After a false start, RBMs have come on strong, but the advent of computerized physician order entry leads some to believe there are better ways to control imaging utilization
Ask radiology benefit management (RBM) companies who benefits from their work, and they will claim that everybody does: health plans and insurers, because RBMs save them millions of dollars in unnecessary imaging fees; referring physicians, because RBMs teach them the appropriate studies to order; and patients, because RBMs save them from needless exams and, just as important, unnecessary radiation exposure. The RBMs can even argue that they help radiologists by bringing rigor and quality control to the radiology landscape. By holding down health care costs generally, the RBMs can claim to benefit the public at large.
Others aren’t so sure. Radiologists, financially the losers when an RBM axes a study, have long depicted RBMs as self-interested and, when it comes to patient care, imbued with conflicts of interest. Does an RBM pull the plug on a scan because it thinks the scan really is incorrectly ordered, or because it has the stronger motive to save its client some money?
Over the years, RBMs have grown into relative behemoths. Collectively, they monitor outpatient imaging for close to 100 million health-plan members in the United States. At least half of the privately insured patients for whom a radiology exam is ordered pass through an RBM review process, whether or not they know it. Recently, RBMs have set their sights on a new target: Medicare patients. For a fee, the RBMs want to monitor outpatient imaging of Medicare recipients. They claim that they can save the program millions, and RBM lobbyists have convinced the Obama administration to support them.
This has raised a new level of alarm. Both the ACR and a consortium of radiology-equipment manufacturers have come out against the extension of RBM precertification to Medicare patients. The ACR points to disruption of the physician-patient relationship, among other impacts, but if the RBMs get their hands on all Medicare patients, the most significant impact is likely to be reduced imaging volume. Neither the equipment makers nor radiologists want less business at a time when the economy is contracting.
At the same time that the Medicare scenario has been unfolding, something else has been playing out in the RBM landscape. New companies, armed with computerized decision-support and radiology order-entry tools, have entered the market, claiming that they can do the same things that the RBMs do for a fraction of the cost. The decision-support vendors argue that their computerized tools raise the think-about-it barrier for ordering physicians as effectively, but more quickly and cheaply, than RBMs do. Just when the RBMs were looking unassailable, they are under attack from a new direction. A demonstration project for decision-support/order-entry systems is almost certain to be part of any Medicare assessment of an imaging-preauthorization process.
In June, the ACR allied with the Centers for Diagnostic Imaging and several vendors to launch the Imaging e-Ordering Initiative with the purpose of educating payors and lawmakers on the value of e-ordering solutions in reducing excessive radiation and costs associated with unnecessary imaging.
Medicon’s Famous Failure
The attempt to control unnecessary imaging began, by most accounts, in the mid-1980s, a time when managed care companies were coming into their own and the deployment of CT and MRI were adding expensive new fees to imaging budgets. The problem of radiology overutilization had been around as long as imaging itself had been an option for referring physicians.
“We all recognized there was useless imaging,” Michael Komarow, MD, says. “This had gone on from the very beginning, first with chest radiographs, and then with CT scans costing $1,500.” For 20 years, Komarow says, he was a practicing radiologist, then medical director for a pioneering New York RBM that became a giant. Now, he is chief medical officer (CMO) for a small Manhattan-based RBM that focuses on the secondary health-plan market.
Komarow says that what doomed attempts to control radiology overutilization made by health plans themselves was that they relied on the same set of staff to review radiology as well as pharmacy, laboratory, and other services. The trouble was that these reviewers knew little, if anything, about imaging (particularly