Coverage for Partial-Breast Radiation Therapy Spreads Slowly
Texas Payors Rated in athenahealth’s PayerView Debut
Third-Party Payor-Reimbursed Study Validates Virtual Colonoscopy
Medicaid Spending Data for 2005 Now Available Online; Total Tab Tops $305 Billion
Interactive CDs Apply Financial Analysis to Businesses

Coverage for Partial-Breast Radiation Therapy Spreads Slowly

Throughout 2006, several Blues plans announced that they would begin covering partial-breast radiation therapy for early-stage breast cancer patients, including multicatheter, 3D conformal radiation, and MammoSite brachytherapy. Health Care Service Corp, which operates Blues plans in Texas, New Mexico, Oklahoma, and Illinois, accepted the procedure, as did Blue Cross Blue Shield of Tennessee. About 50 health plans currently cover the treatment, but many payors do not, including Blue Shield of California, UnitedHealth Group, and Humana Inc.

Richard Hudes, MD, chief of radiation oncology at St Agnes Hospital, Baltimore, and a member of the American College of Radiology committee on health care policy, says the reason for the discrepancy could be that partial-breast radiation therapy has yet to be sufficiently demonstrated as equivalent to and safer than whole-breast irradiation for some patients. “The proponents of partial-breast irradiation say that you’re going to have a more convenient 1-week time period and less volume of normal breast and other structures irradiated,” Hudes notes.

But for many payors, the results of the current Phase III clinical trial—which tests three different methods of offering partial-breast radiation—will be a crucial determining factor. “Most payors will pay for high dose rate [HDR] brachytherapy, because that specific treatment is widely recognized,” Hudes explains. “There’s no state that doesn’t pay for HDR brachytherapy. But the cost of the catheter is such that you don’t want to just cavalierly find out if you’re going to be paid or not. That’s why, up until we finish the study, our primary recommendation is to usher people to participate in the clinical study so that we can have definitive proof that the partial-breast irradiation is equivalent to standard whole-breast irradiation. That’s definitely the party line.”

Otherwise, many patients electing to receive partial-breast irradiation will pay out-of-pocket for a procedure that costs about $2,500 more than traditional radiation therapy—despite recommendations from both the American Society of Breast Surgeons and the American Brachytherapy Society that the procedure be considered for women over the age of 45 with small tumors. Hudes predicts that the partial-breast trial could be complete as early as the end of 2007; however, after that, more carriers can be expected to reimburse for the treatment. “The accrual for that has been faster than expected,” he says, “so that’s been very positive.”

—C. Vasko

Texas Payors Rated in athenahealth’s PayerView Debut

Does one insurance company really pay faster than another, or is it just your imagination? A new service from athenahealth Inc, Watertown, Mass, takes the guesswork out of how well individual health plans perform.

This fall, the Texas PayerView rankings were released, the first PayerView state ranking from athenahealth. Earlier this year, the company released a nationwide PayerView report that was drawn from athenahealth’s complete database of more than 8,000 providers and 700-plus medical groups.

Following the same model as what was used in the national model, insurers from the Lone Star State are evaluated based on a number of criteria. PayerView takes a detailed look at financial and administrative performance as well as medical policy complexity in payment performance with physicians. Seven different metrics were used for each of the three specific categories.

For example, financial performance takes into account the length of time it takes a health plan to pay a claim from the date that service is provided to the patient. Other metrics include the percentage of claims that are paid in full the first time they are submitted and the number of billed charges that insurers transfer to the patient for payment.

The report also analyzes the administrative performance of insurers and the impact that the company’s execution of such tasks has on the physician. PayerView looks beyond just the rate of claim denials; it measures behaviors that make it more difficult for the clinician to collect from the patient, such as line items requiring back-end reworking.

Other administrative duties put under the microscope were how many claims necessitated the physician’s office to call the health plan for clarification or corrective action when a claim had been submitted, as well as the number of claims that never make it into the insurer’s system after being filed by the clinician.

The final component of PayerView is the medical policy compliance of payors: athenahealth determined their “unclear zero pay,” or the number of claims that are unpaid without a clear reason. According to athenahealth, the basis for these denials tends to be ambiguous, generally due to the complexity of a payor’s rules.

This wealth of information is designed to help health care providers better evaluate their payor mix. Also, athenahealth hopes payors will use PayerView to guide quality improvement efforts.

“Transparency continues to be one of the dominant themes in health care today, reinforced recently by the President’s executive order requiring federal agencies to gather information about the quality and price of care and share that information with beneficiaries,” says Todd Park, co-founder and chief development officer of athenahealth. “And yet, for the other major health care supply chain member, the insurer, there is virtually no actionable apples-to-apples data available to measure how well or poorly they perform one of their primary functions—paying for health care. The Texas PayerView ranking makes this various insurer and payor performance data publicly available and is an important step in bringing transparency to all stakeholders in health care.”

A sample of the Texas PayerView results includes:

  • Medicare B-TX outperformed the state’s private insurers on denials, denying only 5.6% of claims submitted;
  • Medicaid-TX denied Texas physicians’ claims 23% of the time, greater than any other insurer, and averaged 65 Days in Accounts Receivable (DAR);
  • Among national, private health insurers, Humana paid physicians the fastest, averaging only 28.5 DAR, followed by Aetna with 30.2 days; and
  • Private health insurer UniCare Life & Health Insurance Co shifted responsibility to the patient to pay the physician more than any other payor on the ranking.

The complete Texas PayerView rankings and methodology used are online at The site, which divides the rankings and performance of specific insurers by region, is free.

Claim performance data from the second quarter of 2006 was analyzed for more than 330 providers and 59 medical practices. More than 295,000 charge lines were reviewed, including government and private payor organizations with at least 1,500 charge lines of data for the quarter.

Which state will be next to receive such an in-depth look at payor behavior is still being decided. In the meantime, clinicians across the country will have access to the new national PayerView when it is available this June. According to athenahealth, many payors voiced intentions to modify their practices after seeing their ranking on the first list. Any changes will be evidenced by the new report.

athenahealth provides services, knowledge, and software for medical practices, including a physician revenue and clinical cycle management solution that integrates Web-based practice management and EMR software.

Dana Hinesly is a contributing write for  Axis Imaging News. For more information, contact .

Third-Party Payor-Reimbursed Study Validates Virtual Colonoscopy

A University of Wisconsin study published online in the September issue of Radiology tests the clinical accuracy of CT colonography using the commercially available V3D-Colon platform distributed by Viatronix Inc, Stony Brook, NY.1 The results of the study further validate virtual colonoscopy (VC) as an effective adjunct to optical colonoscopy (OC), offering sensitivity equal to or better than that of the traditional method of screening for colon cancer. “The results of the study prove that combining 3D CT colonography examination with an existing OC practice can be a viable and generalizable means toward achieving the goal of detection and removal of large polyps in the majority of the screening population,” Perry J. Pickhardt, MD, lead author of the study, said in a press release.

One interesting aspect of the study is how it was funded—via third-party payors in a deal brokered by Pickhardt and supported by Viatronix. Axis Imaging News spoke with Viatronix President Zaffar Hayat about the vendor’s role in the trial.

IE: Please provide some background on the study.

Hayat: Pickhardt was at the Department of Defense in 2001 when they conducted a very large-scale trial that was published in December 2003 in the New England Journal of Medicine.2 …When Pickhardt joined the University of Wisconsin, he met with different payors, based on the results of that trial. He explained that, first, in a 1,233-patient trial, VC was proven to be an effective tool for screening, and only 20% to 25% of the population gets screened. Second, in some places, there are waiting lists for VC screening because the gastroenterologists don’t have the capacity.

The business argument was that people are not getting screened, so if we offer a less-invasive procedure, perhaps we can screen more people. Colon cancer can be eliminated in more than 95% of the cases if the screening is done. Pickhardt wanted to show the HMOs in the state of Wisconsin what the results were—that VC had been a successful CT colonography screening program. That’s what this study focuses on—that yes, people are accepting it.

According to Pickhardt, through word of mouth, the University of Wisconsin has actually maxed out its capacity. One of the other [findings] is that because more people are getting screened, they are not decreasing the patient volume for the gastroenterologists. Because more people are coming to the University of Wisconsin, more referrals are being made to gastroenterologists. Also, this whole program has been a success based on the fact that in the near term, more people are getting screened; in the long run, if you save one or two patients and remove polyps before they become cancerous, it’s a huge savings to the insurance company. This is the nation’s first insurance-reimbursed program, and believe me, it seems to be catching on.

IE: Is the payors’ primary incentive the fact that effective screening drives down the money they pay out?

Hayat: Long-term costs, yes. About 55,000 to 100,000 people per year die of colorectal cancer. But with screening, more than 95% is preventable. And they’ve just used VC as an alternate screening method; OC has existed for many years, and it still will be there for patients who need that treatment. But from the economic side, VC screening helps. When talking to general audiences, if you ask people which one they would prefer—a quick CT scan versus an invasive procedure—people prefer VC. So, we set out to prove that it’s economical, effective, and accepted, and, hopefully, it will have wider adoption.

IE: Which carriers participated in the University of Wisconsin study?

Hayat: Physicians Plus Insurance, Unity Health Insurance, and Group Health Cooperative.

IE: Are you working with providers to negotiate these deals in other states?

Hayat: Yes.

Cat Vasko is associate editor of  Axis Imaging News. For more information, contact .


  1. Pickhardt PJ, Taylor AJ, Kim DH, Reichelderfer M, Gopal DV, Pfau PR. Screening for colorectal neoplasia with CT colonography: initial experience from the 1st year of coverage by third-party payers. Radiology. 2006;241:417–425. Available at: Accessed November 16, 2006.
  2. Pickhardt PJ, Choi JR, Hwang I, et al. Computed tomographic virtual colonoscopy to screen for colorectal neoplasia in asymptomatic adults. N Eng J Med. 2003;349:2191–2200. Available at: Accessed November 16, 2006.