Physicians?not a cost-driven third party?should be the decision makers in determining whether a scan is necessary.

David Fisher

There are better alternatives to the growing trend of prior authorization in the medical imaging community that support physician choice, protect patient safety, and preserve access to care. Rather than leaving the decision-making to a third party, physicians should be equipped with tools, such as physician-developed imaging appropriateness criteria and clinical decision support systems, to determine whether scans are medically necessary for their patients. These tools facilitate informed health care decisions and keep these decisions in the hands of the physician.

Physician choice is a critical pillar of medicine. By definition, prior authorization requirements place a barrier between patients and what their doctors determine is the right scan at the right time. Radiology benefit managers, or RBMs, are one form of prior authorization that threatens these choices. For instance, we know that physicians may order fewer tests to avoid the difficulty of navigating an RBM’s authorization procedures.1 Moreover, RBMs’ methodology and processes have not been validated as an effective clinical decision tool. No peer-reviewed clinical evidence exists indicating that RBMs’ algorithms for approving, denying, or altering scans are safe. Due to this lack of transparency and accountability to the public, the Department of Health and Human Services expressed concerns about the use of RBMs in the Medicare program in its response to a 2008 Government Accountability Office report.

RBMs are transparent about intending to reduce scan volume; however, the data on the savings they claim to offer is not as clear. While RBMs initially reduce costs, the ongoing administrative burden of RBMs shifts costs to physicians. A study published in the Journal of the American College of Radiology found that “significant RBM-related costs are shifted onto physicians and their staff members who expend resources complying with RBM requirements. This cost shifting creates scenarios in which RBMs are cost saving from the perspective of a health plan but actually increase costs to the health care system overall.”1

Many claims regarding RBM savings in the public and private sector are made with the narrow perspective of savings directly obtained by Medicare or private health plans and not with a holistic view of health care systems. Similar benefits management programs such as pharmaceutical benefits programs have spread administrative burden down to providers at substantial cost.2 It is worth remembering that time spent by physicians and other care providers fighting for scans is not merely a dollar figure lost but also time that could be spent with their patients.

The movement to broadly limit access to imaging services through prior authorization programs comes on the heels of a natural slowing in imaging services’ growth. Recently, House Energy and Commerce Health Subcommittee Chairman Joe Pitts (R-Pa) and Ranking Member Frank Pallone (D-NJ) reminded the Medicare Payment Advisory Commission (MedPAC) that imaging growth “has remained modest with spending in 2008 growing at 2.9 percent and 2009 levels decreasing by 2.1 percent. In addition, spending per beneficiary dropped by 1.5 percent from 2008 to 2009.”3 The implementation of prior authorization measures such as RBMs is, in part, a product of a misperception about the growth of imaging and the employment of outdated imaging utilization data in regulatory decision-making.

Physicians—not a cost-driven third party—should be the decision makers in determining whether a scan is necessary. By encouraging the use of physician-developed appropriateness criteria and clinical decision support software, we can realize many of the benefits RBMs claim to offer, without the significant red tape that RBMs impose. Prior authorization measures should not emplace artificial barriers between patients and receiving the right scan at the right time.

David Fisher is the Executive Director of the Medical Imaging and Technology Alliance (MITA), a division of the Association of Electrical & Medical Imaging Equipment Manufacturers (NEMA), the collective voice of medical imaging and therapy equipment manufacturers, innovators, and product developers. For more information, visit www.medicalimaging.org.

refrences
  1. Lee D, Rawson J, Wade S. Radiology benefit managers: cost saving or cost shifting? J Am Coll Radiol. 2011;8:393-401.
  2. Sakowski JA, Kahn JG, Kronick RG, Newman JM, Luft HS. Peering into the black box: billing and insurance activities in a medical group. Health Aff (Millwood). 2009;28:w544-54.
  3. Pitts J, Pallone F. Letter to MedPAC Chairman Hackbarth, May 20.