Washington, D.C. – The Access to Medical Imaging Coalition (AMIC) today expressed concern that President Obama’s 2015 budget would harm patient access to advanced medical imaging technologies by implementing prior authorization requirements through radiology benefit managers (RBMs).

“President Obama’s budget threatens patient access to care and important imaging services through burdensome prior authorization requirements,” said Tim Trysla, executive director of AMIC. “As an alternative to inserting an artificial middle-man between physicians and their patients via prior authorization schemes, the Administration should follow the lead taken by Congress in crafting a SGR policy which includes the adoption of physician-developed appropriate use criteria (AUC). AUC has proven effective in driving appropriate imaging use without compromising patient access to the right scan at the right time.”

According to a recent analysis, medical imaging utilization per Medicare beneficiary declined by 5.1 percent since 2009 and spending on imaging services for each Medicare beneficiary has dropped 16.7 percent since 2006. Utilization of imaging services within Medicare has also declined substantially since 2006, a downward trend that has been twice confirmed by the Medicare Payment Advisory Commission (MedPAC), which noted in its March 2012 Report to Congress that imaging represents the slowest growing category in the fee-for-service Medicare program. Despite this trend line clearly showing reductions in the spending and growth rate for imaging utilization, policymakers are still seeking to implement harmful prior authorization systems.

Meanwhile, there is a dearth of scientific, peer-reviewed research on the safety, efficacy or impact on administrative costs of prior authorization and RBMs. In fact, a study in the June 2011 issue of the Journal of the American College of Radiology found that relying on RBMs to conduct prior authorization for advanced imaging increases costs and red tape, placing a burden on physicians and potentially causing delays in treatment.

Another study, commissioned by the Patient Advocate Foundation in April 2012, explored the impact of health coverage denials on patients seeking medical imaging exams, ultimately finding that, of the 4,360 patients who contacted PAF between 2007 and 2011 for help in accessing the test they needed, 81 percent of the insurance denials for imaging procedures were due to prior authorization programs – and 90 percent of the denials reversed were in fact covered by the patients’ health plans.

Alternatively, physician-developed AUC require physician decisions to adhere to clinical guidelines developed by national medical society experts, rather than an arbitrary go-between. A number of recent studies have confirmed the value of AUC to empower physicians and drive appropriate usage of medical imaging. For example, researchers highlighted simple and inexpensive ways in which incorporating single-photon emission computed tomography (SPECT) AUC in electronic medical records (EMRs) aided primary care physicians in ordering the right test for their patients.

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