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REVISED AND REFERRAL CHANGE: WAS RESOLUTION 702

1 AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES 2 3 4 Resolution: 231 5 (A-09) 6 7Introduced by: American College of Cardiology 8 American College of Radiology 9 10Subject: Radiology Benefits Managers: Practicing Medicine Without the Patient 11 12Referred to: Reference Committee B 13 (Monica C. Wehby, MD, Chair) 14 15 16Whereas, Third party payers have contracted with radiology benefit management firms (RBMs) 17whose guidelines recommend one diagnostic imaging modality over another regardless of 18physician judgment, clinical factors and appropriate patient care; and 19 20Whereas, The statements in the RBMs’ imaging guidelines, as well as the interpretation of these 21guidelines, are incongruent with up-to-date literature and imaging guidelines published by 22medical professional societies; and 23 24Whereas, Payers are allowing RBMs to dictate major clinical decisions for medicals providers 25and patients and hindering physician autonomy; and 26 27Whereas, The decisions by third party payers and RBMs requiring physician use of specific 28practice parameters do not involve the direct input of actively practicing local physicians and 29relevant physician organizations prior to any endorsement or use of any required practice 30parameters; and 31 32Whereas, The decisions by third party payers and RBMs requiring physician use of specific 33practice parameters do not include the rationales used to select such practice parameters; and 34 35Whereas, Medical specialty societies have developed appropriate use documents designed to 36help physicians, payers, and patients define what constitutes reasonable usage, while 37complementing the current clinical use guidelines and performance measures; therefore be it 38 39RESOLVED, That our American Medical Association address the intrusion of radiology benefit 40managers (RBMs) into the doctor-patient interaction (e.g., denying one diagnostic test in favor 41of another) by a) studying the prevalence of forced test substitution and denial of requested 42imaging services by RBMs contracted by third-party payers; b) advocating against such 43practices; c) supporting the use of appropriate use criteria (AUC) developed by medical 44societies and expert physicians as an alternative to RBMs; and d) reporting back progress on 45this issue at the 2009 Interim Meeting. (Directive to Take Action) 46 47Fiscal Note: Implement accordingly at estimated staff cost of $12,000. 48 49Received: 04/30/09 50

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Resolution: 231 (A-09) Page 2

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2RELEVANT AMA POLICY 3 4H-410.969 Payer Use of Practice Parameters - The AMA: (1) advocates that any decision by third party payers requiring physician use of 5specific practice parameters involve the direct input of actively practicing local physicians and relevant physician organizations prior to any 6endorsement or use of any required practice parameters; (2) advocates that any decision by third party payers requiring physician use of 7specific practice parameters include the rationales used to select such practice parameters; (3) advocates that any decision by third party 8payers to require physician use of specific practice parameters be followed by an evaluation of the impact of implementing such practice 9parameters; and (4) advocates that third party payers be assigned liability arising from requiring participating physicians to adhere to a specific 10set of practice parameters. (Consolidated by CMS Rep. 8, I-96; Reaffirmation I-98; Reaffirmed: CMS Rep. 4, A-08) 11 12H-410.970 Use of Practice Parameters - Our AMA: (1) urges organizations that have developed practice parameters to recognize that practice 13parameters are educational tools, not mechanisms to determine reimbursement or credentialing, to assist physicians in clinical decision making 14and are not replacements for clinical decision making. Physicians must retain autonomy to vary from practice parameters without retribution in 15order to provide the quality of care that meets the individual needs of their patients; (2) encourages physicians to be cost conscious and to 16exercise discretion, consistent with good medical care, when implementing practice parameters; and (3) encourages physician organizations 17developing practice parameters to include appropriate explanatory disclaimers to ensure that practice parameters are used in a manner that is 18consistent with AMA policy. (Consolidated by CMS Rep. 8, I-96; Reaffirmation I-98; Reaffirmed: Res. 820, A-00; Reaffirmation A-06) 19 20H-410.971 Clinical Algorithm Impact on Patient Care - The AMA has established the following policy that incorporates provisions regarding 21the use and development of clinical algorithms, which may include the following: (1) Clinical algorithms are guidelines established to aid a 22physician in the diagnosis and treatment of patients. As such, they should be used by the physicians as guidelines, but recognizing that each 23patient is an individual and has unique needs and problems, the physician should use his or her best judgment in the use of the guidelines and 24should never be forced to specifically follow these guidelines rigidly. (2) Clinical algorithms should include suggested tests and procedures to 25arrive at a correct diagnosis in the most direct and expeditious manner. These guidelines should suggest criteria as to when referrals to the 26correct specialist/subspecialist are appropriate and in the best interest of the patient. (3) The treating physicians should always have the option 27of ordering the suggested tests, procedures and referrals at their discretion, and may opt to make these choices earlier or later than is 28suggested, and is not mandated to make any of these choices, depending on their clinical assessment of the patient and their needs. (4) When 29the algorithms are created, physicians from the specialty(ies)/subspecialty(ies) who diagnose and treat the condition should participate in their 30creation. These physicians should be representatives from their official specialty society(ies). (5) The validity of any clinical algorithms should be 31under constant review and evaluation by the appropriate specialty/subspecialty society(ies). (6) Whenever possible consensus clinical data 32from peer review journals will be used. (Res. 719, I-95; Reaffirmed: CSA Rep. 8, A-05) 33 34H-410.974 Development of Practice Parameters by Non-Physician Organizations - Practice parameters developed by the federal 35government, managed care plans, third party payers, utilization review organizations, or other non-physician organizations should be developed 36and implemented in conjunction with relevant physician organizations. Such non-physician organizations should consult with relevant physician 37organizations prior to the development and implementation of practice parameters. (Consolidated by CMS Rep. 8, I-96; Reaffirmed: Res. 820, 38A-00) 39 40H-410.980 Principles for the Implementation of clinical practice guidelines at the Local/State/Regional Level - Our AMA has adopted the 41following principles regarding the implementation of clinical practice guidelines at the local/state/regional level: (1) Relevant physician 42organizations and interested physicians shall have an opportunity for input/comment on all issues related to the local/state/regional 43implementation of clinical practice guidelines, including: issue identification; issue refinement, identification of relevant clinical practice 44guidelines, evaluation of clinical practice guidelines, selection and modification of clinical practice guidelines, implementation of clinical practice 45guidelines, evaluation of impact of implementation of clinical practice guidelines, periodic review of clinical practice guideline recommendations, 46and justifications for departure from clinical practice guidelines.. (2) Effective mechanisms shall be established to ensure opportunity for 47appropriate input by relevant physician organizations and interested physicians on all issues related to the local/state/regional implementation 48of clinical practice guidelines, including: effective physician notice prior to implementation, with adequate opportunity for comment; and an 49adequate phase-in period prior to implementation for educational purposes. (3) clinical practice guidelines that are selected for implementation 50at the local/state/regional level shall be limited to practice parameters that conform to established principles, including relevant AMA policy on 51practice parameters. (4) Prioritization of issues for local/state/regional implementation of clinical practice guidelines shall be based on various 52factors, including: availability of relevant and high quality practice parameter(s), significant variation in practice and/or outcomes, prevalence of 53disease/illness, quality considerations, resource consumption/cost issues, and professional liability considerations. (5) clinical practice 54guidelines shall be used in a manner that is consistent with AMA policy and with their sponsors' explanations of the appropriate uses of their 55clinical practice guidelines, including their disclaimers to prevent inappropriate use. (6) clinical practice guidelines shall be adapted at the 56local/state/regional level, as appropriate, to account for local/state/regional factors, including demographic variations, patient case mix, 57availability of resources, and relevant scientific and clinical information. (7) clinical practice guidelines implemented at the local/state/regional 58level shall acknowledge the ability of physicians to depart from the recommendations in clinical practice guidelines, when appropriate, in the 59care of individual patients. (8) The AMA and other relevant physician organizations should develop principles to assist physicians in appropriate 60documentation of their adherence to, or appropriate departure from, clinical practice guidelines implemented at the local/state/regional level. (9) 61clinical practice guidelines, with adequate explanation of their intended purpose(s) and uses other than patient care, shall be widely 62disseminated to physicians who will be impacted by the clinical practice guidelines. (10) Information on the impact of clinical practice guidelines 63at the local/state/regional level shall be collected and reported by appropriate medical organizations. (CMS Rep. D, A-93; Reaffirmed: CMS 64Rep. 10, A-03)