United, ACR Push Appropriateness Criteria

UnitedHealth Group (UHG), Minneapolis, one of the country’s major providers of health insurance, and the American College of Radiology (ACR) have sealed a deal to make the college’s imaging examination appropriateness criteria available to United’s clinicians. Initially, the guidelines will be advisory only, but the payor acknowledged that a mandatory program could be in the cards.

Reed V. Tuckson, MD, is senior vice president for consumer health and medical care advancement for UHG. UHG is the parent company of UnitedHealthcare (UHC), a publicly traded insurer that provides health coverage or other health services across the country to about 55 million persons, through itself and five associated companies under the UnitedHealth aegis.

Like other carriers, the giant UHC has seen its outlays for imaging grow by double digits annually and is looking for ways to rein in the cost. Laurie Paidosh, director of radiology programs for UHC, says its total imaging bill annually is about $3.5 billion. She says UHC’s yearly increases in imaging payout have been “consistent with industry standards” of 15% to 20%.

Rather than impose radiological examination criteria on its 450,000 physicians through a preapproval process, UHC has linked with the ACR to try a soft-edged, educational approach it hopes will make harsher steps like mandatory radiology approval unnecessary.

“We certainly are aware that there is a degree of inappropriate use of these important health care assets,” says Tuckson, “and we are well aware that waste is occurring.”

Tuckson suggests that eliminating inappropriate imaging could save the company billions. He says high-end imaging like MR and CT is the initial target. But, Tuckson insists, UHC wants to approach the problem of inappropriate imaging in a way that will educate the 450,000 clinicians in its various networks about what is an appropriate radiology examination, rather than imposing choices on them.

A First for the ACR

Jim Borgstede, MD, FACR, chairman of the ACR’s Board of Chancellors and a practicing radiologist in Colorado Springs, says Colorado is one of the states, along with North Carolina and Texas, where UHC will be rolling out its use of the appropriateness criteria. “I think they are looking at the criteria that are causing them the biggest volume of inappropriate usage first, so you look at something like back or neck pain,” he says.

Borgstede says this is the first time an insurance carrier has chosen to use the ACR’s appropriateness criteria “in toto” as a guideline to clinicians as well as radiologists. He says UHC’s approach can be thought of as a “pilot program” that other insurance carriers will be watching.

To date, Borgstede says, the ACR has developed about 190 appropriateness criteria that spell out which examinations are called for in a given clinical instance. Various examinations for a condition, chronic hip pain, for instance, are ranked in an order of preference that may begin with simple x-rays and move to more complex tests as results mandate. The appropriateness criteria are available to clinicians on the ACR’s web site ( www.acr.org ) and on CDs, says Borgstede. But under the college’s licensing agreement, UHC will be able to make them available through its own web portals and by other means of UHC’s choosing.

UHC’s use of the criteria is an important foot in the door for the ACR in its fight, as Borgstede puts it, “to preserve the long-term viability of our specialty.” The ACR sees its agreement with UHC as being a step toward what both parties call a “scientific” basis for ordering imaging examinationsas detailed in the ACR’s appropriateness criteria. If UHC’s nearly half a million clinicians warm to the use of the criteria when ordering tests for their patients that might send an industry-wide signal that a nonmandatory process could be used to control unneeded imaging.

But Borgstede says he thinks the timeline for reducing inappropriate imaging is a short one. “I think it’s a matter of months to see decreases in utilization through this arrangement with UHC,” he says. “If they don’t see that, then my suspicion is they will rachet up the bar. Rather than the carrot, they’ll use the stick. They’ll say we’re not just going to encourage you to use these criteria, we’re going to require you to use these criteria.”

The UHC View

For its part, UHC clearly prefers to begin its process by making the ACR guidelines available to its doctors and see if that sends a message that reduces inappropriate utilization before UHC has to take other steps.

Tuckson says UHC also may mandate notification for some examinations when they are ordered. He says the timeline expected to judge the program’s success is this year.

The ACR appropriateness criteria are at times complex. Tuckson says UHC will initiate a series of telephone consults to physicians who may be confused when ordering tests. He also says part of the ACR’s continuing role in the relationship will be to keep the criteria continually updated and to make them as user friendly as possible for the clinical community.

Borgstede agrees that many clinicians may not know the appropriateness criteria even exist, much less how to use them. “I don’t think most clinicians are as aware of the criteria as we would like them to be,” he says, “and so this is another opportunity for us to get the criteria out there and get some exposure for the clinicians. If the clinicians need help interpreting the criteria, they can call United or they are certainly welcome to call their individual radiologists in their community. I feel very strongly that we as radiologists should act as consultants and not merely as interpreters.”

Tuckson says employers are already asking UHC to develop new health benefit packages that reward the use of appropriate imaging and punish the use of inappropriate imaging. The use of the ACR’s appropriateness criteria, he says, “at least allows for that foundation of the implementation of such programs to be laid. It permits us to ensure that the criteria that are used for the designation of such quality are fair and appropriate, because it is in fact the profession that is determining them, as opposed to health plans.”

This has to be music to the ACR’s ears. The college’s push now is to establish radiology as the definitive specialty for most imaging. Borgstede says this year legislation will be introduced in Congress to create what the ACR is calling a Designated Physician Imager or DPI. The DPI bill would establish equipment safety and training standards for doctors in order for them to legally perform imaging.

“It’s a much more comprehensive program than merely the appropriateness criteria,” Borgstede says.

–By George Wiley

Insured Health Care Costs Payment Trends

According to the third annual Blue Cross Blue Shield Medical Cost Reference Guide, employer and employee contributions to premiums rose more than 50% between 2000 and 2004. For single-person coverage, employer contribution rose approximately 52% (from $2,064 to $3,137), while employee contribution rose 65% (from $336 to $558). For family coverage, employer contribution rose 63% (from $4,477 to $7,289) and employee contribution rose 61% (from $1,656 to $2,661). Other key payment trends noted in the Medical Cost Reference Guide: government and health plans pay for more than 80% of health care costs; consumers’ share of health care costs has remained steady, yet the dollar amount has risen 50%; and the share of federal revenues devoted to health care fell between 1993 and 2000 (from 24% to 17%), while state and local governments’ share rose (from 20% to 22%). The guide projects that overall health care spending in the United States will likely rise more than 3% to exceed18% of the country’s gross domestic product by 2013.

Average Annual Premium Contibution, 2000-2004

Source: Adapted from Kaiser Family Foundation and Health Research and Education Trust, 2004; Blue Cross Blue Shield Medical Cost Reference Guide, 2004.


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