The Blue Cross and Blue Shield Association (BCBSA) has issued a plan that would move the healthcare system away from a fee-for-service model to a patient-centered model. However, the Medical Imaging and Technology Alliance (MITA) and Access to Medical Imaging Coalition (AMIC) have called on Congress to reject the BCBSA proposal that would call on  Medicare to use prior authorization for advanced imaging services.

The action plan, “Building Tomorrow's Healthcare System: The Pathway to High-Quality, Affordable Care in America,” provides specific recommendations to improve healthcare quality and tackle rising costs and is based on the experience of BCBSA's 39 plans in all 50 states and federal territories.

The proposal lays out specific, actionable steps the government should take in four key areas:

1. Reward safety: National and local leadership along with new provider incentives are needed to eliminate preventable medical errors, infections and complications that harm hundreds of thousands of people each year, costing billions of dollars.
2. Do what works: The incentives must be changed to advance the best possible care and reward quality outcomes, instead of paying for more services that are ineffective or redundant and add unnecessary costs to the system.
3. Reinforce front-line care: A higher value must be placed on primary care and on ensuring there is an adequate workforce of professionals to deliver necessary, timely and coordinated care that results in better outcomes and lower costs.
4. Inspire healthy living: With 75 percent of today's healthcare dollars spent on the treatment of chronic illnesses—many of which are preventable—consumers must be empowered and encouraged to make better choices, live healthier lives and better manage their health.

If adopted, the recommendations would save $319 billion over the next decade, according to an economic analysis by Ken Thorpe, PhD, chair of the department of health policy and management at Rollins School of Public Health, Emory University in Atlanta.

The plan refers to a partnership between Wellmark Blue Cross and Blue Shield and a radiology benefit management company to ensure appropriate outpatient diagnostic imaging utilization, the use of evidence-based clinical criteria and appropriate exchange of member information. The program has consistently demonstrated an annual return of at least 3-to-1 and realized a gross return on investment of over 10-to-1 in its first two years, according to BCBSA.

However, according to MITA, there is no peer-reviewed health economic research that shows prior authorization actually produces savings for the Medicare program. MITA referred to a recent American Medical Association physician survey found that 63 percent of the 2,400 respondents said that prior authorization delays needed medical procedures.

Likewise, AMIC cautioned that prior authorization is an ineffective and unproven mechanism for encouraging appropriate imaging utilization and likely will result in denying seniors’ access to life-saving diagnostic and therapeutic services.

Additionally, MITA emphasized that the Department of Health and Human Services (HHS) has stated that a prior authorization program would be "inconsistent with the public nature of the Medicare program," due to the lack of transparency and reliance on private companies using proprietary systems to deny physician-prescribed care. According to HHS, the Medicare appeals process could overturn a "high proportion" of denials, rendering such a policy ineffective and highly burdensome.

AMIC noted that the BCBSA proposal comes on the heels of Blue Cross Blue Shield of Delaware’s (BCBSD) failed attempt to impose prior authorization requirements on patients. Following intense scrutiny of the quality of BCBSD’s delivery of care under its prior authorization program for cardiac nuclear imaging, BCBSD was ordered by the Delaware Insurance Commissioner to scrap prior authorization and instead use the American College of Cardiology’s FOCUS program.

To read the action plan, click here.