RBMs: The Debate Heats Up
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.
Don Ryan, MHA
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 advanced imaging). “You have to understand why the test you’re talking about is not appropriate, or that referring physician will make a fool of you,” Komarow says. Overutilization was a known problem; the classic estimate, even today, is that at least 30% of ordered radiology exams are unnecessary, but no one was getting a handle on the problem. Then, in 1989, a visionary appeared on the scene. Alan Mintz, MD, was a radiologist who believed that he could control utilization by capping the fees paid to imaging providers and then relying on those imaging providers (the radiologists themselves) to cut back on unnecessary exams in order to meet their capped reimbursement contracts. It was a nice idea, but it didn’t work. In addition to the fact that asking radiologists to control imaging might be like asking foxes to oversee egg production, there were more serious impediments to the future of Medicon, the company that Mintz founded. First, there was pushback, not just against Medicon, but against managed care and Medicon as part of it.
David Soffa, MD, MPA, FACR
David Soffa, MD, MPA, FACR, says that the gradual way in which CT and MRI spread forestalled focus on cost by health plans. The plans were themselves under attack by providers. Managed care was getting a black eye. “Managed care was falling out of favor, so nobody was doing much about utilization,” Soffa says. This made it hard for Medicon to make headway, although it did persevere. The second blow to Medicon, Soffa says, was that it put the onus of controlling overutilization on the wrong physicians. “Basically, the radiologists are at the end of the process,” Soffa says. “They see the case when it’s done, not when it starts, so they are not located in the stream up front, where they could adjudicate if the study is appropriate or not. The ordering physician is the one. It’s his or her patient.” The focus of utilization control must shift to the physician ordering the imaging exam. “For radiologists to question the ordering physician is very difficult,” Soffa says. “They can ask, ‘Why did you order this?’ They are not in a position to stop a case. It’s really the ordering physician who needs to think about what he or she is doing.” The third blow to Medicon was that Mintz couldn’t handle gaps in his company’s capitation, according to Thomas G. Dehn, MD, FACR, now an executive with RBM giant National Imaging Associates, Inc, Hackensack, New Jersey. “He had a direct-capitation model; leakage out of the network was the biggest problem,” Dehn says. “If you expect a fee from the insurance carrier, and you’re a broker of services, you put together a network of physicians who agree to capitation. If 30% of the carrier’s business goes to other physicians outside your network, you’re essentially paying for that imaging twice, once under the cap and then in the billings by the noncontracted physicians. It was a problem, and they stumbled for a long time.” Medicon went through several iterations before it failed. Mintz himself was undaunted. He launched a new venture focused on health and aging, but he didn’t live to see that blossom; he died in 2007. Mintz had planted an acorn with RBMs. Before he died, he would have seen RBMs growing like mighty oaks. Medicon’s successes, in the midst of its struggles, got the attention of the ACR. Dehn says that he was recruited by the ACR to conduct a speaking tour on managed care and financing. It was on that tour that another event took place that was to shape the future of RBMs. “I had started toying with the idea of providing RBM for a fee,” Dehn says. “It was just a sketchy business plan. I was on a speaking trip when people from Corning Clinical Labs (now Quest Diagnostics) came to hear me. They were interested in delivering radiology services in the way they were already doing it for laboratory services. We held some informal meetings. They asked, weeks later, if I would start a company. I told them the infrastructure was robust for radiology services.” What happened next was a game changer. Corning Clinical Labs, an offshoot of Corning Glass, came up with backing to launch an RBM. “They put down seed money of at least $10 million,” Dehn says. The brief success of Medicon had also inspired an attempt at another RBM, which had taken shape quickly in California. This startup was called National Diagnostic Systems. Soffa says that he was put in charge of the radiology piece at National Diagnostic Systems. The company, he says, was one of the first to leverage the burgeoning capabilities of IT. Soffa says that a key step was the development of the client server, which made the file server outdated. With the client server, it became possible to call up only the specifically needed data. “Instead of the entire telephone directory, you just got all the plumbers. It was a big change in speed,” he says. It was also a harbinger of how critical electronic data management would come to be for the RBM industry. Soffa says that National Diagnostic Systems had two other impacts on subsequent RBMs. One was that it recognized Medicon’s error in making the radiologist the utilization gatekeeper. It focused, instead, on the ordering physician as decision maker, something that Soffa says had been pioneered at the University of Indiana by giving feedback to physicians ordering laboratory tests. “The bottom line is to make physicians, at the time of the order, think about what they are doing,” Soffa says. “To this day, that is the major effect of this kind of program.”
Patrick Courneya, MD
The other impact was equally formative, Soffa says. National Diagnostic Systems was the first to implement preauthorization as a way to hold down unnecessary studies. Medicon quickly copied this move, Soffa says, and National Diagnostic Systems and Medicon competed for contracts, but eventually, both companies failed. In the meantime, Dehn and the Corning team were designing a new RBM, which came to be called National Imaging Associates. It remains a major company, and is one of the five that control the RBM industry today. To get National Imaging Associates going, Dehn brought in a team that included Soffa (who was picked up from the failed National Diagnostic Systems) and a salesperson, Victor Panza, who says that, for a decade, he was the company’s senior vice president for national network management. Panza began to travel the country, calling on health plans, marketing National Imaging Associates. Dehn says that a key step for National Imaging Associates was the development of its own algorithms for applying the appropriateness criteria and other markers that would determine whether an ordered study was approved or denied. “We decided to build our own,” Dehn adds, because the systems on the market were wholly inadequate. Panza says that at first, National Imaging Associates stayed with a capitated model as its offering to health plans, but it was more successful when it switched to what is now the prevailing RBM business model, the administrative services only (ASO) contract. Under ASOs, fees are paid to RBMs to review imaging orders and then preauthorize or deny imaging requests. “We were reinventing every few months,” Panza says. The breakthrough came in 1997, he says, when National Imaging Associates got an ASO contract with Highmark Blue Cross Blue Shield that gave the RBM 2 million covered lives under management. “We used to joke around that when we got to 5 million lives, we each got a Porsche,” Panza says. The Highmark contract got them two wheels. National Imaging Associates, Panza says, “was forced to build out our systems and rise to the occasion,” but the company had broken the barrier with the big health plans. “After Highmark, they started coming in quickly, when we demonstrated we could deliver on a large contract like that,” Panza says. The Market Grows Others had been following the RBM scene and organizing their own ventures. In New York’s populous Hudson Valley, a group of radiologists founded New York Medical Imaging, which changed its name to CareCore National (Wappingers Falls, New York), added nonradiologist investors, and rapidly grew. Don Ryan, MHA, who had been a New York Medical Imaging consultant when the company formed in 1994, became board chair and CEO of CareCore, and he holds those positions today. “Things took off fairly quickly,” Ryan says. “The first three or four years were formative. By 1996-1997, we had a million lives we managed. In late 1998, we added a couple more million, and it’s grown quickly since then. We deliver a valuable service consistently.” CareCore, like many of the big RBMs, has branched into benefit review for other services. Along with its 30 million covered lives for radiology, it also monitors another 16 or 17 million for oncology, drug, and radiation therapy services, Ryan says. In addition, CareCore reviews cardiac imaging, pain management, and sleep diagnostics for 7 million covered lives. In 1998, Soffa left National Imaging Associates and joined American Imaging Management, Chicago, Illinois, where he is senior vice president for medical affairs. Soffa calls American Imaging Management the end-stream successor to Medicon. It is another of today’s major RBMs. Soffa says that a breakthrough for the company came when it began to use IT heavily to add power to its utilization-control systems. By 2004, American Imaging Management had 5.6 million lives under coverage, a figure that has now grown to 30 million, Soffa says. Of those, only a million are covered under capitation, with the bulk covered under ASO contracts. In 2007, American Imaging Management was acquired by health-plan giant WellPoint, Indianapolis, Indiana. According to the company, it and its affiliates cover one in nine US residents. Soffa lauds WellPoint for bringing resources and relationships to American Imaging Management. It also brings a ready-made clientele. National Imaging Associates is the only other major RBM that has corporate ownership. It became a subsidiary of Magellan Health Services, Avon, Connecticut, a national specialty-care management company, at about the same time that WellPoint bought American Imaging Management. National Imaging Associates now has about 18 million covered lives under contract, according to the company; in 2008, National Imaging Associates had total revenues of more than $295 million. Under Magellan’s guidance, National Imaging Associates is moving heavily into radiology carveout contracts. Only one of the other RBMs has returned to the risky waters of capitation to anything like this degree. RBMs can lose big money if their caps are exceeded; on the other hand, if they set the caps properly, they can earn large amounts. “In terms of revenue, to us it is overwhelming that a capitation or carveout is the way to go,” Dehn says. The IT capabilities acquired with Magellan’s purchase of National Imaging Associates have made capitation less risky than in the old Medicon days, he adds. “Medicon had no idea how much was leaving the network. With the capabilities we have now, on any given day, we can report to a given customer how many studies, in real time, are being handled, on services as they are delivered,” Dehn says. More Competition Two other RBM giants were also being put together at the same time that National Imaging Associates, American Imaging Management, and CareCore were finding their sea legs. Both had started out as operators of imaging networks before morphing into RBMs. MedSolutions, Franklin, Tennessee, sold its imaging centers and became an RBM in 1997. According to the company (which declined to provide an interview source), it also offers an assortment of capitated management plans, including plans for Medicare and Medicaid recipients. MedSolutions claims advanced-imaging savings for a specified health plan of 30% to 42% in 2005 and 2006 and suggests that reductions in imaging outlays of $3 per member, per month, can be achieved with the help of an RBM. The other RBM that began as an imaging network provider was HealthHelp, headquartered in Houston, Texas. HealthHelp’s founder (now president and CEO), Cherrill Farnsworth, says that her plan, in 1994, when the company began, was to “help insurers buy radiology correctly.” To do this, she put together an imaging network offering capitated contracts. She quickly changed horses. “My colleagues didn’t like capitation at all because we were seen as withholding care,” she says. She refocused HealthHelp as an RBM. “When I founded HealthHelp, I didn’t even know the word RBM,” Farnsworth says. She found herself running one. As an RBM, HealthHelp prospered, and Farnsworth’s name was soon on the list of the Houston 100, the top business owners in a business-oriented city. Today, according to Valarie Borow, MD, CPC, HealthHelp’s senior vice president and medical director, the company has about 12 million covered lives under contract to various health plans, including Humana. The company is rolling out a plan to add radiation-oncology benefit management to its roster of services, and that will bring more savings to its clients, Borow says. She adds that the company projects that 4.3 million more covered lives can be taken on through this venture. These, then, are the five RBM giants: American Imaging Management, National Imaging Associates, CareCore, HealthHelp, and MedSolutions. To them, add a sixth (and much smaller) player that deserves mention for its focus on a largely untapped market.
Michael Komarow, MD
Care to Care, New York, New York, was founded in 2007 to offer RBM services to small and midsized health plans that were overlooked by the big RBMs, Panza says. After he left National Imaging Associates in 2006, Panza worked for American Imaging Management briefly, as a consultant; then, for a year, he joined Care to Care, which had “found a niche to exploit.” Panza has now completely switched gears (and gone over to the enemy, some might say). He is vice president for imaging utilization solutions at a company that sells decision-support software. Some predict that such software will someday be the death knell for the RBMs. Komarow is now Care to Care’s CMO. Before coming to Care to Care, Komarow was what he calls “a founding member” of CareCore, and he eventually became CareCore’s CMO. He says that Care to Care was founded and is owned by a group of New York entrepreneurs who made their mark in the imaging center business. None of them are radiologists, he adds. Care to Care focuses on the small to midsized health plans “because that’s the part of the market that’s still available, when you come right down to it,” he says. “There are lots of health plans with 50,000 to 200,000 members that don’t have an established relationship with an RBM,” Komarow says. “They’ve been trying to do utilization management themselves, some of them; others haven’t dealt with imaging as a source of savings. Their record keeping leaves a lot to be desired, but radiology has become an obvious choice to save money, whereas it might not have been three or four years ago.” Care to Care now has about 700,000 lives under contract. Komarow says, “I’m reasonably confident we’ll have several new clients in the next six to eight months. I’m not worried about paying my mortgage.” Panza estimates that RBMs now review benefits for 100 million to 130 million covered lives and have saved their health-plan clients hundreds of millions of dollars. Figures are hard to come by because there is no RBM umbrella organization. According to a study1 that has R. Robert LaGalia, National Imaging Associates’ executive vice president for finance and administration and cofounder, as one author, utilization rates for CT and MRI at one site declined 16% and 17%, respectively, in the two years after RBM prior authorization was mandated. Other RBM executives cite different rates. Borow says that, overall, her company has reduced imaging utilization for its health-plan clients by about 25%.
Cherrill Farnsworth
Another effectiveness marker is an RBM’s return on investment (ROI) to its clients. At American Imaging Management, Soffa pegs the ROI as falling between five to one and 14 to one. At CareCore, Ryan estimates client ROI at four to nine times the cost of CareCore’s services, depending on factors such as the client’s efficiency, its patient base, what part of the country it’s in, its imaging volumes, and its aggression with “the tools and the rules,” he says. “The ROI in this business is probably higher than we’d like to see it,” Ryan says. “We compete, so what we charge gives clients a good ROI.” The major RBMs must be doing their jobs. They continue to add covered lives to their books. Can they keep growing? Will competition from automated systems bring them up short? Certainly, if the RBMs have their way, they will prosper more than ever, and they’re laying plans to do so. Medicare is only one way. Today and Tomorrow Patrick Courneya, MD, is a Minnesota family practitioner, not a radiologist. Courneya, nonetheless, is deeply caught up in the imaging world, where he is committed to lowering costs. He thinks that this can be done most effectively through automated decision-support/order-entry systems for radiology, and he is betting that such a deployment will outdistance the RBMs. In addition to operating a family practice, Courneya is medical director for care delivery systems for HealthPartners Health Plan, which calls itself the nation’s largest. Headquartered in Bloomington, Minnesota, HealthPartners provides care through a network of 10,000 physicians and staff in 70 locations in Minnesota and western Wisconsin. Prior to 2006, when it began a pilot project with radiology decision support/order entry as part of a Minnesota consortium, HealthPartners had been without RBM services. The pilot project ended in February 2008, but since February 2009, radiology decision support/order entry has been rolled out to consortium physicians across Minnesota, including HealthPartners physicians. Courneya says, “We saved more than $6 million with [a decision-support/order-entry system] over the past two years, based on what it would have cost without any management approach, and we think this will be a natural upward trend as high technology expands.” Courneya says that the computerized decision-support tools adopted by outpatient imaging providers in the HealthPartners network quickly showed that it could improve the quality of radiology orders. “There was a better match between the patient’s clinical circumstances and the diagnostic exam being ordered,” he says. Courneya adds that what really excited him about the decision-support/order-entry tool was that it could be brought right to the point of care. With a desktop or laptop in the exam room, the ordering physician could use the tool to arrive at imaging decisions with the input of the patient, who could be observing the decision-support process. “That becomes an important tool as the patient and the provider decide if a study is necessary. By having good information in the exam room, the physician can show the patient that a scan is really not going to be helpful and tell the patient what to watch for when a scan might be needed in the future,” Courneya says. He notes that Minnesota physicians, with a 70% implementation of electronic medical records (EMRs), may be ahead of the national curve when it comes to health IT. He adds that American Imaging Management continues to provide some data feeds to those using the Minnesota decision-support/order-entry system, but he says that decision support is the wave of the future. It’s faster than waiting on RBMs for prior authorization, and it is effective in cutting down unneeded imaging, he says. Courneya foresees the day, not too far off, when decision-support tools will be able to combine data from radiology reports with clinical outcomes and further refine imaging-appropriateness criteria. He’s eager to participate in any decision-support exhibit for Medicare. He says, “There’s no question; we’ll apply for that kind of demonstration project.” Courneya says that RBMs have built up too much business to be deeply threatened, at least for now, by decision-support deployment. “It does put competitive pressure on the RBMs, though,” he says. Panza, who has worked at several RBMs, says that he’s convinced that radiology decision support/order entry will eventually bring huge competitive pressure to bear on RBMs. He says that decision-support reductions in imaging volume give results comparable to those of RBMs at a fraction of the cost. “As soon as I saw this, I said, ‘This is the future of radiology management,’” Panza says. “When health plans see how this works, it will be hard for them to pay the RBMs 25 to 30 cents [per member, per month] when they can get this for a nickel.” The RBMs themselves seem divided in response to the decision-support challenge. Education of the ordering physician, which decision support offers, is, after all, a fundamental principle of RBM operation. Some RBMs are rushing to enhance and polish the automated decision-support types of educational ordering tools that they have in place; others are skeptical. “There is reason to believe that inappropriate utilization is related to inappropriate demand, not inappropriate decision support,” Dehn says. “The ACR has been publishing the decision-support argument for years, and it hasn’t done anything. That decision support will accomplish the job is highly in doubt. Because the science is interesting, many patients ask for scans, and physicians are loath to turn down those patients.” Dehn continues, “The other challenge to demand management is the typical case of a physician on a Friday afternoon: A patient shows up with a chronic headache. That physician is busy, and there isn’t time to ask about the nuances of a chronic headache. The electronic solution is to move the patient through, and ordering is used in that way. More than half of inappropriate utilization is inappropriate demand, not inappropriate knowledge. In many cases, the ordering physicians don’t care about decision support.” Ryan makes a similar argument. “Thinking that decision-support tools will be used by 600,000 physicians across the country is naive,” he says. “We tried to use decision-support tools. It didn’t work. UnitedHealth has a decision-support plan, and it’s about half as effective as a true prior-authorization program.” At American Imaging Management, Soffa takes a friendlier stance on decision support. Asked where the company is headed, he says, “In a nutshell, we’re moving into decision support and other areas. American Imaging Management has a cardiology product where we more deeply manage cardiac imaging and device implantation. We have Web-based delivery and real-time decision support. We can do it in radiology, specialty pharmacology, cardiac, and many other areas.” He adds that there are many companies offering decision-support products, saying, “For big institutions with big EMRs, those might work, but for others, they will have to link together via Web. That’s where imaging management is going: Companies are morphing into decision support.” At HealthHelp, too, the emphasis is shifting to decision support. Borow says that HealthHelp has never focused on precertification and has always preferred the educational format, so decision support fits its format. “In a precertification model, it’s all about yes and no,” she says. “If you get a no, the next time, you will change what you say. Physicians become very adept at learning the buzzwords. In true precertification, you may get a 60% savings, but then they fall off because the physicians learn the right answers, and you never taught them anything.” Borow continues, “They haven’t been told why that study was not approved. We always say why the imaging is not appropriate. For example, we say, ‘With MRI, you can’t visualize the intestinal walls well; CT would be more appropriate.’ We also share information about the radiation dose of CT. We got laughed at when we talked about medical radiation seven years ago.” Farnsworth says that decision-support tools will also be critical if and when RBMs begin benefit management for Medicare. “In order to take on this growth, we will have to take on computerized decision support,” she says. “Whereas now we use technologists, nurses, and physicians, that part is going to have to be more electronic.” David Levin, MD, is a former medical director at HealthHelp and is now a consultant. He offers a cautionary note about decision support: by itself, decision support/order entry has no enforcement mechanism. The RBMs have physicians who say no, or get the ordering physician to change the order. “It’s fairly easy to game an order-entry system,” Levin says. “You need a group of physicians on the back end. The peer-to-peer calls are your enforcement mechanism.” Flashing the Badge The ability to deny approval of an imaging procedure is, according to some, the key to the RBMs’ effectiveness, but there is deep division on how much to rely on outright denial. Not surprisingly, the same RBMs that take a soft stance on decision support also try to avoid hard denials. Their more conservative counterparts (called radiology police in the popular press recently) are more willing to use denial to control overutilization. “Prior authorization for advanced imaging is the most powerful tool that any of us has,” Ryan says. “We use evidence-based criteria to drive the ordering physicians to use the most appropriate study.” Ryan prefers the term noncertification to denial. “Our impact on high-end services probably runs in the 15% to 20% range,” he says. At National Imaging Associates, Dehn calls denial a moving target, and he estimates that hard denial runs at 8% to 15% of ordered exams, depending on populations and benefit packages. “In health plans where we have a long history, we see denials of 4% to 5%.” The low denial rates claimed by some competitors don’t pencil out, Dehn says. “They claim 1% or 2% denials, but those numbers don’t work. If 8% to 10% of the utilization we see is grossly wrong, then that’s tacit acceptance that poor quality is OK.” At HealthHelp, the emphasis is definitely on education. “We are not about denials,” Borow says. “We don’t want our physicians telling someone we didn’t allow their health care to go forward. We put a very experienced physician on the phone.” Borow says that hard denials at HealthHelp are only about 0.25%. “We’re now getting about 75,000 imaging requests per month, and we get maybe three denials per month,” she says. Levin points out that the physician review process culls a lot more exams than those culled by denial. “The better statistic is what percentage of studies end up not getting done,” he says. “I think that number is somewhere around 4%, and in another 1% to 2%, the study is changed to a more appropriate exam.” Borow notes that HealthHelp also monitors patient histories as cases move through the approval/payment process, and it frequently discovers that false information has been given that resulted in an exam being approved wrongly. In those instances, ordering physicians are told to repay the costs of the exam, she says. Repeat offenders can be referred for loss of privileging by their health plans, but this rarely happens. She says, “We had about 350 physicians on review this past year, and all of them changed their behavior.” American Imaging Management and Care to Care also say that their companies prefer consultation and try to avoid hard denials. Komarow says that the company’s denied, withdrawn, or modified cases make up about 15% of those screened. “The cases that are denied get denied because they really aren’t proper,” he says, using the example of denial of a lumbar MRI ordered for a patient with two days of back pain, when it’s known that most back pain resolves on its own. The RBMs have several control mechanisms (denial, removal of privileges, and retrospective auditing), and when push comes to shove, they do use them. They can revoke privileges not only from referring physicians, but from radiology providers, too. In one instance, Dehn says, an attempt was made to eliminate marginal radiology providers by requiring any radiology provider to have at least five modalities on the premises. Flexing muscle, though, is not the way the RBMs would like to be seen. They would rather be seen as helpful; the image they want to promote is that they are instructive. “If physicians could stay up to date with all the evidence-based criteria, RBMs wouldn’t exist,” Ryan says. Social Work or Steerage RBMs are taking on new specialties to monitor, in addition to radiology, and this is a trend that seems to be building. The RBMs are looking at other ways to cement relationships with clients, too. At HealthHelp, when cancer is detected in imaged patients, the company will send a data feed to its health-plan client. It’s an effort to “reach out to that patient or physician to assist in a better outcome,” Borow says. “We don’t get paid, but we’re looking at ways to collaborate to improve overall outcomes. Information is our most valuable asset.” At National Imaging Associates, a move is afoot to work directly with patients to satisfy their imaging needs. Once an exam has been preauthorized, National Imaging Associates may contact patients to help them find an appropriate imaging provider, according to Kariena Greiten, senior vice president for product innovation, who came to the company from Magellan after its acquisition of National Imaging Associates. “Clearly, one of the important things is to ensure patients access to the right test at the right time. We make sure our consumers are provided with information about the facilities they select and about radiology providers in the marketplace,” Greiten says. Greiten says that this outreach saves time for the ordering physician. She notes, “It’s taking the burden off the provider and assuming the job of getting the consumer to the imaging center. There could be outreach by telephone, or the consumer could go online. How we build that model comes down to the individual health plan.” She adds that, like other RBMs, National Imaging Associates is moving into benefit management for new specialties and subspecialties. “We’re going to see more opportunity to apply National Imaging Associates’ clinical expertise to other diseases or other areas of medicine touched upon by diagnostic imaging. What I see us doing is leveraging core capabilities in diagnostic imaging and applying those in related markets. Through that evolution, we will engage the consumer in health care decisions and interaction with providers,” she says. Will it work? Komarow, an attorney as well as a radiologist, sees red flags. “Once you get in between the physician and the patient, you take on responsibility of care for the patient. I would not do that blithely,” he says. Premerus Premerus, a project of MedSolutions, is a kind of odd man out among new ventures being tried by RBMs. None of the other RBMs seem poised to follow the Premerus lead into brokering subspecialty radiology interpretations. In fact, skepticism abounds about whether Premerus will succeed. The line of thought behind Premerus, according to MedSolutions, is simple enough. General radiologists can’t equal the skills brought to advanced imaging by subspecialty radiologists. On CT, MRI, and other advanced studies, the Premerus argument goes, generalists miss important findings that the subspecialists notice. Therefore, Premerus will provide skilled subspecialists, via teleradiology, to interpret high-end imaging for any health-plan client willing to foot the bill. The payoff to the health plan will come in the form savings resulting from correct diagnoses more of the time. In a 2008 poster presentation,2 Premerus summarized its own unpublished validation study by stating that it had found 44% nonconcordance between general and subspecialty radiologists’ interpretations, with subspecialty readings claimed as the more efficient and accurate of the two. The company estimated that this could result in payor savings of approximately $4.45 per member, per month, based on results for the 575,000 members of the health plans involved in the study. Many radiology groups, however, have subspecialists of their own interpreting high-end studies, and who is to say what skills a given general radiologist might have acquired? At National Imaging Associates, Dehn bristles at the suggestion of a we’re-better-than-you argument. “That approach is predicated on inappropriate interpretation by local radiologists,” he says. “I feel very strongly that radiologists, when they come out of medical school, are well trained, and the mistakes made are very infrequent. To build a business model on local interpretation being improved by moving to somebody else is a false premise.” Komarow adds, “When I was doing quality management at CareCore, our number of questionable calls was much lower than that. We were taking in random exams and having overreadings done for them. We weren’t seeing 40% discordance.” Ryan is even more blunt: “As a radiologist said to me the other day, ‘Who died and went to heaven and decided that these guys are the ones to fix things?’ They’re still radiologists, and they’ll have the same variations as every other radiologist.” CareCore does not contemplate offering an interpretation service, he says. Medicare When the Obama administration, in early 2009, suggested the use of RBMs to precertify Medicare imaging exams, it did so, at least in part, based on a Government Accountability Office assessment that RBMs could save Medicare $260 million over the next decade. The RBMs themselves say that is a miniscule figure. Ryan points out that through the Medicare Advantage program, RBMs are already involved in precertification for Medicare recipients. “If we take the roughly 700,000 lives in Medicare that we manage for our clients and monetize that across the whole Medicare population of 40 million plus, we think the savings will be in the range of $1.2 billion to $1.6 billion per year,” Ryan says. While the RBMs say that they don’t know for sure what will happen, most are looking at Medicare benefit management as a bonanza about to take place. Some think that congressional compromise will result in a piece of the pie going to decision-support deployments as well. Farnsworth says that precertification of Medicare imaging claims is coming; the question is how the RBMs will be involved. Medicare could work through its fiscal intermediaries and involve all the RBMs by region, Farnsworth suggests. She says that all the big RBMs will be involved. “None are big enough to take on the Medicare population entirely,” she says. “Together, it could be done.” Farnsworth says that assumption of benefit management for Medicare will assure the RBMs of a near-term growth curve, but she projects high growth for the RBMs generally. “All the insurance companies are really getting ready to need to save a lot of money,” she says, with reference to the current economic downturn. “The insurers will have to get a lot more efficient, which means high growth for us. We’re preparing for high growth and we’re getting high growth.” Conclusion While there are continual complaints that the RBMs make patients wait for imaging and other treatments while precertification takes place, and complaints that some patients are denied needed care, it’s clear that the RBMs are saving their health-plan clients money. If National Imaging Associates’ stated 2008 revenues of $300 million are converted into even low-end industry claims of ROI (four to one), that’s a potential savings of $1.2 billion. From warning referring physicians away from high-radiation-dose CT scans for children to edging increasingly into patient-friendly services such as scheduling, treatment collaboration, and provider location, RBMs can and do argue that what they do has a wider social benefit. “We try to do the right thing for the health care beneficiaries,” Ryan says. It’s clear that the RBMs are entrenched, and that in the near term, at least, they aren’t going away. Even the ACR, which has long treated the RBMs as sworn enemies, may be throwing in the towel. In late January 2009, the ACR, in conjunction with the RBMA, issued a set of guidelines on RBM programs.3 That document states, “The purpose of this paper is to create a benchmark against which radiology benefits management programs can be measured. This paper is not an endorsement of radiology business management companies or their approach to the marketplace.” Nonetheless, by laying out a best-practices approach, the ACR may be conceding that its best way forward is to negotiate with RBMs on precertification paradigms that are as radiology friendly as possible. Komarow may have summed things up best by saying, “This is too expensive a field not to have some oversight.” Health insurance companies would seem to agree.