of MID’s DSS for Identifying Appropriate Versus Inappropriate Advanced Imaging Orders
      (pp. 111-116)

      This chapter presents recommendations about the acceptability of MID’s DSS for distinguishing appropriate versus inappropriate advanced imaging orders, answering the statute question:

      Was the system for determining appropriateness in the demonstration acceptable for identifying appropriate versus inappropriate advanced imaging orders?

      The use of the DSS for identifying appropriate versus inappropriate advanced imaging orders in the demonstration was not generally acceptable to clinicians in the form that was deployed. Furthermore, the system was not efficient, as it did not assign an appropriateness rating to more than one-half of the ordered advanced images.

      Clinicians who received and reviewed guidelines associated with their...

    • 9. Recommendations About Volume of Utilization in Response to Physician Exposure to Advanced Imaging Appropriateness Criteria at the Time of Orders
      (pp. 117-120)

      This chapter presents recommendations based upon multiple chapters presented earlier in this report to address the statute question:

      Would exposing physicians to advanced imaging appropriateness criteria at the time of order affect the volume of utilization?

      Empirically, within MID, exposing physicians to advanced imaging appropriateness criteria at the time of order did not have a substantial impact on volume.

      In Chapter 4, we observe that providers who receive higher proportions of inappropriate feedback about advanced image orders are no more likely to change their future volume of orders than are providers with higher proportions of appropriate feedback. In Chapter 5,...

    • 10. Recommendations About the Advisability of Expanding the Use of Appropriateness Criteria for Ordering Advancing Imaging to a Broader Population of Medicare Beneficiaries
      (pp. 121-126)

      This chapter presents recommendations based upon multiple chapters presented earlier in this report to address the statute question:

      Is it advisable to expand the use of appropriateness criteria for ordering advanced imaging to a broader population of Medicare beneficiaries?

      As implemented, MID has involved a broad population of practices, providers, and Medicare beneficiaries. The results of our analyses suggested that it is not advisable to expand the use of appropriateness criteria for ordering advanced imaging to a broader population of Medicare beneficiaries. Our analyses suggest that the demonstration is not ready to be scaled up and that several issues will...

    • 11. Recommendations About the Advisability of Allowing High-Performing Physicians to Be Exempt from Requirements to Consult Appropriateness Criteria
      (pp. 127-134)

      This chapter presents recommendations to address the statute question:

      If expanded to a broader population of Medicare beneficiaries, should physicians who demonstrate that their ordering patterns are consistently appropriate be exempt from requirements to consult appropriateness criteria?

      RAND has conducted empirical analyses of the stability of rates of appropriateness to advise whether certain types of physicians should be exempt from a potentially broader appropriateness criteria program and whether this exemption should be affected by image type and/or by patient characteristics. Using a decision-theoretic approach, it is feasible to provide a model to address the question of what types of ordering...

    • 12. Recommendations About the Value of Live Feedback on the Appropriateness of Advanced Imaging Orders from a Decision Support System Compared with Feedback Reports to Individual Physicians or Physician Practices
      (pp. 135-138)

      This chapter presents recommendations to address the statute question:

      To what extent is live feedback on the appropriateness of advanced imaging orders from a decision support system better or worse than feedback reports to individual physicians or physician practices?

      Since the limited number of orders submitted by many clinicians has limited the extent of dissemination of aggregate practice- and person-level feedback that has been distributed, RAND has not been able to conduct empirical analyses of the relative impact of aggregate feedback reports to individual physicians or physician practices.

      The design for the demonstration was to first expose clinicians to the...

    • 13. Recommendations About Strategies for Motivating Physicians to Comply with Ordering Advanced Imaging Appropriately According to Appropriateness Criteria
      (pp. 139-140)

      This chapter presents recommendations to address the statute question:

      In what ways can physicians be motivated—including financial incentives—to comply with ordering advanced imaging appropriately according to appropriateness criteria?

      MID was structured such that physicians would maintain their usual reimbursement rates for ordering images during the demonstration; financial incentives were not provided for ordering more or fewer images or more or less appropriate images. Even without financial incentives, most clinicians were conceptually interested in learning how to improve ordering patterns. As described in Section 6.2, this suggests a willingness by ordering clinicians to participate that might be enhanced further...

  13. Section IV: Conclusion

    • 14. Conclusions
      (pp. 143-150)

      The sizable growth in utilization of advanced imaging during the last decade for Medicare FFS beneficiaries prompted CMS to examine reasons for the growth and strategies for controlling the growth of services that were not clinically appropriate. The MID instructs the U.S. Department of Health and Human Services to collect data on Medicare FFS patients using DSSs to determine the appropriateness of services in relation to established criteria and to provide participating physicians with feedback reports that permit comparison against physician peers on adherence to appropriateness criteria.

      This report summarizes data associated with analyses of claims, decision support data, and...

  14. Bibliography
    (pp. 151-158)
  15. Technical Appendix A: DSS and Claims Methods
    (pp. 159-170)
  16. Technical Appendix B: Evaluation of the MID: Focus Group Methodology
    (pp. 171-176)