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  • Final Research Report

    Medicare Imaging Demonstration Evaluation Report for the Report to Congress

    Justin W. Timbie, Peter S. Hussey, Lane Burgette, Neil S. Wenger,

    Afshin Rastegar, Ian Brantley, Dmitry Khodyakov, Kristin Leuschner,

    Beverly Weidmer, Katherine L. Kahn

    Peter S. Hussey Co-Principal Investigator

    Katherine L. Kahn Principal Investigator and Project Director

    David Nyweide CMS Project Officer

    RAND Health

    RR-706-CMMS

    April 2014

    Prepared for the Centers for Medicare & Medicaid Services

    Report is 508 compliant

    The statements contained in the report are solely those of the authors and do not necessarily reflect the views or policies of the Centers for Medicare & Medicaid Services. The RAND Corporation assumes responsibility for the accuracy and completeness of the information contained in the report. This document may not be cited, quoted, reproduced or transmitted without the permission of

    the RAND Corporation. RAND's publications do not necessarily reflect the opinions of its research clients and sponsors. RAND® is a registered trademark.

  • Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2014 RAND Corporation

    R® is a registered trademark

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  • Preface

    Increasing use of advanced medical imaging is often cited as a key driver of cost growth in medical spending. In 2011, the Medicare Imaging Demonstration (MID) from the Centers for Medicare & Medicaid Services (CMS) began testing whether exposing ordering clinicians to appropriateness guidelines for advanced imaging would reduce or eliminate ordering of inappropriate advanced images. Decision support systems (DSSs) were selected as the vehicle for delivering these guidelines for Medicare fee-for-service patients. The DSS tool is intended to provide immediate physician feedback on the appropriateness of a test ordered for a patient, based on current medical specialty guidelines.

    The MID was authorized by Section 135(b) of the Medicare Improvements for Patients and Providers Act of 2008. The statute instructs the U.S. Department of Health and Human Services (HHS) to collect data on fee-for-service Medicare patients 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. The statute emphasizes the use of DSSs to achieve these goals and prohibits the use of prior authorization requirements. CMS, an agency within HHS, entered into a four-year contract with the RAND Corporation in 2010 to evaluate the demonstration. The overall goal of this project is to determine the extent to which exposure to medical specialty guidelines through DSSs is associated with changes in the use of advanced imaging, if at all.

    This report describes results from RAND’s mixed-methods evaluation using combinations of quantitative and qualitative analyses of decision support data, Medicare claims, focus groups, and surveys. Based on these analyses, we also provide recommendations for the consideration of policymakers.

    This work was sponsored by CMS under contract No. HHSM-500-2005-00028I, for which David Nyweide served as the contracting officer’s representative. The research was conducted in RAND Health, a division of the RAND Corporation. A profile of RAND Health, abstracts of its publications, and ordering information can be found at www.rand.org/health .

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  • Contents

    Preface............................................................................................................................................ iii Figures............................................................................................................................................ xi Tables ........................................................................................................................................... xiii Abbreviations .............................................................................................................................. ..xv Section I: Report Overview ............................................................................................................ 1 1. Background and Description of the Demonstration and Its Evaluation ..................................... 3

    1.1 Literature Review ............................................................................................................................... 4 1.1.A. Growth and Decline in Utilization............................................................................................. 4 1.1.B. Reasons for Decline in Utilization ............................................................................................. 5 1.1.C. Applying Appropriateness Methodology to Advanced Diagnostic Imaging ............................. 6 1.1.C. Prevalence and Consequences of Inappropriate Utilization of Advanced Diagnostic Imaging 7 1.1.D. Interventions Designed to Limit Inappropriate Use of Advanced Diagnostic Imaging ............ 9 1.1.E. Effectiveness of DSSs in Promoting Appropriate Use of Advanced Imaging in Outpatient

    Settings ........................................................................................................................................ 12 1.2. The Medicare Imaging Demonstration ............................................................................................ 15 1.3. General Approach and Requirements for the Demonstration .......................................................... 18

    1.3.A. Decision Support Systems ....................................................................................................... 19 1.4. Approach to the Congressional Statute Questions ........................................................................... 21

    Convener-Level Results Associated with Advanced Image Ordering ............................................... 21 Advanced Imaging Utilization Before and After MID ....................................................................... 21 Physician and Patient Experience with Appropriateness Criteria for Advanced Imaging ................. 21 Statute Questions to Inform Recommendations for Future Decision Support ................................... 22 Conclusion .......................................................................................................................................... 22

    Section II: Convener-Level Results Associated with Advanced Image Ordering with Decision Support Systems for Practices Associated with the Medicare Imaging Demonstration ......... 23

    2. Analysis of DSS Data ............................................................................................................... 25 2.1. Introduction to the DSS Analysis .................................................................................................... 25 2.2. DSS Beneficiary and Clinician Samples ......................................................................................... 25 2.3. DSS Image Order Sample................................................................................................................ 28 2.4. Unadjusted Results—Likelihood of Orders Receiving an Appropriateness Rating ........................ 35 2.5. Clinician Decisionmaking Following DSS Feedback ..................................................................... 38 2.6. Unadjusted Results—Appropriateness ............................................................................................ 46 2.7. Conclusion ....................................................................................................................................... 56

    3. Analysis of the Impact of the MID Demonstration on the Appropriateness of Advanced Imaging Orders ....................................................................................................................... 59

    3.1. Unrated Orders ................................................................................................................................ 59

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  • 3.2. Models of Appropriateness ......................................................

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