Radiology Associations Call for Congress to Ignore BCBS Plan

October 13, 2011

The Blue Cross Blue Shield Association plan unveiled last week that touches on advanced imaging services has industry leaders up-in-arms, calling for Congress to leave plan-of-care decisions between doctors and their patients.

The Blue Cross Blue Shield Association plan unveiled last week that touches on advanced imaging services has industry leaders up-in-arms, calling for Congress to leave plan-of-care decisions between doctors and their patients.

In a move that would shift the healthcare system away from fee-for-service to a patient-centered model, this proposal would require prior authorization for advanced imaging services. Some economic analyses estimate the measure could save $319 billion over the next decade.

However, many in radiology say there is no proof that adding this step as a blanket measure will produce any benefit. In fact, they say, the change would affect not only radiologists, but it could also delay treatment options for older patients who rely heavily on imaging studies for diagnoses.

“No evidence exists that mandating prior authorizations for medical imaging will actually result in any cost savings,” said Tim Trysla, executive director of Access to Medical Imaging Coalition (AMIC). “And requiring it for services that the Medicare program already covers for seniors will only result in denial or delay of services.”

Medicare would likely overturn any denials of coverage, so the end result would be wasted time and money, he said. Instead, Trysla suggested alternatives, such as physician-developed appropriateness criteria and decision support tools as methods to bolster proper imaging use without negatively affecting patient access.

BCBS recently piloted a similar measure for cardiac nuclear imaging services in Delaware. Ultimately, the Delaware Insurance Commissioner determined requiring prior authorization for these services didn’t improve the quality of patient care. The group recommended BCBS abandon the effort and follow the American College of Cardiology’s FOCUS program, a national movement designed to help cardiologists only order appropriate imaging tests.

Although industry leaders said there is no evidence-based data to support the benefits of using prior authorization, they did point to anecdotal data that does exist to the contrary. According to a recent American Medical Association physician survey, 63 percent of the 2,400 responders said prior authorization slows down necessary medical procedures. The Department of Health and Human Services is also on the record as saying prior-authorization programs could work against Medicare as a public program because they would rely on private companies to deny doctor-ordered care.

Putting an extra hurdle in place only complicates the process patients undergo to receive imaging studies, said Dave Fisher, executive director of the Medical Imaging & Technology Alliance.

“We know that these programs are highly burdensome and reduce access to care. Policymakers should not place additional hurdles between patients and necessary diagnostic and screening services,” Fisher said, supporting Trysla’s call for alternative strategies. “Instead, healthcare providers should use evidence-based, physician-developed appropriateness criteria to ensure patients have access to the right scan at the right time.”

If Congress approves the plan, it is possible that prior authorization requirements could impact your workflow. It is likely, Trysla said, that you would see the pace at which you provide services slow down.

“This would cause a major disruption to same-day imaging services,” he said. “You could especially see a bottle neck on the ambulatory side without any evidence-based proof that it will result in improvements in care.”