In June 2008, the Government Accountability Office (GAO) released a long-awaited study on imaging utilization. If CMS follows GAO’s recommendations on effective methods for curbing overutilization, private payors are likely to follow. That’s why the radiology community was disturbed to hear GAO’s statement that overutilization is a far-reaching issue that can be best addressed with stringent prior-authorization programs.
“Several plans attributed substantial drops in annual spending increases on imaging services to the use of prior authorization,” the report states. “In contrast, CMS employs an array of retrospective payment safeguard activities that occur in the post-delivery phase of monitoring services and are focused on identifying medical claims that do not meet certain billing criteria. The private plans’ experience suggests that front-end management of these services could add to CMS’s prudent purchaser efforts.”¹
There is no question that inappropriate utilization of advanced imaging services is occurring, but is it as widespread as the GAO report suggests? Who is responsible for the problem, and what’s the best way to manage it?
That question of management is what three Minnesota payors—HealthPartners, Blue Cross Blue Shield (BCBS), and Medica—were asking themselves in 2004. Although they all considered some form of prior-authorization program administered by a third-party radiology benefit management (RBM) company, in the end, they chose a different route: offering medical groups the option to run physician-focused decision-support solutions.
A New Age
Liz Quam, director of the Center for Diagnostic Imaging (CDI), Minneapolis, says, “Health plans all over the nation were realizing that they needed to do something about utilization, but they didn’t know how. RBMs had become the most politically correct way for health plans to address utilization, not because it’s the best idea, but because it’s the easiest to implement without getting grief from anybody.”
Patrick Courneya, MD, a family practice physician in Roseville, Minn, and medical director of HealthPartners, was involved in the conversation about how best to prevent overutilization. “We started looking at diagnostic imaging as an issue in 2004,” he recalls. “We had some promising discussions about decision support, but they didn’t go very far, so we began to move ahead with prior-notification programs. Multiple payors in the market were doing it at the same time.”
He stresses that the program initially adopted by HealthPartners was a prior-notification (not prior-authorization) system, so decision-making power would ultimately rest in the hands of providers, not a third-party RBM. “We were never planning to deny any orders,” he says. “We simply required that providers contact our utilization-management vendor. If the provider and that company disagreed, it would be duly noted, but the claim wouldn’t be denied.”
Jim Tierney, CEO of Suburban Radiologic Consultants, Minneapolis, points out that this system still represents a significant hurdle for referring physicians. “The prior-authorization programs adopted by the three payors required any physician referring a patient for an MRI, CT, or PET scan to go through a Q and A in order to generate an authorization number,” he says.
Tim Signorelli, CEO of Consulting Radiologists, Minneapolis, adds that Medica’s original plan also created inconveniences for imaging practices, and there was no way to know whether BCBS and HealthPartners would address the issue when they went live with similar programs. “[Medica] said that if a patient came to an imaging center without an authorization number, the center should not do the study, and if it did, the study it wouldn’t get paid,” he recalls. “That puts the imaging provider in a very difficult position.”
Quam says that the tide began to turn when her team asked for permission to test a new decision-support tool. “It was very well received by everybody, and because of it, some of the other large imaging providers in the state looked into getting the same thing,” she notes. “It isn’t because it’s a better tool. It’s because it feels better if it’s the radiologist saying, ‘Are you sure you want this CT with contrast?’ than it does if you’re in Minnesota calling Houston or Connecticut to hear the same thing. It’s human nature, and it’s also efficiency.”
Around the same time, Courneya and his colleagues at HealthPartners were paying close attention to Harvard