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Rapid Growth Prompts Health Plans to Target Advanced Imaging Services
Cost, Quality and Safety Concerns Prompt Renewed Oversight
News Release
Feb. 21, 2008
FURTHER INFORMATION, CONTACT:
Alwyn Cassil (202) 264-3484 or acassil@hschange.org
Along with escalating cost pressures resulting from the rapid growth in imaging utilization, there also are growing concerns about patient safety and quality of care related to rapid increases in magnetic resonance imaging (MRI), computed tomography (CT) scans, positron emission tomography (PET) scans and nuclear cardiology imaging.
For example, according to a 2007 McKinsey and Co. analysis, the number of CT scans performed in the United States grew 13 percent annually between 2000 and 2005, rising from 12 CT scans per 100 people in 2000 to 22 scans per 100 people in 2005.
Repeated imaging may result from poor quality images generated by substandard equipment or from inaccurate interpretation of results by inadequately trained physicians. Regardless, repeated use of CT scans, for example, can expose patients to excessive amounts of radiation, because these scans generally emit significantly larger amounts of radiation than traditional X-rays.
"Health plans are targeting selected, high-cost services, such as advanced imaging, for more aggressive oversight rather than imposing stricter controls across all services, hoping a targeted approach will help avoid physician and patient backlash against perceived intrusion on physician autonomy," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded in part by the Robert Wood Johnson Foundation (RWJF).
Plan strategies range from informing physicians about evidence-based imaging guidelines to requiring prior authorization of services to credentialing physicians and imaging equipment. Mindful of the physician backlash against managed care in the 1990s, plans are instituting requirements they perceive to be less intrusive and burdensome for physicians. Some physicians, however, view the requirements as administratively onerous and obstacles to patient care, according to the study.
"Despite physician objections, health plans generally have stood firm because they believe the cost savings and patient safety gains outweigh the negatives," said HSC Health Researcher Ann Tynan, M.P.H., coauthor of the study with HSC senior consulting researchers Robert A. Berenson, M.D., of the Urban Institute, and Jon Christianson, Ph.D., of the University of Minnesota.
The study’s findings are detailed in a new HSC Issue Brief—Health Plans Target Advanced Imaging Services: Cost, Quality and Safety Concerns Prompt Renewed Oversight—available online at www.hschange.org/CONTENT/968. The study, funded by RWJF, is based on HSC’s 2007 site visits to 12 nationally representative metropolitan communities: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; northern New Jersey; Orange County, Calif.; Phoenix; Seattle; and Syracuse, N.Y. HSC has been tracking change in these markets since 1996.
Other key study findings include:
- A few health plans have emphasized working collaboratively with physicians to decrease unnecessary imaging utilization by using claims data to identify patterns of questionable imaging use by individual physicians. Plans then provide information to physicians to initiate discussions about appropriate imaging use. Some plans provide physicians with guidance on imaging appropriateness, generally in the form of evidence-based guidelines developed by professional societies like the American College of Radiology and the American College of Cardiology.
- Some health plans require prior authorization—also called precertification or preauthorization—for advanced imaging studies, meaning physicians must request and receive approval before conducting imaging studies. Lacking such approval, health plans typically deny payment to the provider performing the imaging study, even though a different provider may have ordered the study. A Cleveland health plan, for example, instituted a prior-authorization program for advanced imaging studies after observing an annual 20 percent increase in utilization. After instituting prior authorization, the plan saw a large reduction in the growth rate of advanced imaging utilization, while having a denial rate of only 1.5 percent.
- Credentialing—also called privileging or certifying—of imaging equipment and of physicians who interpret imaging studies is another strategy used by a relatively smaller number of health plans but being contemplated by others. Credentialing requirements limit the number of service sites and physicians that the plan will reimburse for advanced imaging studies. Credentialing of imaging equipment means that qualified professionals regularly inspect the equipment to ensure that it is functioning properly and meets certain standards developed by medical professional societies and accreditation organizations.
- In addition to credentialing of imaging equipment, plans also credential physicians performing and interpreting imaging studies. They require physicians to meet certain training and education standards to be included in the plan’s network and receive payment for imaging services. This reflects concerns that some physicians with in-house imaging equipment are insufficiently trained in radiology to interpret test results accurately.
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The Center for Studying Health System Change is a nonpartisan policy research organization committed to providing objective and timely research on the nation’s changing health system to help inform policy makers and contribute to better health care policy. HSC, based in Washington, D.C., is funded principally by the Robert Wood Johnson Foundation and is affiliated with Mathematica Policy Research, Inc.
