The Race to Manage Imaging Costs

Can electronic decision support give RBMs a run for the money?

Radiology benefits managers (RBMs) have been the proposed method of reducing imaging overutilization, and with a proven track record, they pack a strong financial argument. But are they the right way and are they the only way? Electronic decision support, which uses algorithms based on appropriateness criteria, is coming into the forefront as another contender in the race to manage imaging costs.

But is this technology ready for “prime time”? Can the government see its value in time to put it to work as a solution for the nation’s healthcare woes? Many say it’s not only possible, but it’s crucial to embrace this and other forms of health IT to not only curb spending, but also bring healthcare into the 21st century.

As the U.S. government begins to sink its teeth into the daunting task of healthcare reform – a sizeable chunk of which will directly affect medical imaging – many questions arise regarding the most effective way to reduce healthcare spending. However, there is no consensus on which is the best way to control the spiraling costs of high-tech imaging.

While some seem convinced a radiology benefits management program is the only solution, others in the imaging community argue that leveraging health IT – namely, decision support tools – can not only lessen the government’s financial burden, but also promote better patient care, effectively manage imaging utilization, and aid in the transition to an eventually all-digital healthcare system.

RBMs: Help or Hindrance?

In order to pay for the proposed healthcare reform, the Obama administration’s biggest challenge lies in finding ways to curb spending in the current healthcare system.

What currently worries many groups in the imaging community about the pending healthcare reform is the potential inclusion of a policy that would use RBMs to control Medicare beneficiaries’ access to certain imaging services. RBMs are for-profit companies employed by insurance carriers to ensure appropriate spending for imaging by approving or denying reimbursement for imaging exams. In this model, physicians are required to call the RBM company to verify plan coverage before ordering the exam.

RBMs have been in use by the majority of commercial plans in the private sector for a little more than a decade, but last June, the U.S. Government Accountability Office came out with a report that recommends that the Centers for Medicare and Medicaid Services (CMS) use more front-end practice management approaches, such as prior authorization, to address the rapid growth in Medicare spending on imaging services, which they found had more than doubled between 2000 and 2006.

Upon reviewing the GAO report’s recommendations to implement RBMs, the Department of Health and Human Services (HHS) questioned the feasibility and raised concerns over the administrative burden RBMs would cause, especially if denials turned into appeals. HHS also expressed concern over the method used to obtain the data that was in favor of RBMs. Much of the data was self-reported by the RBMs, and there were no independent studies conducted to truly measure RBMs’ success.

But HHS was not alone in its skepticism of the RBM model. Groups such as the American College of Radiology (ACR), the Medical Imaging & Technology Alliance, and the Access to Medical Imaging Coalition immediately became alarmed by the GAO’s report and countered with the argument that RBMs are not the answer. Their concerns are founded on the idea that medical decisions are too important to be taken out of doctors’ hands and trusted to outside entities that are based on a payer-centric model.

Instead, these groups are lobbying for a more physician- or patient-centered model that ensures the patient receives the right test at the right time without compromising or interfering with the patient-physician relationship. A common complaint from physicians is that RBMs are burdensome and hinder the healthcare process.

Ramin Khorasani, MD, MPH, vice chair of the department of radiology at Brigham & Women’s Hospital (BWH) in Boston, sees this issue as one involving several layers of cause and effect. Imaging contributes greatly to the care doctors provide. However, a lack of adoption of evidence into current practice exists in imaging and generally across the board in medicine.

As a result, there is suboptimal use of imaging in many clinical circumstances, which results in unnecessary, inappropriate, or redundant use of imaging. This creates waste and negatively impacts the quality of care, he says. From a quality perspective, suboptimal use of imaging is not good, but most of the focus has been around reimbursement.

Once payers began to see a rapid growth of high-tech imaging, they responded by bringing in third-party RBMs to help reduce the cost of imaging.

In Khorasani’s opinion, however, the RBMs essentially created barriers to an optimal flow of information and created hindrances to physicians for getting what they needed. He explains that the more disruptive the RBMs became to physician workflow, the more frustrated physicians would become and ceased going through the hassle of ordering imaging exams, hence reducing the use of imaging and reducing its associated costs.

Many physicians would argue that working with RBMs causes delays in patient care. Since insurance plans use different RBMs, the doctors have to make calls to different places all the time. Khorasani says each RBM uses its own set of criteria and its own forms, too.

Then there’s the length of time each phone call takes. Some may take only two minutes, but others can take 15 minutes, 20 minutes, or even 45 minutes. This manual process of prior authorization slows the expedition of care, which is not favorable to doctors, whose time is precious when trying to see as many patients in a day as possible.

“RBMs are creating unhappy physicians, and ultimately, unhappy patients,” Khorasani says.

Putting Evidence-Based Medicine to the Test

Many groups strongly feel that the problem of unnecessary, inappropriate, or redundant imaging exams can be addressed by the adoption of an evidence-based imaging model that makes imaging decisions based on appropriateness criteria. One method of achieving this goal is through the use of electronic decision support (EDS) technology.

At BWH, Khorasani has been long involved in developing and using EDS. In 2004, he and others at BWH collaborated with local payers to use EDS tools in lieu of RBMs. Working with Kitchener, Ontario, Canada-based Medicalis’ technology called Percipio*, the BWH team achieved its goals of improving quality and, in four years, reduced costs for one of the payers by about 15 percent.

With Percipio, the physicians are provided with tools embedded into their workflow that allow them to order and schedule exams, as well as be advised of its appropriateness. From a content perspective for the decision support, BWH is using content from Medicalis, which includes a mix of BWH best practice criteria (local content), ACR, American College of Cardiology, American College of Physicians, plus other peer-reviewed journal articles which are updated on a monthly basis.

Every exam is ordered in exactly the same way, regardless of its cost, the patient’s insurance plan, or other factors. The system is designed to give the physician automatic approval preauthorization on his computer screen in realtime. If the exam is deemed inappropriate by the EDS, it will tell the physician which test to order instead. If the physician decides not to follow the advice, he must seek peer-to-peer consultation or speak with the onsite radiologist.

An additional quality safeguard is a report generated on a quarterly basis that compares physicians’ performance to their colleagues on how they are using radiology. According to Khorasani, because consequences exist for ignoring decision support, the physicians tend to be more conscientious about the exams they are ordering and quality will, as a result, improve.

“The successful health IT tool that will actually help change physician behavior is going to be – without a doubt – decision support,” he says.

Khorasani confirmed his hunch that by focusing on quality, the cost would take care of itself. “Our goal was to improve quality, and we knew that by going after that, it will also have some impact on cost because we believe strongly that inappropriate use of imaging is a reality, even in our own organization,” he says.

Right Scan, Right Time

Not surprisingly, the news of last summer’s GAO report also struck a chord with EDS vendors. Scott Cowsill, senior product manager for Burlington, Mass.-based Nuance Communication’s healthcare diagnostics division, says when he heard the federal government was advised to use RBMs for imaging utilization management and was given no other alternatives, he got “butterflies in [his] stomach.” He is well aware of the potential issues that accompany a prior authorization model such as RBM and how much trouble it can cause for physicians and their patients.

“Really what it comes down to is physicians have a problem with the RBM model. They have to take time out of their day to make a phone call on a ‘Mother, may I?’-type model,” Cowsill says. “And then there’s the trust issue. Doctors are thinking, ‘Do the RBMs have the patients’ best interests at heart?’ while patients are thinking, ‘Who is really making decisions for me?’”

Together with Liz Quam, director of the Center for Diagnostic Imaging Institute, Cowsill gathered the support of other vendors and members of the imaging community last fall to launch a grassroots operation to make sure lawmakers are aware of decision support as a favorable option worth considering. After contracting a lobbying firm, they started appealing to Washington to present the case for EDS tools.

Cowsill says, “It was honestly more educational in nature. We were simply just letting them know, ‘Don’t make legislative decisions based on not having all the facts.’ We wanted to let them know that decision support technology is available.”

And the feedback he received from the legislators was encouraging. He says they had been thinking about this type of solution, but they weren’t sure if it existed or if it was ready for ‘prime time’ for mass appointment for CMS. The next step, according to Cowsill, was to ensure EDS was “etched into legislation as a possible alternative – not necessarily starting with the comment that we should do away with RBMs and DS is the only solution – but let’s leave the door open to this possibility.”

Cowsill says the government responded positively as soon as they recognized that EDS could do for imaging what e-prescribing has done for prescription drugs – a sector of healthcare which has previously been targeted for cost containment.

It was out of this necessity to educate lawmakers about the benefits of e-ordering that the Imaging e-Ordering Coalition – an alliance between healthcare providers, technology companies, and diagnostic imaging organizations to promote the widespread adoption of health IT – was founded. This group consists of the American College of Radiology, Reston, Va.; Center for Diagnostic Imaging, Minneapolis; GE Healthcare, Waukesha, Wis.; Medicalis; Merge Healthcare, Milwaukee; and Nuance, and together they are getting actively involved in ensuring that health IT is written into the legislative and regulatory proposals that will ultimately shape healthcare reform.

They are steadily involved with CMS’ upcoming Medicare Imaging Demonstration Project, for which they will act as a resource on EDS.

The Coalition is also making a push to the Congressional Business Office to consider their proposal for scoring, which means the government can refer to facts it has gathered in order to make an informed decision.

RBMs have already been scored, and Cowsill is confident that if EDS were scored, it would receive a much higher rating. He says there is strong evidence the EDS model can be done at a fraction of the cost of an RBM model. Because EDS is electronic, it makes sharing information easier, allows for standardization and consistency, and promotes interconnectivity and interoperability. Cowsill says these are all pillars of healthcare reform. He adds EDS also has the ability to reap the benefits of outcomes analysis – something the RBM model does not have. It’s also customizable and mass-deployable via the Web.

Even rural facilities that may not have Internet access at the point of service can call the imaging center and have them run it on their behalf. “It will still be quicker than a phone call to an RBM,” Cowsill says.

With the Imaging e-Ordering Coalition’s lobbying efforts and more evidence surfacing in support of EDS, it’s likely that the federal government will view EDS as a legitimate contender along with RBMs as a solution for an imaging management utilization program, with the ultimate goal of making healthcare affordable and accessible to all Americans.

“RBMs, depending on who you ask, may have served their purpose well, but electronic decision support is next-gen, and it’s certainly a proven solution at managing utilization. It’s our best attempt to make sure that the right patients get the right test at the right time,” Cowsill says. “This is how this country is moving in delivering healthcare.”

Khorasani agrees, pointing out that EDS is a favorable choice that puts us in a better position to move to a paperless healthcare system. “The approach of using healthcare IT tools is really the direction that makes most sense because it also allows us to adopt electronic health records, which everybody knows is important in reducing errors, reducing waste, and improving quality.”

– Jane Kollmer is editor of rt image. Direct all questions and comments to jkollmer@rt-image.com.

*The Percipio product has been deconstructed and includes the following: SmartReq, an electronic requisition tool; Medicalis Decision Support Server, a decision support tool; RADXT, engagement of local imaging expert tool; and Medicalis Analytics, an order and report outcomes analytics tool.