AHIP Coverage (November/December 2008)
Quality First
Private sector initiatives inform government effort to control escalating use of high-tech diagnostic imaging.
By Lisette Hilton
A report released in June by the U.S. Government Accountability Office analyzes a dramatic upswing in the use of high-tech diagnostic imaging in Medicare Part B and recommends strategies to help Congress safely curb spending on imaging services, many based on radiology benefit management programs already in place at private health insurance companies.
The GAO report, “Medicare Part B Imaging Services: Rapid Spending Growth and Shift to Physician Offices Indicate Need for CMS to Consider Additional Management Practices,” found that, from 2000 to 2006, spending for imaging services paid under the physician fee schedule more than doubled—increasing to about $14 billion. Spending on high-tech imaging, including CT, MRI, PET scans, and nuclear cardiology studies, rose almost twice as much a year, on average, as standard imaging, such as ultrasound and X-rays.
Private sector health plans use evidence-based guidelines to ensure patient safety and quality of care while reducing wasteful use of high-tech diagnostic imaging services. In fact, GAO turned to AHIP for interviews and the private payor perspective, and AHIP was among the organizations to review the report in draft and provide comments before it was published.
On the heels of GAO’s report, AHIP released a white paper supporting the report’s findings, pointing out that the alarming patterns described by GAO also have been observed in the private sector, and highlighting strategies health plans use to address the quality, safety, and cost concerns resulting from these trends.
GAO’s Findings
According to Bruce Steinwald, a director in GAO’s health care team, the government report unveils several concerns.
In addition to the huge increase in imaging services Medicare Part B spending from 2000 to 2006, the report indicates a shift in the composition of services over that period, from standard imaging services, such as X-rays and ultrasound, to advanced imaging, such as MRI, CT scans, and nuclear medicine.
“During the period [2000-2006], the amount of spending for advanced imaging started to exceed spending for other imaging services, and there was a pronounced movement of that spending to doctors’ offices, away from hospital settings,” Steinwald says.
The report documented substantial variability in spending geographically, with beneficiary spending on imaging services provided in physician offices varying almost eight-fold across the states in 2006—from $62 in Vermont to $472 in Florida. Physician spending on in-office imaging was the highest in the South, Northeast, and in certain states in the West, according to the government report.
The report also surfaced a potential for financial motivation, according to Steinwald, who says “... the amount of revenue that doctors receive for imaging, as compared to providing therapeutic services in some specialties, increased substantially.”
Steinwald explains that GAO looked at private health plans’ radiology benefit management programs to identify strategies that might help Medicare reverse spiraling spending on diagnostic imaging. The government was interested particularly in the private sector’s use of front-end, versus post-payment, approaches.
“CMS tends to use post-payment claims review as its prime method of trying to manage the benefit, and we suggested in our report—in fact we made a recommendation to CMS—that they use a more front-end approach, in addition to post-payment claims review, to better manage this imaging spending growth,” Steinwald says.
The report also identified a need to monitor quality of care, according to Steinwald. “This report really wasn’t about quality ... but one of the points that we made parenthetically was that when there is movement of services from hospitals to doctors’ offices, there’s less oversight.
We expressed some concern about the quality of services and appropriateness,” he says.
Issues of quality, oversight, accreditation standards, and the need for appropriate training to review images are heightened as services move to physicians’ offices, where trained radiologists may not be available. In fact, radiologists are reviewing fewer advanced imaging scans, and their share of Medicare payments for all imaging services is declining. In 1995, radiologists reviewed 83 percent of advanced imaging scans. By 2005, the number had declined to 58 percent, according to a 2007 study by the Office of Inspector General.
Similarly, a 2007 report by the Medicare Payment Advisory Commission found that radiologists received 40 percent of Medicare payments for all imaging services in 2005, while cardiologists, for example, received 25 percent.
Just after the release of the GAO report, Congress successfully overrode a presidential veto, making the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331) law on July 15. The legislation requires that by 2012, providers of advanced diagnostic imaging services, inclusive of nuclear medicine, MRI, CT, and PET, must obtain accreditation as a condition for reimbursement. In addition, it establishes a two-year voluntary program to collect data regarding physician compliance with appropriateness criteria in order to determine the appropriateness of advanced diagnostic imaging services furnished to Medicare beneficiaries.
Industry’s Stance
AHIP’s white paper, “Ensuring Quality through Appropriate Use of Diagnostic Imaging,” points to potential consequences of a trend left unchecked. It references studies showing that a range of 20 percent to 50 percent of high-tech diagnostic imaging for a variety of conditions fail to provide information that improves patient diagnosis and treatment and may be considered redundant or unnecessary. In other words, they provide no benefit.
Then, there is the concern about health: the relationship between inappropriate imaging and unnecessary exposure to radiation.
One estimate indicates that as many as 1.5 percent to 2 percent of all cancers in the United States may be attributable to radiation from CT scans, a concern that is magnified for children and pregnant women, according to the paper.
Front-end strategies to arm physicians with evidence-based information works to reduce unnecessary images, according to AHIP members, who report that these programs are successful in orienting the use of high-tech imaging to more appropriate interventions that fulfill the promise of longer and higher quality of life. Health plans have demonstrated a reduction of up to 82 percent in utilization of inappropriate imaging, which has implications for quality, and reductions in spending of up to $2.00 per member per month over two years in some instances. Mature programs can hold annual cost trends between 5 percent and 7 percent and have reduced the average growth of utilization from 25 percent to 1 percent, according to the paper.
Accreditation and Advance Notification
In 2006, the national health plan UnitedHealthcare began to see a significant increase in high-tech imaging usage and found that it didn’t necessarily correlate to evidence-based guidelines, according to Lewis Sandy, M.D., senior vice president, clinical advancement for UnitedHealth Group, Minnetonka, Minnesota.
UnitedHealthcare responded with the launch of its “Excellence in Radiology” initiative, with two programs specifically aimed at quality and cost: one to promote accreditation of imaging facilities and the second focused on “advanced notification.”
“In the imaging accreditation program, we’re working collaboratively with the American College of Radiology (ACR) and the Intersocietal Accreditation Commission (IAC) to promote accreditation of facilities using the standards set by the ACR and the IAC,” Sandy says. “From a quality point of view, people should not be exposed unnecessarily to radiation—particularly the new CT scanning modalities (e.g., 64-slice CT scan) that offer fairly high doses of radiation. An inadequate examination or low technical quality is a waste of dollars, a waste of time, and results in radiation exposure that the patient will have to go through again.”
The accreditation process provides a comprehensive assessment of an imaging facility against rigorous professional standards, including training and experience of personnel; the safety, condition, and sophistication of equipment; ongoing quality assurance activities; staff training; and the quality of patient care. While facilities are showing significant interest in accreditation, and many are moving forward with the process, there’s still work to be done, according to Sandy. Starting in 2009 and into 2010, many UnitedHealthcare health plans will require, through payment policies, that enrollees receive imaging services in accredited facilities, he says.
The radiology notification strategy, an advance notification strategy, identifies non-evidence-based usage of high-tech imaging services. “We’re asking physicians’ offices to notify us in advance, either by phone, fax, or Web portal, that they want to have a patient undergo a CT, PET, MRI, nuclear medicine or nuclear cardiology study,” Sandy says. “This applies to outpatient imaging only. It’s not for urgent situations; it’s not for the emergency department; it’s not for inpatient care.”
UnitedHealthcare reviews physicians’ requests based on the evidence and consensus standards developed by key medical specialists such as the American College of Radiology, American College of Cardiology, and so forth. If information is incomplete or indicates some variation from the evidence, the health plan initiates a “peer-to-peer discussion” of the case between a UnitedHealthcare physician and the physician requesting the imaging.
This approach differs from traditional front-end prior authorization programs, according to Sandy. “Our program is a notification process, with a professional dialogue in some cases; no requests for imaging services are ‘denied.’ At the end of the day, the decision-making still is in the hands of the physician [requesting the service],” he says.
The program, in place since 2007, has resulted in changes to the usage patterns of high-tech imaging, bringing them into closer alignment with evidence-based medicine standards.
Plummeting costs are another result of the program.
“What we have found is that around 3 percent of the time, the physicians will change the modality of the procedure that they do based on these clinical dialogues,” Sandy says. “And around 9 percent of the time, the test simply isn’t ordered after the dialogue. We have found our imaging utilization has basically been flat, and our overall imaging cost trends have been cut i 11.2008 coverage - jes ad:Layout 1 10/8/2008 4:38 PM Pagne h1alf over the past two years.”
Decision-Support Tools
A technology-based point-of-care solution is at the heart of the radiology benefit management program used by Health- Partners Inc, a regional integrated health care organization in Minnesota and surrounding states with more than one million medical and dental plan members, a 600-phyisician medical staff practicing at 25 clinics, 60 dentists practicing in 16 dental clinics, and two hospitals. Its innovative approach to frontend management of imaging usage delivers evidence-based information to doctors in the exam room.
Patrick Courneya, M.D., associate medical director for care delivery systems at HealthPartners, says the health plan started examining rising imaging costs in 2004 and 2005.
“We saw the [cost and usage] trends rising consistent with the trends around the rest of the country, which were 12 percent to 13 percent per year overall for diagnostic imaging. When you looked specifically at high-tech diagnostic imaging, it was running closer to 18 percent to 21 percent, depending on the year,” Courneya says.
Courneya, a practicing family physician, says he had conversations with providers in the community throughout 2005 to get a better feel for the issues.
“All of them did acknowledge that the growth of use was a problem that needed attention, and there was disagreement on the best approach, but it validated our concerns and suggested to us strategies that might be fruitful,” he says.
Today, the doctor attributes the burgeoning use of high-tech imaging to a few factors. One is our cultural (physician and patient) affection for technology and the tendency to adopt it without careful consideration of how to put it to the most effective use. Other issues, according to Courneya, are that technology is changing so rapidly that providers might not be able to keep up, and with more physicians getting into the business of offering imaging to their patients, there is increased financial incentive for some doctors to order the tests.
The HealthPartners strategy ultimately focused on making it easy for physicians to base their decisions on evidence by building data into the electronic medical record. Doctors access the decision-making support tool while in the exam room with patients. Similar to the UnitedHealthcare program, the decision support provided by HealthPartners is not designed to override physician decision making—just enhance it.
“We never considered denial of the service an option in the program,” Courneya says.
In Minnesota, where physicians tend to form large medical groups, many are already using or implementing electronic medical records (EMRs), so using a technological approach in the exam room wasn’t a problem, according to Babette Apland, MS, MBA, senior vice president, health and care management, HealthPartners Inc.
“We use the American College of Radiology and American College of Cardiology guidelines and have embedded those guidelines into the physician’s practice, through the EMR, so they can do the self-monitoring, and the health plan doesn’t need to be involved,” Apland says. “We have a review process, so we are retrospectively reviewing the ordering patterns to get a sense of the overall consistency with guidelines.”
Providers have the option of using the health plan’s vendor for decision support or building their own decision-support tool, taking into consideration the HealthPartners specifications.
The HealthPartners medical group gave the software to any physician practice that used the same EMR, improving and speeding adoption.
Physicians are embracing the approach, according to Apland.
“The delivery of health care services has become so complex— so ever evolving—that not being required to carry all that information in your brain, but rather to have easy access to it at the point of delivering care, is an innovation that I think physicians feel enhances their practices,” she says.
The approach is working, according to Courneya.
Since the program was implemented in February 2007, 93 percent of MRI and CT scans have met the criteria of evidence-based guidelines; 1.5 percent have been withdrawn; none have been denied; more than 7,000 unnecessary high-tech scans have been avoided (out of a total of 97,000); and the plan reduced imaging costs by $6.6 million in 2007.
Roughly 70 percent of the plan’s members go to clinics that use the clinics’ own decision-support tools, almost all through their EMRs.
“This approach minimizes workflow disruption in the practice.
It was much easier for the physicians to administer decision support through the EMR than to contact the health plan and get feedback through a prior notification program,” Apland says. “We heard from our medical group that this point of service information allows the physician to more easily engage the patient and inform them in the decision whether or not to have the imaging.”
Lessons Learned
Sandy says health plans that try to implement these strategies without physician and physician staff input are making a mistake. “Any program that prompts change in the workflow for physicians and their office staffs would not be met with enthusiasm, for obvious reasons. So, I think it’s incumbent on anyone administering such a program to be extremely attentive to how the program operates and to minimizing the administrative burden,” Sandy says.
UnitedHealthcare, for example, learned in its pilot program that its network physicians on occasion had to wait on the phone to speak with UnitedHealthcare physicians for peerto- peer discussions.
Now, UnitedHealthcare physicians call providers’ offices and wait for its network doctors to have time to talk with them.
“It’s interesting—with the findings of the GAO report, and new legislation just passed this summer indicating that ultimately facilities need to be accredited to be reimbursed— these are good examples where the private sector has been an innovator and has led the field, not only in identification in a set of issues, but also in developing, testing, and implementing some solutions to those issues,” Sandy says.
Lisette Hilton is a freelance writer based in Florida. She has covered health care for more than 18 years.
