Payers Seek to Rein in Radiology Costs

As health insurers grapple with the high costs of diagnostic imaging, oncologists will increasingly be required to defend their image orders. Prior authorization for high-technology imaging is already becoming routine in some markets, and big health plans like CIGNA and UnitedHealthcare are introducing new strategies to rein in radiology costs. Insurers contend that there is too much diagnostic imaging equipment in America, much of it being used to conduct unnecessary studies. As a group, oncologists are not viewed as the villains in this problem. But as payers try to identify those they consider at fault and eliminate the problem, oncologists will be caught up in the “solution.” “A lot of plans are seeing imaging costs going up double digits year over year—in some cases, rising 20 or even 30 percent,” said Christopher G. Ullrich, MD, a radiologist in Charlotte, NC, and Chair of the American College of Radiology Managed Care Committee. “Even though drug costs have been a focus of attention in recent years, imaging costs are actually going up faster.” Prior Authorization Program Introduced In his state, the dominant health plan, Blue Cross and Blue Shield of North Carolina, earlier this year introduced a prior authorization program for diagnostic imaging via American Imaging Management (AIM), a Deerfield, IL-based company that is scrutinizing imaging requests for more than 22 million lives. The new program requires prior authorization for any computed tomography, magnetic resonance, positron emission tomography, or nuclear cardiology study. “Given the rapidly escalating cost and use of these high-tech scans, we wanted to make sure our members were getting the right scan for their circumstance,” said Mark Stinneford, a spokesman for the North Carolina Blues. American Imaging Management has contracted with more than a dozen Blues plans, as well as other major insurers. Utilization management works, said David J. Soffa, MD, MPA, Senior Vice President of Medical Affairs at AIM. “With imaging management techniques, we can get out anywhere from 22 to 35 percent of really inappropriate outpatient imaging that's being performed.” AIM's strategy, he added, is to educate physicians about the appropriate use of imaging, and prior authorization creates the interface to allow this to happen. “This is the only intervention that really works in terms of getting busy physicians to understand the importance of ordering the imaging appropriately and to communicate best imaging practices. The innovations have been so fast and furious that it's almost impossible for a general radiologist to keep up, much less a busy practitioner.” ‘Hassle for Physicians’ Anthony F. Shields, MD, PhD, is a busy researcher, professor, and clinician at the Barbara Ann Karmanos Cancer Institute. A specialist in gastrointestinal oncology, he regularly orders CT, MRI, and PET images—but he gets calls only from private insurers about the PET orders in which he seeks to stage, re-stage, or monitor tumors in situations not yet approved by CMS. Unlike the situation with many prior authorization requests, Dr. Shields' staff cannot field the calls. “They specifically say that it's got to be physician-to-physician, and they will not accept anything less,” Dr. Shields said. “I'll end up having to dial some number and speak to a physician there to get the PET scan agreed upon.” In most cases, Dr. Shields gets the approval he seeks, prompting him to wonder whether the prior authorization strategy is worth anybody's time. “They are certainly a hassle for the physicians who are taking care of these patients. In that regard, they add a cost to our system, both from the insurer's side and from my side.” On the other hand, Dr. Shields wonders if the hassle factor may be the whole point. “Obviously their desire is to dissuade us from even bothering to appeal these and hopefully decrease the use of such scans,” he said, adding that, despite his appeals, he did get a request denied recently. “I don't know how many other physicians just throw up their hands and say, ‘Forget it.’” Oncologists tend to receive approvals for their scan orders because in most cases they are justified, Dr. Soffa said. As a discipline, oncology is not considered to be a culprit in the overuse of imaging technology. Rather, utilization management seeks to decrease the use of what he calls “truly discretionary” imaging—an MRI for a typical migraine headache, for example, or for other conditions that will probably clear up on their own. Multiple Factors behind Imaging Increase But oncologists need to be in the utilization-management programs until the waste is wrung out of the imaging industry, Dr. Soffa said. Correcting the problem should be a shared responsibility of the medical community. “What is going on is bad medicine with wasted radiation exposure and misleading false-positive results. The only real way to get it out of the system is to understand who is ordering inappropriately and provide a mechanism for increased scrutiny and real education.” The steady increase in imaging volume is due to several factors, some of which have more to do with money than medicine, Dr. Ullrich said. As many physicians seek to increase their revenues by buying imaging technology, the American College of Radiology has become a vocal critic of self-referral, saying it motivates physicians to order unnecessary images to keep the machine busy. Proliferation of Imaging Equipment Self-referral is probably linked to the overall proliferation of imaging equipment in use, a trend commonly assailed as driving up health costs. The greater Pittsburgh area has 120 MRI units, more than the entire country of Canada has, Dr. Ullrich noted. Another financial driver is the malpractice environment in which many physicians practice, prompting them to order scans that confirm their diagnoses. Meanwhile, advances in imaging technology are steadily increasing the physician's ability to understand what is going on inside a patient's body. Therefore, not all increased utilization is undesirable. That fact sometimes fuels patient requests for additional scans, Dr. Ullrich said. Dr. Shields agreed. He regularly gets “pushback,” he said, from patients who want a scan to reassure them that a new tumor has not emerged. On occasion he has ordered scans rather than argue. “It is very difficult and time-consuming for me to sit there and explain to the patient, ‘Well, the scan may pick up the disease before you have symptoms, but you would be incurable at that point.’ That is not an argument that patients want to hear.” Appropriate Use Debated Further complicating the situation is the fact that, for some situations, there is no consensus among oncologists about appropriate use of scanning technology. For example, Dr. Shields once weighed in on an online discussion with colleagues on the use of PET imaging for surveillance after the treatment of breast cancer. Since previous work had shown no benefit from doing routine bone scans for such patients, even more expensive PET scans would not help patients in the long run, Dr. Shields said. He received two replies to his posting. “One was from a physician saying, ‘Great, I'm really pleased that somebody stood up and said that you shouldn't do surveillance monitoring with PET scanning.’ The other was from somebody saying, ‘I'm glad you're not my doctor.’ So it's clear that there's a dichotomy of opinion out there about how much imaging should be done.” Dr. Shields is a co-investigator for the National Oncology PET Registry, which is collecting data on the use of PET for diagnosis, monitoring, and staging of cancers in previously unapproved indications to help answer some of the pending questions about its use. Health insurers are uniform in their opinion that less imaging should be done, and that is the goal of utilization management programs. While prior authorization is the most prevalent strategy, other strategies are emerging. Earlier this year, UnitedHealthcare, one of the nation's largest insurers, announced an imaging accreditation program, signaling to diagnostic imaging providers that the insurer may require accreditation by ACR or another accrediting body before it will reimburse for images. Currently, fewer than half of imaging providers are accredited, so this initiative may pressure owners of old equipment or substandard operators to get out of the business. Meanwhile, two other large insurers—Empire Blue Cross Blue Shield, the largest insurer in New York, and CIGNA, a national player—recently contracted with National Imaging Associates, a subsidiary of Magellan Health Services, to have NIA handle radiology management on a fully insured risk arrangement. NIA declined to be interviewed, but a company news release indicated enthusiasm for the profits to be made in radiology management. “NIA has everything to gain by making ordering of testing the most onerous that it can,” Dr. Ullrich said.

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