White House may stand behind radiology benefit managers

The Imaging e-Ordering Coalition is concerned the Obama administration has failed to grasp the effectiveness of clinical decision support to control imaging utilization, instead favoring the conventional method of radiology benefit managers. In response, the coalition is preparing a white paper to explain the benefits of clinical decision support.

Radiology benefit managers (RBMs), which disappeared from the health reform bill on both the House and Senate sides of Congress, resurfaced during a meeting with legislative staffers at the end of April, said Liz Quam, director of the Center for Diagnostic Imaging Institute, and cofounding member of the Imaging e-Ordering Coalition.

RBMs use prior authorization to control what imaging studies are permitted and when. E-ordering with clinical decision support uses electronic guidance to direct appropriate imaging ordering. The coalition contends this is a better approach to controlling imaging utilization.

As Diagnostic Imaging previously reported, clinical decision support requires the referring physician to enter clinical information like the patient’s symptoms, known diagnoses, age, and other factors in a decision support program. The information is processed through an algorithm that relies on the American College of Radiology’s Appropriateness Criteria to create a decision support score. A high score means the test is appropriate and necessary. A low score asks the doctor to rethink the exam but allows him or her to order the test anyway. Radiation dose and duplicate exam alerts are also built into the system.

“We were greatly successful in both houses of Congress because you didn’t see RBMs anyplace in the healthcare bill,” Quam said. “It just goes to show you nothing’s dead in Washington, ever.”

In a meeting with the Imaging e-Ordering Coalition and legislative staffers, Keith Fontenot, director for Health Programs in the Office of Management and Budget (OMB), said RBMs assured him they could keep imaging utilization flat, according to Quam.

“We heard that from some other folks on the hill too,” she said.

Diagnostic Imaging requested an interview with Fontenot through the OMB’s press office. Instead, Kenneth Baer, OMB’s communications director, provided the following statement: “The administration supports, as part of an effort to digitize healthcare, technologies that assist healthcare providers by giving them the best information when they need it to make the best decisions possible with their patients.” He also denied that Fontenot expressed support for the RBM approach.

The prospect of RBMs keeping the utilization rate flat is alarming, Quam said.

“How can the rate be flat without rationing access to imaging?” she said. “There are always more technical advances that are going to get us to other kinds of imaging studies.”

For instance, using CT colonography to screen for colon cancer would contribute to an increased utilization rate.

“There is no way, if we’re going to continue to have a vibrant, continuously progressing healthcare environment, that imaging services aren’t going to expand,” she said. “So if you’re going to show me a flat line on utilization, that’s dead on a human being and certainly it is in the imaging industry, too.”

To expand services the utilization rate must increase, otherwise providers aren’t being reimbursed or some patients are not receiving the services they require, she said.

As a consequence of the April meeting, the Imaging e-Ordering Coalition must create a white paper to compare costs of RBMs with clinical decision support, Quam said.

“As I tried to explain the difference between an RBM and clinical decision support, the comment [of one of the purchaser representatives] on the RBM was ‘Oh that’s so 80s.’” Quam said. “For old people like me, that says it all right there.”