April 2008
A new study by the Center for Studying Health System Change (HSC) confirms what many in the diagnostic imaging industry already know: As advanced medical imaging services grow at double-digit rates, health plans are scrutinizing their use more closely and targeting such high-cost services for more aggressive oversight.
The findings by HSC, a highly regarded think tank, will likely be examined by Congress as it formulates Medicare legislation this spring and may well play a key role in any systematic reform effort under the new president in 2009.
According to the study, health plans are targeting selected, high-cost services for more aggressive utilization management rather than imposing stricter controls across all services. Plans hope the targeted strategy will help avoid physician and patient backlash against perceived intrusion on physician autonomy and the administrative burden associated with utilization control requirements.
Since 2000, the use of advanced imaging has grown significantly for both commercial health plans and Medicare. The annual growth rate in the number of CT scans performed in the United States per 100 population between 2000 and 2005, for example, was 13%, rising from 12 CT scans per 100 people in 2000 to 22 scans per 100 people in 2005. For Medicare, in particular, the average annual growth rate for CT and MRI scans was 15% or higher from 2000 to 2004.
Reducing Imaging Utilization
Although in 2007 Medicare capped reimbursement rates for imaging performed in physician offices and diagnostic imaging centers, some health plan respondents said they haven’t reduced rates for imaging services because of concerns that high-quality providers would drop out of networks, thereby limiting member choice of providers.
Instead, plans are pursuing strategies ranging from physician feedback and education to more intensive approaches, such as prior notification, prior authorization, and credentialing of physicians and equipment. In addition, some plans are using claims data to find patterns of questionable image use by individual physicians, the study found.
Plans also are providing information to physicians as a way to begin a discussion about appropriate imaging use and some are providing physicians with evidence-based guidelines from professional societies, such as the American College of Radiology and the American College of Cardiology.
One health plan in Phoenix, for example, reported success in reducing the use of high-cost nuclear testing by providing prescribing cardiologists with data on their utilization patterns and asking physicians to use a checklist before deciding what diagnostic tests to order. Through this process, cardiologists are asked to explain why a simpler and less expensive test, such as a treadmill stress test, would not be adequate. According to a plan respondent, targeted cardiologists did begin using treadmill stress tests in many cases, obviating the need for the more expensive nuclear test.
Despite physician objections to utilization controls for imaging, health plans generally have stood firm because they believe they have the support of employers and that the cost savings and patient safety gains associated with the increased oversight outweigh the potential negative effects, finds the study. As plans expand imaging management, there is a need for independent evaluations that address not only the magnitude of cost savings from various health plan strategies, but also the magnitude of the costs generated for providers and patients and the implications for patient safety and quality of care.
The study, issue brief no. 118, Health Plans Target Advanced Imaging Services: Cost, Quality, and Safety Concerns Prompt Renewed Oversight, is available at www.hschange.com/CONTENT/968/.
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