The White House’s 2015 budget, unveiled last week, had a familiar ring to it with regard to how it deals with medical imaging. If passed, it would allow CMS to require prior authorization for advanced imaging through radiology benefit managers (RBMs).
Similar to how misguided “get tough” polices are touted to reduce crime even as rates of serious crimes are already falling, prior authorization feels like an excessive measure that might do more harm than good, considering imaging utilization rates have begun their own decline in recent years.
The Medicare Payment Advisory Commission has found that the utilization of imaging services within Medicare has fallen. In a reversal of the trend seen in the early-to-mid 2000s, per beneficiary spending on imaging services has been cut by 16.7 percent since 2006. Researchers at the Harvey L. Neiman Health Policy Institute in Reston, Va., found that medical imaging ranked near the bottom of Medicare service categories by spending growth in 2011, according to a study published in the American Journal of Roentgenology.
All that positive news does not mean more couldn’t be done to discourage inappropriate imaging and drive down unnecessary spending even further, though a host of professional associations chimed in to say that the recommendations for further improvement outlined in the proposed budget are not the way to go. The American College of Radiology issued a statement saying prior authorization is “unnecessary and will ultimately raise costs, interfere in the doctor-patient relationship and restrict ready access to imaging care.” The Medical Imaging & Technology Alliance and the Access to Medical Imaging Coalition issued similar statements.
Critics of prior authorization suggest a more sensible measure would be the adoption of physician-developed appropriate use criteria, implemented through decision support tools when ordering advanced imaging. A similar measure was included in the bill written to replace the sustainable growth rate.
Clinical decision support integrated with an electronic ordering system would be more efficient than prior authorization and preserve physician autonomy. Additionally, as pointed out by a 2011 study in the Journal of the American College of Radiology, RBMs don’t necessarily produce savings but more likely shift costs onto physicians and other areas of healthcare.
The proposed budget has little chance of passing, with analysts describing it more as a political document to help define the Democratic Party priorities in this midterm election year. Even though the budget may be D.O.A., it signals that there is still some support for prior authorization among policy makers, and fans of alternative measures need to be prepared to continue defending their position.