Insurer in Pennsylvania limits specialty-run imaging

Pennsylvania's largest health insurer has launched what could be a major attack on specialty-run imaging services. The strategy to rein in imaging costs has taken root in the western part of the state and will soon move eastward. If successful, the landscape for entrepreneurial diagnostic imaging could change drastically.

Highmark Blue Cross Blue Shield in western Pennsylvania last summer initiated quality standards for all imaging modalities, but most significant are requirements for advanced imaging services and for staffing imaging facilities.

Practices offering CT or MR, for example, must provide at least five modalities from a list that includes plain film, general or ob/gyn ultrasound, echocardiography, nuclear cardiology, mammography, and fluoroscopy. In addition, a Highmark-credentialed radiologist with advanced cardiac life support certification must be present at all imaging centers. Facilities must operate a minimum of 40 hours a week, including one evening per week and at least two Saturdays per month.

"The day of completely uncontrolled and unregulated diagnostic imaging is coming to an end," said Victor Panza, senior vice president of national network strategy at National Imaging Associates, a utilization management company that helped Highmark develop and implement the guidelines. Highmark plans to roll out similar guidelines in cental Pennsylvania in July.

Providers across the country are beginning to routinely apply stricter standards to high-end diagnostic imaging. In December, UnitedHealthcare of Minneapolis, the nation's largest health insurer, announced it would use American College of Radiology accreditation and imaging appropriateness criteria. In New England, Anthem initiated higher co-pays for advanced imaging exams. Mid-Atlantic Medical Services, a UnitedHeathcare company, recently announced it would not credential any new imaging sites in central Pennsylvania.

"Everyone is trying to get a handle on the proliferation of imaging in outpatient centers," said Dr. Robert Pyatt, president-elect of the Pennsylvania Radiological Society.

Two major trends have impelled insurers to retool their imaging coverage. The first is the recognition that nonradiologists who self-refer utilize imaging to a greater degree than physicians who refer to radiologists. The second is the proliferation of so-called boutique imaging centers that offer MR and/or CT imaging only. The one-modality facilities hinder the profitability of multimodality practices. Boutique centers essentially siphon off high-end imaging profits, leaving full-service imaging centers to rely on low-margin procedures such as mammography and ultrasound, said Dr. Alan Kaye, radiology chair of Bridgeport Hospital in Connecticut.

The financial ramifications of losing high-end business to entrepreneurial centers are huge, Kaye said. Decreased profits delay the purchase of new equipment or the updating of current systems, further diminishing a center's competitive advantage. In addition, hospitals could potentially halt low-margin services if their imaging centers are not profitable.

To Highmark's credit, it formed an advisory committee that included radiologists, orthopedic surgeons, cardiologists, and others, said Dr. William Poller, associate director of breast imaging at Allegheny General Hospital in Pittsburgh, PA, and a member of the committee. Some people complained that hospital-based radiologists were receiving special treatment, he said.

"The entrepreneurs around the table were not happy. But Highmark made a business decision that was in the best interest of their clientele," Poller said.

Vendors and nonradiologist imagers had threatened to sue Highmark, claiming that the tighter restrictions violated antitrust laws. As of December, no lawsuits had been filed to stop the initiatives, Poller said.

"We have expected providers to raise issues with us," said Michael Weinstein, a spokesperson for Highmark. "Our goal was to achieve high-quality care by addressing issues raised by our customers, such as access, repeat testing, and quality equipment."

The PET community has been upset by a guideline requiring that PET imaging be done in a hospital setting. A letter to Highmark signed by members of the Academy of Molecular Imaging, the Institute for Clinical PET, and the Institute for Molecular Technologies stated that the new policy will likely increase rather than decrease healthcare costs and will also reduce the quality of care.

"We know of no data to support [Highmark's] assessment that results are better utilized when PET is performed in a hospital setting than in a non-hospital based setting," the letter said.