Utilization management involves more people in imaging choices

December 3, 2004

A common complaint among radiologists has become almost a cliche: A head CT scan is ordered by a referring physician to rule out pathology as a source of headaches. All too often, the scan is the first thing the referring physician thinks of instead of the last. Almost always, the scan turns out to be negative.

A common complaint among radiologists has become almost a cliche: A head CT scan is ordered by a referring physician to rule out pathology as a source of headaches. All too often, the scan is the first thing the referring physician thinks of instead of the last. Almost always, the scan turns out to be negative.

But we have reason to expect this scenario to happen less often in the future. Imaging costs are soaring, and payers and the patients they insure are concerned. Utilization review, with some new technological twists and different approaches, is once again entering the picture.

This month's cover story, beginning on page 26, explores the phenomenon of utilization review, documenting the high costs of medical imaging services that are driving it and the different approaches that are being used.

Of course, utilization review isn't new. Payers have long used review mechanisms to some degree. How much they were used has usually been a function of how steeply costs were rising.

That remains the case. As in the mid- to late '90s-the last time utilization review for imaging was really popular-healthcare costs are on a steep upward trajectory. In this election year, drug costs were singled out for attention, but, surprisingly, imaging costs are right behind. As the cover story notes, an analysis that pegged imaging costs at $65 billion to $75 billion in 2000 projects that they could hit $96 billion by next year.

Once, utilization review was largely a job performed by people with green eyeshades in back rooms. Preauthorization for imaging studies was the primary strategy. That remains one approach today, but now it's being joined by high-technology strategies that employ computerized decision support systems. In one example from the cover story, billing data identified doctors who relied heavily on imaging and singled them out for counseling.

In another case, physicians at Brigham and Women's Hospital and Massachusetts General Hospital are using automated order systems that give physicians an appropriateness score when they refer a patient for imaging. Computerized physician order entry systems, a prerequisite for such an approach, are still relatively rare, but their use is growing.

The initial reaction to utilization review among physicians is often negative. Certainly, it is true that bringing in the bureaucracy tends to make systems less responsive and more cumbersome for referring and interpreting physicians. It may also slow down the ability of physicians to embrace new imaging strat-egies and technologies that could prove more effective.

But there could also be a silver lining. Study after study has shown that much of the growth in imaging utilization comes from specialists who acquire imaging equipment and self-refer. To the extent that utilization review could slow this process or change practice economics in a way that makes self-referral less attractive, it might be welcome by radiologists and nuclear medicine physicians.

Another potential benefit is a greater focus on quality. Along with more careful use of imaging equipment, more attention should be paid to getting the best results from it. That includes not using imaging when it is not indicated, but always using it when it is.

The bottom line is that soaring imaging costs and utilization review to address them will bring more and more people into the imaging decision. What used to be a discussion involving a referring clinician and perhaps a consulting radiologist now involves communications systems, computers, peer reviewers, outside consultants, and professional associations. Many will lament this course, but it's the inevitable result of cost pressures in medical imaging.

What are your thoughts on this topic? Please e-mail me at jhayes@cmp.com.