Over the past several months on SIRIUS XM channel 111’s “The Business of Health Care” program, we have been discussing appropriate use criteria (AUC) from the provider perspective. In essence, AUCs are designed to optimize patient outcomes by ensuring that providers are not administering too much, too little, or inappropriate care. Last week I spoke with two experts on AUC from the payer perspective: Dr. Virginia Calega, Vice President of Medical Management and Policy at Independence Blue Cross and Blue Shield; and Deborah Godes WG02, Senior Director at McDermott+Consulting who has significant expertise in the Medicare rollout of AUCs for medical imaging.

In our discussion, we focused on three key concepts for both payers and providers in the rollout of AUCS: development, dissemination, and the goals of implementation.



The development of AUCs comes mainly from the provider community, specifically “provider-led entities” (PLEs). In the U.S. there are currently 17 Medicare approved PLEs, including Massachusetts General Hospital, the American College of Cardiology and the American College of Radiology. In order to develop accepted AUCs, PLEs are required to use an evidentiary review process (including a systematic review of the literature); grade the evidence identified (via accepted methodologies); utilize a multidisciplinary team approach in AUC development; identify recommendations as evidence based or consensus based; update AUCs on a continual basis; and requalify the PLE every five years. The AUCs can also be derived from the evidence base or from a consensus base (panel of experts) on a given therapy/procedure.



Once established, AUCs are then disseminated to the medical community via clinical decision support mechanisms (CDSM). CDSMs can be “housed” on mobile devices or on personal computers. These CDSMs also need to be qualified in order to ensure they work. Medicare is in the process of qualifying a number of CDSMs to certify that they’re demonstrating ease of use, enhancing clinical decision making, mapping to an approved AUC, and inspiring confidence in the providers who will be using them. The Medicare rollout for medical imaging AUC use was originally scheduled to begin on January 1, 2018. However, due to beta testing (to ensure providers have confidence in using CDSMs), the rollout has been moved back to January 1, 2019.


Goals of Implementation

Ultimately, payers like Medicare will employ AUCs to evaluate provider care and improve the overall quality of service. AUCs utilize a grading system—appropriate (in which the benefits clearly outweigh the harms), may be appropriate, and rarely appropriate. Grading of the patient situation/condition will likely occur at the point of care. Beginning in January 2019, Medicare will require providers to include their appropriateness grade (if available based on an established AUC) on the claim form as part of the payment process. The goal is to use this provider information to identify those providers who are “outliers,” more often providing inappropriate care. Outliers will be further scrutinized by Medicare in the claims submission process and may have to submit for prior authorization.

For private payers, the thinking is that as valued-based payment becomes more accepted (and providers are more at risk for the cost of care), these AUCs will be used by provider groups to identify those clinicians who are outliers. Providers will then hopefully use AUCs as a “quality control mechanism” to ensure appropriate care is being delivered and to use “peer pressure” to ensure providers in a practice/system are providing the right care to the right patient at the right time.

If Medicare’s AUC initiative is a success, it is likely that AUCs will become more widespread and come to determine how care is delivered and paid for. This is likely a good thing for healthcare in its attempts to bend the cost curve and provide good quality care for the masses.


For audio of this episode of “The Business of Health Care” on Business Radio Powered by the Wharton School on Sirius XM Channel 111, click below: