While radiologists and patients struggle with insurance companies and the implementation of radiology benefit managers (RBMs), the state of Delaware recently announced an encouraging piece of legislation that forces Blue Cross Blue Shield of Delaware (BCBSD) to adopt the American College of Cardiology’s FOCUS Program, based on national medical society-developed appropriate-use criteria. The ruling marks an important moment for patients and the advanced imaging community as they struggle to combat government-issued cuts, prior authorization, and RBMs.

“Prior authorization and radiology benefit managers that prevent patients from receiving lifesaving and timely care are of serious concern to us,” said Tim Trysla, executive director of Access to Medical Imaging Coalition (AMIC), an organization comprised of the American College of Radiology, American College of Cardiology, multiple patient groups, and a portion of advanced imaging manufacturers. “AMIC has long advocated the adoption of national medical society-developed appropriate-use criteria to ensure proper utilization of innovative medical imaging technologies and help physicians make clinically effective decisions about the care their patients receive.”

The Delaware Department of Insurance, concerned with patient denials and the prospect that patients were being harmed by RBM practices, investigated BCBSD after a report that the insurance company refused a cardiac test to a patient. A subsequent Senate Commerce Committee investigation concurred with the department’s findings.

“We are encouraged by the fact that the Senate Commerce Committee did a report on the Delaware situation and looked at the denials—and even looked at the question of whether patients were being harmed and delayed,” said Trysla. “We were also encouraged that our partners at the American College of Cardiology and others were actively involved in the fact that Delaware adopted the use of their FOCUS Program, which we believe is the right way to go.”

The FOCUS Program is a national quality improvement initiative designed to help cardiovascular professionals best utilize appropriate-use criteria and reduce inappropriate imaging. Under the Delaware ruling, BCBSD will pay for physicians to participate in the online appropriate-use criteria-based FOCUS Program. The program will support physician decision-making and the use of best practices for decisions regarding cardiovascular diagnostic imaging.

“What AMIC is trying to do, at both the federal and state levels, is to make sure that evidence-based tools are in the hands of physicians as they order advanced imaging in order to avoid additional cuts or just arbitrary policy changes in advanced imaging,” said Trysla. “This is important so that we can turn this debate around from just utilization and direct it more toward appropriateness with the general understanding that the number one cost driver in the health care system is still the physician’s pen and how he is practicing medicine.

“Obviously, RBMs, which don’t rely on these evidence-based tools, aren’t transparent and only are looking at making savings by prior authorizations and general denials. We don’t think it’s good medicine or good for the health care system.”