Radiology benefit management credited for slowing imaging growth

A radiologist, well known for research on diagnostic imaging utilization trends, has pointed to the growing prominence of radiology benefit management companies for slamming the brakes on rapidly growing high-tech imaging utilization.

Dr. Vijay M. Rao, radiology chair at Thomas Jefferson University Hospital in Philadelphia, described a direct correlation between the two trends during a lecture Oct. 30 at the 2009 Economics of Diagnostic Imaging National Symposium in Arlington, VA. "Clearly, these programs have had a great impact on the marketplace," she said.

As reported in a 2008 analysis by the Government Accountability Office, high-tech imaging grew rapidly in the early 2000s. The GAO blamed MR, CT, and PET performed in referring physicians' offices for a doubling of Medicare's imaging-related costs to $14 billion from 2000 to 2006. To stem the growth, the GAO made a controversial recommendation that Medicare contract with RBMs, as private insurers had done, to address their imaging utilization problems.

Though RBMs have been in business since the mid-1990s, their approach to imaging cost containment only gained the acceptance of private insurers in recent years, Rao said. In 2005, about one in 10 commercially insured patients was subject to imaging prior authorization through an RBM. By 2009, seven of 10, or 130 million beneficiaries, were affected.

Five RBM companies account for most of that total, she said. National Imaging Associated and CareCore National each cover 30 million lives. American Imaging Management provides oversight for the imaging ordered for 27 million lives. MedSolutions and HealthHelp managed imaging for 25 million and 18 million beneficiaries, respectively.

Those top five RBMs have released data that suggest the use of high-tech imaging has gone down, or at least stalled, in several states where they offer services, Rao said. According to statistics from HealthHelp, MRI and CT utilization rates decreased more than 3% on average in six large urban markets for 2008 alone, leading to estimated savings of more than $8 million. More than 15,000 out of 404,612 requests for CT, MR, or nuclear imaging studies, including PET, were either dropped or changed during that period.

"The data clearly show (RBMs) have been effective," Rao said. "These programs are here to stay, at least for a while."

RBMs claim to promote benefits for healthcare such as curbing imaging self-referral by stemming unnecessary imaging exams. They also boast greater savings due to the psychological barrier that discourages referring physicians from ordering studies unless they really are necessary, what RBMs call the "sentinel effect."

However, radiology experts including Dr. David Levin, chair emeritus of radiology at Thomas Jefferson, and Dr. Richard B. Gunderman, vice chair of radiology at Indiana University, who shared the stage with Rao, expressed skepticism about RBMs' effectiveness in dealing with self-referral and their ability to objectively measure the sentinel effect. They also raised questions about the appropriateness of some RBM prior authorization criteria.

"We have to recognize that RBMs are not going to be able to stamp out self-referral," Levin said. "Anybody who really wants to can game the system. After a while they learn what indications would get the study approved."

Though Levin criticizes some RBM policies, he is a medical advisor for HealthHelp, a firm that has favored physician education over mandatory utilization review to control imaging costs.

Using an automated response system provided by meeting organizers, Rao asked members of the audience, mostly private practice radiologists, if their practices had been affected by prior authorization requirements. About 86% of the 200 or so attendees in the room responded affirmatively to the query. More than half noted they have been "extensively" affected by these programs. Thirteen percent of respondents said they have seen very little impact, and 3% claimed to have seen none at all.

Rao compared the conference's audience response system results with those provided by a Diagnostic Imaging poll conducted in March that found more than 70% of practices have been affected by prior authorization.