Prior authorization and association guidelines are showing up as primary tools that health plans and radiology benefits managers (RBMs) are using to target the overuse of CT, MR, PET and nuclear cardiology procedures.
According to Health Plan Week (HPW), both groups feel that the key 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, MD, senior vice president of health services for Independence Blue Cross, told HPW. But when physicians follow the American College of Radiology (ACR) guidelines, they tend to order fewer tests, resulting in lower costs and less patient exposure to radiation.
Recent reports from the Government Accountability Office (GAO) and the trade group America's Health Insurance Plans (AHIP) on the overuse imaging tests came as no surprise to the health plans. What surprised them was that 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 percent each year, according to AHIP and the GAO.
The AHIP report blamed much of the growth on financial incentives, as physicians adapt their practice patterns to meet the growing supply of local imaging centers, producing the "if you build it, they will come" phenomenon, reported HPW.
The ACR has conceded 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.
Gregg Allen, MD, chief medical officer at MedSolutions, told HPW that the ACR view is certainly on target to ensure that there is a firm quality baseline in place, however, it does not get to the heart of the problem.
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, MD, senior vice president and chief medical officer of Health Care Service Corporation (HCSC), said that the company is not requiring accreditation of imaging providers now, however, it is considering expanding its quality management program to evaluate the quality of equipment and credentials of technicians.
Financial incentives are not the only culprit, according to quality managers, HPW reported. Time management, defensive medicine and practice patterns that increasingly incorporate imaging tests early in a patient's treatment are also a contributing factor.