“If you don’t know where you’re going, any road will get you there”
– The Cheshire Cat, Alice in Wonderland
Even our most rudderless acquaintances would surely take offense at the idea that they act without considering the repercussions of their actions. Why then do we sometimes observe carefully implemented plans that yield outcomes which can neither be described as desirable nor surprising? Was taking action an end in and of itself?
A recently-published Brookings white paper draws attention to an example of this in Medicare’s history of payment for advanced medical imaging (CT, MRI, nuclear scans) over the last 20 years. In that time, wide payment and practice swings occurred based on factors largely removed from clinical value, effectiveness, or costs. The Brookings paper’s authors find that “there is no evidence that the results [of the driving policy shifts] were anticipated or planned.”
So what shifted? First, in 2008-2010, after years of physicians increasingly referring patients to non-hospital imaging centers for advanced imaging, Medicare payments began prioritizing hospital outpatient imaging over non-hospital centers. This resulted in a 40% decline in advanced imaging studies being ordered for Medicare patients. Second, payment amounts have continued to diverge across sites of service, with the prioritized hospital imaging being paid at a significantly higher rate, even though the clinical services offered are nearly identical.
Today, advanced medical imaging is characterized by rapid technological advances, such as the use of AI, providing benefits to patients, providers, and payers. But to move from breakthrough to standard of care, even innovations proven to deliver improved clinical outcomes require agile consideration from major healthcare stakeholders to enable clinicians to evolve from the status quo. Palmetto GBA, who handles healthcare claims for Medicare beneficiaries in seven southeastern US states, is one of these leading stakeholders.
Palmetto has led efforts to ensure coverage for innovative healthcare services, such as the AI-driven HeartFlow FFRCT Analysis for patients with coronary artery disease. Importantly and unique among its peers, Palmetto has also adopted site neutrality when paying claims for the HeartFlow Analysis, enabling similar reimbursement amounts in both hospital and non-hospital settings, in line with the recommendations of the Brookings white paper.
Through Palmetto’s work, physicians can use HeartFlow to assess a patient’s heart health non-invasively in any clinical setting without worrying about financial imbalances. Prior to site neutrality, CMS reimbursement sometimes fell by 90% or more if the service was delivered at a non-hospital imaging center, making it difficult to serve Medicare beneficiaries in these sites.
By establishing coverage and payment site neutrality, Palmetto’s decision to expand access to HeartFlow for millions of Medicare beneficiaries has a clear goal: clinicians can use an innovative pathway to improve patient outcomes, reduce unnecessary procedures, ensure efficient use of resources, and enable a better patient experience as they provide care in convenient locations.
In our interconnected healthcare environment, almost every decision can either support or suppress innovation. Leaders like Palmetto can either take purposeful steps to enable clinicians to choose new innovative pathways, or they can simply remain static and enable the status quo.
To this thought, the Brookings white paper authors write “Surely, we can do better.” And they are correct. As Medicare seeks to enable value-based medicine across the U.S., we must know where we are going if we are to have any chance of choosing the right road to get there.