As insurance giant pushes outpatient imaging into freestanding facilities, radiology pushes back.
Voices across radiology cried foul last summer after Anthem Inc. announced its intention to stop paying for outpatient MRI and CT scans performed at hospitals when, according to the company’s third-party review process, the patient could have saved money by going to a freestanding imaging facility.
The buzz surrounding the policy, which as of press time affects patients in 14 states, quickly reached fever pitch—and has stayed there ever since. Constituents from within and outside the specialty, as well as healthcare consultants and thought leaders, continue to express myriad concerns, opinions and predictions about the move’s implications for the short and long terms alike.
“There is noise coming from all sides, and although it’s too early to know anything for certain, the noise itself isn’t going to stop anytime soon,” says Lea Halim, a senior consultant with the Advisory Board Company.
Anthem’s policy, enacted as its new Imaging Clinical Site of Care program and administered by its AIM Specialty Health subsidiary, initially brought the program into effect in four states in which Anthem operates—Indiana, Kentucky, Missouri and Wisconsin—in July 2017. The company, which is the largest for-profit managed-care organization in the Blue Cross Blue Shield Association, soon extended the policy’s reach to Colorado, Georgia, Nevada, New York, Ohio and California. As of press time, Anthem was planning to add Connecticut, Maine and Virginia on March 1, 2018.
Under the program’s requirements, referring physicians need to submit prior authorization requests to have MRI and CT services performed at hospital-based facilities. Anthem assesses each request for medical necessity, limiting the designation to four scenarios: the requested imaging is only available in the hospital setting, the patient requires obstetrical observation, the patient is receiving perinatology services or “no other geographically accessible appropriate alternative sites” are available. When Anthem’s reviewers decide medical necessity has not been established, referring physicians must consult an online provider portal for suggestions on freestanding imaging centers.
ACR: Just Say No
The American College of Radiology has vehemently opposed Anthem’s new outpatient-imaging policy since the day the insurance giant introduced it. The society has been urging state radiology societies, hospital associations and medical societies to speak out against the program to state insurance commissioners, governors and attorneys general. ACR’s website presents templates for letters to these stakeholders, along with sample content and op-ed pieces for submission to traditional and social-media outlets. Plus ACR has opened lines of communication with national and state advocacy organizations and is asking members to publicly share anecdotes showing how the policy is affecting individual patients.
Many in the healthcare-provider sphere are troubled by the subtractive impact they anticipate Anthem’s policy will have on the caliber and continuity of patient care. “It assumes a one-size-fits-all approach, which is an overly simplistic view of the imaging market and implies pure commoditization of imaging, making no allowance for differences in scanners, protocols, slice thickness, subspecialties or the like,” says Chris Tomlinson, MBA, vice president of enterprise radiology at 11-hospital, Philadelphia-based Jefferson Health. Authorization methodology this facile all but ushers in lower-quality care, he suggests.
“We object to this economically motivated steerage policy largely because it goes against our priority—upholding the quality of patient care—and forces people to weigh costs over the best options for their health,” says Texas radiologist Ezequiel Silva III, MD, chair of ACR’s economics commission.
Moreover, note Silva and other sources interviewed for this article, some patients who are steered to alternative imaging facilities may end up at sites with inadequate staffing and/or equipment, leading to scheduling delays, imaging procedures and potentially harmful hits to overall care quality. Patient care suffers further, the sources point out, when case-specific complexities are dismissed as irrelevant by Anthem’s third-party reviewers.
“Anthem has truly taken a meat cleaver to patient care with this approach,” remarks Scott Wallace, JD, MBA, managing director of Dell Medical School’s Value Institute for Health and Care at the University of Texas. “It leads to fragmented care because, in many cases, [lack of] interoperability and other issues make it impossible to access priors. It leads to reticence among clinicians to use high-value services that yield meaningful, actionable real-time information. And to add insult to injury, it isn’t going to save money. It’s going to waste money, as there will not be great outcomes for the money spent.”
Hospitals Feeling the Heat
The potential and emerging impact of Anthem’s unfolding hospital-unfriendly policy also appears to be wide-ranging. Hospitals’ margins and revenues will suffer, particularly in areas where Anthem has considerably large pockets of covered individuals, and where it has identified an ample number of freestanding imaging centers to accommodate them, the Advisory Board’s Halim points out. Hospitals that are already grappling with reduced admission rates resulting from insurers’ increased use of RBMs will suffer an even greater financial blow.
Further complicating things, hospitals “must pay for critical services that aren’t financially supported through any other means,” observes James Brink, MD, chair of ACR’s board of chancellors. “The loss of imaging revenues will put a strain on their ability to pay for these services.”
Lyndean Brick, president and CEO of the Advis Group, a healthcare consultancy headquartered in Mokena, Ill., says the Anthem policy puts pressure on hospitals to reduce their charges for MRIs and CT scans if they want to compete with the freestanding operations. Some will find other ways to hold their ground. For example, Brick reports, several of her organization’s clients have asked for assistance developing strategies to establish independent diagnostic testing facilities.
Moreover, radiologists themselves, whether based in hospitals or in private practice, have another set of headaches to worry about. “There is justifiable concern over the impact on longstanding relationships between radiologists and referring physicians,” says Georgia radiologist Mark Bernardy, MD, vice chair of ACR’s economics commission. “It upsets the balance and the dynamic when someone new comes into the picture. Even when it doesn’t impact patient care—and of course it does, by interfering with continuity—it can take a toll on our work.”
Wallace is further concerned about the “bureaucratic and time-wasting angle of it all.” The policy compels clinicians to deal with pre-certification issues, he says, and radiologists will find themselves “spinning their wheels” attempting to interpret studies that are incomplete, deficient or otherwise problematic.
The radiology community can take some comfort knowing it doesn’t stand alone in opposition to Anthem’s Imaging Clinical Site of Care program. For example, Silva says ACR has begun to hear rumblings from consumer groups representing patients worried the development will lead to compromised care. To this Brink adds that Anthem’s move is being met with considerable patient consternation for its limiting of patient choice. “There is pushback,” he says.
Meanwhile, the American Medical Association has stated that redirecting patient traffic to freestanding imaging centers for MRI and CT procedures takes a toll on relationships between patients and their physicians, interfering with the coordination of ongoing care. The AMA “also has serious reservations regarding the policy’s potential impact on timely access to care and health outcomes,” AMA executive vice president and CEO James Madara, MD, wrote in a open letter addressed to Anthem’s chief clinical officer.
The Lung Cancer Alliance has likewise spoken out against the policy, formally requesting that Anthem reconsider it. “We are concerned that restricting patient and physician choice limits access to quality care,” Elridge Proctor, MPA, LCA’s director of health policy, tells RBJ. “Ensuring greater access to early detection and treatment options is the best way to improve individualized outcomes for our lung cancer community.”
Will Other Payers Follow Suit?
The past few months have seen radiology constituents and outside experts question whether other private payers will follow Anthem’s lead on patient steerage for advanced imaging. It’s too soon to say for sure, but some observers envision other payers taking similar but not identical routes to cost savings.
For example, Tomlinson pictures a scenario in which payers set tiered pricing structures for imaging services rather than disallow imaging studies to be completed at hospital-based centers. Such pricing structures, he explains, would be designed to render hospital-based centers too cost-prohibitive a resource for patients paying more out of pocket now than in the past, as many are.
Also possible is insurers devising policies built around an incentive-based “carrot approach,” rather than the punitive “stick approach” adopted by Anthem. According to Wallace and others, at least one such entity—United Healthcare—is “thinking really hard” about working with clinicians on policies that incorporate alternative ways to balance the need to cut costs without potentially compromising or limiting access to care. (United Healthcare declined to comment on this potential development).
“It’s conceivable that so-called steerage policies will provide incentives to patients for choosing lower-cost imaging options when possible,” Halim states. “The carrot of incentives will certainly cause fewer problems for and is more palatable to patients than the stick” being applied by Anthem.
The widespread discontent over Anthem’s shockwave-producing policy raises questions about the program’s staying power and whether Anthem will eventually amend or rescind it. Anthem declined to comment to RBJ on the possibility; a spokesperson reiterated that the insurer continues to perceive the policy as an effective means of saving patients money on each scan and maintaining a lid on premiums.
According to Halim, unpredictable factors such as whether state legislatures attempt to persuade Anthem to repeal the policy—and, if they do, whether they succeed—will likely come into play. Also uncertain is whether there are enough freestanding imaging centers in relevant markets to yield significant savings on imaging services, along with hospitals’ willingness to re-negotiate rates for imaging services.
Neither ACR nor individual practioners are willing to speculate further. “We like to think [such renegotiations] will happen, or, as a second step, for Anthem to work with us on devising some type of compromise,” Silva says. “We have offered to meet with Anthem’s leadership team to discuss that in the short term, but to date we are not aware of any response to our offer.”
“It is a sad state of affairs,” Silva adds, “when energy and resources must be devoted to such a divisive issue—one that shouldn’t be an issue in the first place.”