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AIS's Health Business Daily
Featured Story September 9, 2008 Prior Authorization, Association Guidelines Help Health Plans Target Overuse of Imaging Tests Reprinted from HEALTH PLAN WEEK, the industry's leading source of business, financial and regulatory news of health plans, PPOs and POS plans. Physicians might not like it, but prior authorization is on every health plan's radar screen for managing high-tech imaging services, quality managers tell HPW. The key, health plans and radiology benefits managers say, is to use a streamlined prior-authorization process that functions as a tool to educate physicians about clinical evidence, especially guidelines from professional societies. "There is wide and significant variation in the way physicians practice when it comes to imaging tests," Richard Snyder, M.D., senior vice president of health services for Independence Blue Cross, tells HPW. But when physicians follow the American College of Radiology (ACR) guidelines, they tend to order fewer tests. And this results in lower costs and less patient exposure to radiation. While recent reports from the Government Accountability Office (GAO) and the trade group America's Health Insurance Plans (AHIP) on the overuse of computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) and nuclear cardiology procedures came as no surprise to health plans, it focused attention on the extent of the problem and its quality, safety and economic conse-quences. At the heart of the problem: Nearly half of the almost $100 billion worth of imaging procedures performed each year fail to produce information that improves diagnosis or treatment. And the number of tests being ordered is growing at about 15% to 20% each year, according to AHIP and GAO. The AHIP report blames much of the growth on financial incentives. Physicians, AHIP says, are adapting their practice patterns to meet the growing supply of local imaging centers, producing the "if you build it, they will come" phenomenon. ACR concedes the point, but argues that accreditation, not prior authorization, is the answer. Accreditation ensures that physicians supervising and interpreting medical imaging meet stringent education and training standards. Imaging equipment is surveyed regularly by qualified medical physicists to ensure that stringent safety criteria are met, the group says. Some health plans, including UnitedHealth Group, are linking physician accreditation to reimbursement for imaging. Others are considering it or implementing parts of the process. Paul Handel, M.D., senior vice president and chief medical officer of Health Care Service Corp. (HCSC), says the company is not requiring accreditation of imaging providers now. "However, we are considering expanding our quality management program to evaluating the quality of equipment and credentials of technicians." HCSC operates Blue Cross and Blue Shield plans in Illinois, New Mexico, Oklahoma and Texas. But financial incentives are not the only culprit, quality managers say. Time management, defensive medicine and practice patterns that increasingly incorporate imaging tests early in a patient's workup also come into play. "The ACR view is certainly on target," Gregg Allen, M.D., chief medical officer at MedSolutions, tells HPW. "But it misses the broader picture. Accreditation helps ensure that there is a firm quality baseline in place. But it doesn't get at the heart of [the problem]." Nor do retrospective audits and reviews. "You have to get out in front of it," he says. Prior Authorization Changes Practice Patterns MedSolutions provides radiology benefit management services for CIGNA Corp., Aetna Inc. and several other health plans. Allen says the company started to address the imaging issue five years ago when it began seeing "double-digit year-over-year growth trends" in high-tech imaging. That growth has been in the mid- to high teens for MRIs and CT scans, and in the mid-teens for nuclear cardiology. While the growth rate for PET scans is higher, Allen says the number of PET scans being performed is still relatively low. MedSolutions targets the 85% of high-tech imaging procedures that are performed in outpatient elective settings, where patients typically are not critically ill. Here, MedSolutions has identified a disturbing trend: growth in the number of imaging procedures being used by primary care physicians for screening purposes. "Primary care physicians have been trained to first do a history and then a physical exam as part of the initial patient workup," Allen says. "But CT and MRI procedures have become so readily available that many physicians are using these tests as part of the patient workup." Yet on average, half of these screening procedures offer no useful diagnostic information. A second trend identified by MedSolutions: the growing number of specialists who require referred patients to bring the results of a scan to their first appointment. Allen says this often is used by specialists as a time-management strategy. "It's more efficient from the specialist's standpoint if the patient comes in with the results of a scan. But this has more to do with time management than good medicine." Allen says MedSolutions' quality management efforts have reduced both the number of inappropriate scans being conducted and overall trend lines. While results vary by modality and geographic area, Allen says that "in many cases we're reducing the number of inappropriate scans in the range of 12% to 20%. On the trend side, the rate of increase in the number of procedures being performed is dropping by upwards of 50%. MedSolutions approves 80% to 85% of imaging requests, Allen notes, half of them instantly, the rest within 24 hours. The remaining 15% to 20% are questioned for appropriateness, are withdrawn or are denied. This is where physician education is used to affect practice patterns. "It's a feedback loop that physicians respond to." MedSolutions uses two fee models that use a per-member per-month (PMPM) charge. Under the administrative-services-only model, the health plan assumes the risk. Under the capitated at-risk model, MedSolutions assumes the risk, but charges a higher PMPM rate. The company declines to detail rates for competitive reasons. Health Plans Report Positive Results Independence Blue Cross rolled out its quality initiative in 2006, working with American Imaging Management. Snyder says that the evidence behind doing imaging procedures is evolving quickly, and that primary care physicians have a hard time staying current with the evidence. Since launching its initiative, Independence approves all but about 3.5% of imaging requests. About half of the requests that are not approved are withdrawn, and the rest are denied. "So the denial rate is low, but the impact rate [for the initiative] has been high," Snyder says, explaining that "physicians are learning from the process, and this results in the better use of resources." Snyder adds that Independence was seeing just under a 10% increase annually in the number of tests being ordered across its products. But that number has since declined by 1.5 percentage points. This might seem low, but Snyder explains the current utilization rate "is about 20% less than what we would have predicted." HCSC also partners with American Imaging Management to manage radiology utilization. Handel tells HPW that its quality program is operating in Texas, Illinois and New Mexico, and soon will be extended to Oklahoma. The program is voluntary, and prior authorization is not a specific requirement, Handel says. But "participation rates exceed 50% in Illinois and 70% in Texas." According to Handel, since implementing the program, HCSC has seen its utilization trend rate drop from 12.5% to 5.1% in Illinois and from 11% to 7% in Texas. Highmark, Inc., meanwhile, works with National Imaging Associates to manage utilization. "We started a prior-authorization program for CT, MRI and nuclear cardiology about seven years ago and found that our trend lines went down," Carey Vinson, M.D., vice president and quality performance management director for Highmark, tells HPW. "Then we discontinued it, and within a year our trend line had gone back up. By 2003, Highmark was seeing a 15% to 20% increase in CT and MRI utilization per member per year. The company re-established
the program in 2006 for selected CT and MRI procedures and all PET scans,
and reports a 24% decrease in CT procedures per 1,000 members, and a
12% drop in MRI procedures per 1,000 members. Initially, Highmark saw
an 85% approval rate and a 15% denial or withdrawal rate. "By the
second quarter of 2007, we began seeing a slight increase in the approval
rate and a greater decline in the withdrawal and denial rates,"
Vinson says. "We attribute this to better-educated physicians who
are now ordering fewer inappropriate tests." |
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