Utilization management steps onto center stage

July 1, 2005

The rapid growth in imaging utilization over the last several years has drawn the attention of third-party payers from both the private sector and the government, which are now seeking ways to dampen the upward trends. Simply stated, imaging costs are rising faster than overall healthcare costs, making them stand out like a beacon for attention.

The rapid growth in imaging utilization over the last several years has drawn the attention of third-party payers from both the private sector and the government, which are now seeking ways to dampen the upward trends. Simply stated, imaging costs are rising faster than overall healthcare costs, making them stand out like a beacon for attention.

A number of different approaches have been employed by the insurance industry to oversee the ordering and delivery of imaging services. Some are as simple as requiring a personal identification number for the ordering physician.

More commonly, insurance companies have over time required the requesting physician to contact the company to obtain an approval number, sometimes asking for additional information about indications. In the early days, this was mostly a pro forma process that could be accomplished by office personnel.

Many referring physicians find such requirements frustrating and annoying because they mean extra work for the physicians and their support staff for no additional compensation. This reaction has, in turn, become a negative public relations issue for radiology. Radiologists must rely on the goodwill of the referring physician community to comply with prior approval requirements and to then send the correct information to us. Yet some clinicians don't believe it should be their responsibility to obtain the prior approval so that radiologists can be paid for their work. After all, why should they care?

Another problem is that providers lose and insurance companies win whenever complexity in the billing process increases. Claims are denied unless they are perfect so-called clean claims. The likelihood of achieving perfection decreases with increasing complexity, such as the addition of a requirement for a prior approval number. Claims logic never favors providers: Any error among the multiplicity of required fields leads to denial, and anything that increases complexity guarantees that denials for legitimate services will increase. Insurance companies count on this formula to improve their financial results at the expense of providers.

Each insurance company has its own unique proprietary process, making it difficult for both referring physicians and providers of imaging services to keep track of how to comply. A number of years ago in Massachusetts, for example, one of the insurance companies introduced a 15-digit approval number without notifying providers. The likelihood of getting all 15 digits correct over the telephone was not favorable! Moreover, the computer system we were using at the Massachusetts General Hospital could only handle a maximum of 10 digits in any one field. The company began denying all of our claims. We were unable to successfully collect on any claims until we had negotiated a settlement with the company.

NEW COTTAGE INDUSTRY

Further escalation of the level of control exerted by insurance companies is a clear trend, along with a concomitant increase in the time and effort providers must spend to comply. We are seeing a rapid rise in the medical and administrative overhead related to obtaining approval for imaging studies and the increased likelihood that otherwise legitimate claims will be denied for purely technical reasons and not because of disputed medical necessity.

A number of companies have been formed for the purpose of selling utilization management services to insurance companies. In a typical scenario, clinician providers no longer contact the insurance company directly but are required to call a 1-800 number and present the relevant information about the desired imaging study and the reason(s) justifying it. The examination may be approved immediately without further question by a clerk, or the provider may be required to talk with a nurse and then a physician. The length of time expended may be as little as two or three minutes or as long as 10 to 15 minutes. Whether a provider receives immediate approval or must go through a more extensive process is based on proprietary factors determined unilaterally by the utilization management company. The caller's fate may be affected by the number of phone calls coming in to the company at a given time versus its capacity to handle them.

Utilization management companies either develop their own proprietary medical policies for approving requests for imaging services or license medical policy content from other commercial sources to guide the approval process. The medical content used in the approval process is supposedly based on evidence of procedure appropriateness from the medical literature or expert panels. In practice, however, the approval process appears to function like a black box from the perspective of the requesting physician, who may or may not have practical access to the coverage policies.

These companies advertise that they will save their insurance company clients money by reducing utilization. Indeed, most radiologists would probably agree that many examinations are ordered that either are not indicated or are of marginal value. It is unclear, however, how much of any savings is due to denials of inappropriate requests versus simple denial of a percentage of requests. The utilization management companies and their insurance industry clients should provide information to the medical community about the nature of these savings to justify the extra uncompensated work they are imposing.

Perhaps the secret is better education of clinicians over time by walking them through the approval process on multiple occasions. Perhaps simple frustration produced by the process requirements will inspire clinicians to reset their thresholds for requesting procedures.

It is troubling that an anonymous remotely located person with no knowledge of the complete context in which an examination is ordered can be the arbiter of the care process. Complex medical care and medical management cannot be reduced to a few transactional concepts. Do the 1-800 programs represent true utilization management or just cost reduction through aggravation?

PAY FOR PERFORMANCE

Another direction being taken in utilization management is the establishment of so-called pay-for-performance programs. Unlike the approval programs that attempt to manage utilization on a transaction by transaction basis, pay-for-performance programs set overall goals or targets for either individual physicians or physicians practicing as part of larger entities, such as academic medical centers or preferred provider organizations. The providers are rewarded financially for achieving contracted goals. Pay-for-performance plans are proliferating nationally, in part because they are being strongly promoted by the Centers for Medicare and Medicaid Services and industry-sponsored groups such as Bridges to Excellence and the Leapfrog Group.

In one pay-for-performance arrangement at Massachusetts General Hospital, the institution and its associated medical group negotiated an overall target for higher cost imaging services with an insurance company. The target is expressed in terms of the number of designated examinations provided per year to the covered population of patients. The advantage of this arrangement is that medical decision making stays with the provider organization. Providers continue to have wide latitude in exercising their case-by-case medical judgment, while the group as a whole faces the challenge of staying within the target. This approach has actually challenged us to look at our habits with regard to imaging and, probably, to be more honest in our self-assessment of how we practice.

REAL-TIME DECISION SUPPORT

To help manage our pay-for-performance contracts at MGH, we have developed a point-of-care Web-based decision support system under the direction of Dr. Dan Rosenthal to help clinicians determine the appropriateness of the imaging examinations they are ordering. For each examination, we provide a series of reasons for performing it. After the clinician has selected the desired examination and indications, he or she receives an appropriateness score from 1 (low) to 9 (high) for not only that requested examination but any other reasonable alternatives.

For example, if a brain CT is ordered, the decision support system will provide an appropriateness score for brain CTA, MRI, and MRA as well. The system also provides contact phone numbers for each subspecialty area in the department and just-in-time knowledge in the form of links to articles in the medical literature and other evidence-based summaries describing appropriate utilization of medical imaging. The clinician remains the final decision maker, but substantial information is available in real-time to aid the decision.

Feedback from clinicians has been very positive. They like having information at their fingertips in real-time and being alerted to best practices right at the point of care. Each specialty was consulted in developing the criteria, which also take into account the American College of Radiology criteria. The system fits into the workflow of a busy office far better than does making yet another phone call, being placed on hold, and then going through a quiz. All scores are recorded so that each physician's performance can be assessed over time and fed back to the individual for consideration.

CONCLUSION

All stakeholders-including the public, payers, patients, and providers-have an interest in improving the appropriateness of utilization of all medical services, including imaging. Adding process steps, complexity, and costs to providers, however, and expecting to manage imaging remotely over the telephone through a transactional approach is a solution doomed to failure, and it should be abandoned as soon as possible.

Before adding new layers of bureaucracy and expense to all providers, laws and policies restricting financially motivated self-referral should be strengthened and enforced. Available data suggest that this step alone would substantially reduce the amount of unnecessary imaging being performed in the U.S. Creative new decision support and performance tracking systems, such as the system at MGH, show promise in helping clinicians achieve best practices in utilization of imaging services without adding an extra burden to the workday. They should be further explored.

Dr. Thrall is radiologist-in-chief at Massachusetts General Hospital.