Showdown in Missouri: Decision Support Versus RBMs

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Two years ago, a friend of Missouri state Rep Caleb Jones (R) sustained a shoulder injury while playing with his child. While a physician suggested that an MRI exam might be in order, the man’s health-insurance provider would not cover the cost of the study and instructed him to seek care from a sports-medicine practice. Forced to jump through multiple hoops to address his injury, the man endured prolonged pain and frustration before learning that he had not just bruised his shoulder; he had sustained a fracture—with which he had been walking around for two weeks. “Hearing this story opened my eyes to the convoluted process of obtaining a radiological diagnosis of any kind,” Jones says. Ever since, he has been on a quest to enact legislation to remove radiology benefit managers (RBMs) from the patient-care equation in Missouri (at least partially). Although an initiative to this effect was stymied earlier this year, Jones—who announced, in mid-June, his intention to run against state Rep John Diehl (R), majority leader, in the upcoming race for Missouri’s speaker of the House—is not ready to concede his battle. The initiative took root when Jones expressed his concerns about his friend’s experience to David Jackson, a lobbyist at Pelopidas, LLC, a professional-services network that counts legislative lobbying in Missouri among its engagements. Jackson introduced Jones to Liz Quam, cofounder of the Imaging e-Ordering Coalition and executive director of the Center for Diagnostic Imaging (CDI) Quality Institute. The institute is part of CDI (Minneapolis, Minnesota), which has imaging centers in 10 states (including Missouri). Jackson discovered that MedSolutions, Missouri’s contracted RBM, was receiving $2.1 million per year from the state for 200,000 or so Medicaid enrollees—and that the state had essentially spent that money to have the RBM hard-stop 5,000 exams, at roughly $420 per denied study. “MedSolutions issued a report to the Missouri Department of Social Services, highlighting claims submitted, accepted, denied, and so forth,” Jackson explains. Further, the RBM was skirting Missouri’s requirement that a state-licensed physician conduct utilization review by putting state-licensed physicians on its payroll. The Decision-support Alternative Jones subsequently put forth HB 867 (Authorization for Providers of Medical Assistance Benefits), a bill designed to allow health-care providers to use decision support as an alternative to prior authorization to determine the appropriateness of services to be received by Medicaid recipients. Although similar legislation had passed muster with members of the Missouri Senate, difficulties ensued. The bill was submitted to the House’s standing Health Care Policy Committee, but about 24 hours before the committee concluded its review of submitted items, MedSolutions hired two highly influential lobbyists to “get it off the table,” Quam says. “Unfortunately, we did not have enough time to pull together arguments and rebuttals of our own,” Jackson reports. Jones says that he will not stop trying to get HB 867 enacted. “I fully plan on filing the same legislation next year, and the year after that,” he says. “I will not rest until it goes through, and the misuse of state tax monies” to fund RBM use ceases to occur. He will have plenty of support from entities such as CDI and the CDI Quality Institute. “We have a stake, as part of the Imaging e-Ordering Coalition and of Missouri state medical groups,” all of which “are working to promote better RBM practices and Medicaid changes for the better,” Quam explains. Robert Y. Kanterman, MD, medical director at CDI–St Luke’s and chief of radiology at St Luke’s Hospital (Chesterfield, Missouri), offers insight into the impact of prior authorization on patient care. “The pattern, now, not only compromises patient care; it is extremely disruptive to relationships between referring physicians and patients,” Kanterman says. He has testified before the Missouri House on RBM-related issues. He adds, “We also are finding it challenging and disturbing that health-care decisions—radiology diagnostic decisions, in our case—are increasingly made in out-of-state call centers by people who are not the ones who have seen the patient (and may not have enough of a medical background to make the decisions). In addition, we are having to employ an increasing number of staff to deal with the administrative hassles associated with getting exams approved, as are our referring physicians. Using decision-support tools could prove to be a more optimal model for choosing the right exam in a more efficient manner.” Wisconsin Succeeds Progress in this area is being made elsewhere. In early June, the Wisconsin Department of Health Services announced the launch of the ForwardHealth Alternative Pathway/Gold Card exemption program. It was devised in partnership with the Wisconsin Medical Society; the Wisconsin Radiological Society; and the Marshfield Clinic (Eau Claire, Wisconsin), a nonprofit health system that operates the state’s largest group practice (with more than 700 physicians) and more than 50 community-care centers and hospitals. ForwardHealth, Wisconsin’s Medicaid program, has required prior authorization for CT and MRI studies conducted in outpatient hospital and nonhospital settings since December 2010. Upon approval of the provider’s request for exemption, however, ForwardHealth will now recognize a decision-support tool for advanced imaging as an alternative to prior authorization. Tim Bartholow, MD, CMO of the Wisconsin Medical Society, deems the exemption program likely to be a precedent setter for the incorporation of other site-of-care decision-support tools into Medicaid programs. He states, “This is a tremendous example of physicians working with payors in developing a process to integrate technology and ensure better care and value.”¹