Cally Vinz

A Case for Prior Authorization of Imaging Services

,” Douglas Tardio posed the question: Which is really better for patient care - clinical decision support or prior authorization? Mr. Tardio concluded that it is the latter.

While we agree that both approaches can help manage utilization rates of imaging and reduce health care costs, we beg to strongly differ that prior notification is the better option. This is based on four years of experience with 4,500 physicians in five medical groups using decision support to order 1.3 million high-tech scans in Minnesota. We have hard facts that indicate decision support is better for not only patients, but providers, health plans, and our nation.

In fact, based on the pilot results, the Institute for Clinical Systems Improvement (ICSI) made its decision-support option available to all medical groups and hospital-based clinics in Minnesota in 2010. Today, more than half of all scans in Minnesota are ordered using decision support and this number grows weekly.

In Mr. Tardio’s defense, we assume he is not familiar with ICSI or its decision-support option. We are a non-profit organization representing 64 medical groups and sponsored by five health plans. Minnesota medical groups, radiologists, health plans, patients, and the Minnesota Department of Human Services developed our decision-support option.

What follows is a juxtaposition of the facts we learned in our ICSI pilot against some of the points (paraphrased) made in the article.

• Article: It is estimated that physicians using decision support don’t complete the full review up to 66 percent of the time, resulting in reduced compliance with evidence-based medicine.
• ICSI Trial: A physician must complete the full review to receive a decision-support number required for submitting an order for claims processing.

• Article: Prior authorization matches the unique needs of specific patients with treatments or tests proven to be effective based on a variety of conditions and similar histories.
• ICSI Trial: The appropriateness criteria used in the ICSI pilot are based on American College of Radiology standards and those of other specialty groups. A physician selects a scan based on the patient’s clinical indications, personal demographics, and history the same as with prior authorization.

• Article: It’s common for physicians to demand significantly more inappropriate or unnecessary imaging tests under decision support; prior authorization saves clients twice the amount saved using decision support.
• ICSI Trial: Minnesota experienced an 8 percent annual increase in scans ordered from 2003 to 2006. Prior notification was implemented at the same time the five medical groups initiated decision support. Combined, prior notification and decision support has resulted in only a 1 percent increase in scans ordered over the past four years in Minnesota. Over time, more scans were ordered using decision support than prior notification, with no increase in usage, indicating decision support is just as effective as prior authorization. At this time decision support is used for the majority of orders.

• Article: If the goal is to provide patients with the best, most appropriate treatment or test, decision support fails to deliver because it is considered “optional” by many practitioners.
• ICSI Trial: Providers cannot order a scan without using decision support. It is embedded into their electronic medical record or available via a Web tool and the decision support number is required for claims processing (as is the case with prior authorization).

• Article: Tools used in both systems are virtually identical and equally time consuming from an administration standpoint; decision support requires higher physician participation, and is only faster if physicians opt out of the process by ignoring recommendations.
• ICSI Trial: One pilot medical group spent 308 hours to get prior authorization approval on 1,850 scans in one month. With decision support, it took five hours. Using decision support can minimally increase a physician’s time with the patient, but that time can be used to strengthen the physician/patient relationship, provide an opportunity for shared decision making and enhance the physician’s credibility because the patient leaves the office knowing the appropriate test was ordered versus learning later that is was possibly denied.

• Article: As more payers embrace prior authorization, technology is being introduced to make the process easier and simpler for physicians.
• ICSI Trial: Minnesota health plans asked ICSI to develop the decision-support option. Their experience indicates prior authorization costs up to eight times more than using decision support. They support ICSI’s statewide initiative, and had the option to return to prior authorization requirements and did not do so because of decision support advantages. On the point of technology, the ICSI option works in EHRs or it can be accessed via the Web so it can be seamless or worked into any clinical workflow, and viable for all providers.

Prior authorization was an important first step in helping to rein in the ordering of inappropriate scans. In fact, decision support is an immediate, electronic version of prior notification unencumbered by the inefficiencies, administrative costs and potential delays. We conclude that decision-support is a better option than prior notification for the following reasons:

1. It results in an equal or lower rate of services rendered, yet provides the physician with a utility score, as well as the option to choose a higher utility test. With prior authorization, the physician never knows the utility of their order and may not even know that the test was denied.

2. It is as evidence-based as RBM prior notification.

3. None of the 4,500 physicians in the ICSI pilot, when given an option to switch back to prior notification, did so. Not only do they report that decision support is more cost effective and efficient, they note it also serves an educational purpose by helping them learn which tests offer the highest utility based on a patient’s condition.

4. The major health plans in Minnesota are supporting the switch to the ICSI option.

5. Decision support is more patient-centered - strengthening the patient/provider relationship and eliminating the inconvenience that can occur with prior notification. This is becoming more important as risk sharing agreements arise in the medical home and accountable care environment where patient outcomes and patient/provider partnerships are a key focus.

Cally Vinz is vice president of clinical products and strategic initiatives at the Institute for Clinical Systems Improvement, and has led ICSI’s high-tech diagnostic imaging initiative since its inception.

Articles

While we agree that both approaches can help manage utilization rates of imaging and reduce health care costs, we beg to strongly differ that prior notification is the better option. We have hard facts that indicate decision support is better for not only patients, but providers, health plans, and our nation.

Cally Vinz

Articles

A Case for Decision Support of Imaging Services