Is it goodbye to radiology benefit management (RBM) companies and hello to automated decision-support systems? Not really, as the two aren’t mutually exclusive. Nonetheless, computerized decision-support tools are gaining ground in the outpatient setting.
With CMS about to begin a Medicare decision-support demonstration project for high-end outpatient imaging, and with Minnesota embarking on a consortium-mandatory, statewide decision-support installation, automated protocols that guide referrers to the most appropriate high-end imaging tests for their patients are about to be put to the long-term test.
Cally Vinz, RN, vice president for clinical products and strategic initiatives at the Institute for Clinical Systems Improvement (ICSI), Bloomington, Minnesota, is a true believer in clinical decision support. She calls it a win–win–win for referring physicians, health insurers, patients, and even radiology providers, who won’t have to spend time straightening out inappropriate requests for CT, MRI, and other high-tech imaging exams.
The enthusiasm that Vinz expresses for clinical decision support is based on experience with a pilot project in Minnesota that has outlived itself by two years. Those results have been so positive, she says, that health-insurance providers in Minnesota are now paying to implement clinical decision support statewide and to make it mandatory for ICSI members. Minnesota is also turning to a commercial decision-support vendor to upgrade its system.
If the rest of the nation wants to ride Minnesota’s coattails, Vinz says, there’s no reason that clinical decision support can’t be implemented nationally to hold down costs and guide referring physicians to appropriate imaging tests. “We hope this is how it gets done across the United States,” she says. “I could envision one set of appropriateness criteria across the country.”
That would be a big step, but even states that have studied Minnesota’s program are proceeding slowly. The Washington legislature, in 2009, created an Advanced Imaging Management Workgroup to study and implement evidence-based decision making for high-end radiology, with the goal of holding down cost. The workgroup did exhaustive surveys and issued guidelines to which health plans and providers have agreed. Now, according to Jeff Thompson, MD, medical director of the state’s Health Care Authority (Lacey, Washington), both RBM prior authorization and decision-support automated tools are being used.
Some health care providers, Thompson says, have been given a gold-card pass to use existing decision-support systems developed in-house. For other health plans, the use of a single RBM is allowed. For state-run health programs—Medicaid, worker’s compensation, and the Public Employees Benefits Board—a commercial physician review organization has been hired either to implement clinical decision support or to invoke prior authorization, depending on the nature of the requested imaging tests and the described clinical indications, Thompson says.
For all the ink being expended on clinical decision support at the moment, many problems are still to be solved. Chief among them are what Thompson calls hard stops—the outright denials of requested imaging exams, for which RBMs are notorious.
Also a caution with clinical decision support, Thompson adds, is that the embedded scoring on appropriate use for imaging exams is based primarily on ACR® utilization guidelines or those developed by other medical specialty societies. These guidelines—on which decision-support software programs rely—often lack evidence-based data and are more like recommendations, Thompson says.
“We looked at Minnesota, but we don’t know if that program had a return on investment (ROI) that reduced overutilization; we haven’t seen any published studies,” Thompson says. “I think it’s a rule of thumb that we believe RBMs would have the higher ROI, but the issue is that they cause a lot of disruption of care or access, so we want to balance that in looking at utilization strategies.”
It is this very disruption of access, however, along with the burden and expense of using RBMs’ prior authorization, that has turned Minnesota away from RBMs and in the direction of clinical decision support.
Minnesota’s ICSI is a collaborative funded by member health insurers and health-care providers within the state. The five largest ICSI members operate health plans and/or run hospitals and clinics that cover