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.
People
Jay D. Miller, president and CEO of Vital Images Inc, Minneapolis, was named CEO of the Year in the medical imaging industry by Frost & Sullivan…Anne Vleminckx, who is currently Secretary-General of the Board of Management and is responsible for Investor Relations and Corporate Communication, has been appointed as Chief Financial Officer by Agfa-Gevaert…Susan Wood, formerly of R2 Technology, has been appointed Chief Operating Officer by Medicsight…Andrew C. Cowen, a member of the company’s Board of Directors for the past seven years, has been elected President and Chief Executive Officer of CMS Inc…Hartmuth C. Kolb,PhD, has been appointed Chief Technology Officer of CTI Molecular Technologies, Inc…It has been announced that Joseph D. Biegel has been appointed vice president of product management for Medical Imaging Group…Mike Jackman, formerly Health Imaging’s Chief Technology Officer of Eastman Kodak Company, has become General Manager of Healthcare Information Systems. Jeff Markin, formerly General Manager of Healthcare Information Systems at Kodak, has become General Manager, Regional Operations. Marco Bucci, formerly General Manager of Services for Health Imaging at Kodak, has become Chief Technology Officer. John Farrell, Worldwide General Manager, Growth Services at Kodak has taken on the added role of acting General Manager of Services for Health Imaging. Pam Benkert, has taken on the role of General Manager, Specialty Markets while also retaining her current responsibilities as General Manager of HI’s Film Capture and Output Systems group…Becky Stahl is welcomed by Cassling Diagnostic as its Cardiac IT Business Manager…Alan B. Bialek has joined AllPro Imaging as Sales & Marketing Manager for the company’s line of ScanX Digital Imaging Systems…Fred Trovato has been named regional manager for the Northeastern United States by NovaRad…Bodo Herzog has been appointed European Sales Manager by NAI Tech Products, the first appointment of this position by the company…Imaging Dynamics Company announces its appointment of Rex Harmon as Vice President of Sales, Western US Region and John Hill as Vice President Sales, Southern US Region…Afga-Gevaert announces that following regulatory approval from the German and Austrian anti-trust authorities , the acquisition of GWI, one of the leading European companies active in the fast growing market of Healthcare information systems and the Electronic Patient Record, has been closed.
Industry News
VitalWorks Inc, Boston, has changed its name to AMICAS Inc. The company also sold its medical division to Cerner Corp, Kansas City, Mo, for $100 million…Merge Technologies Inc, Milwaukee, and Cedara Software Corp, Mississauga, Ontario, have entered into an agreement to merge in an all-stock transaction, resulting in a combined company with an annual revenue run rate exceeding $100 million. The headquarters of the combined company will be in Milwaukee. Merge Technologies and AccuImage Diagnostics Corp, San Francisco, signed a definitive agreement by which Merge will acquire AccuImage in an all-cash transaction that is valued at approximately $6 million and expected to close the first quarter of 2005…Eastman Kodak Co, Rochester, NY, acquired OREX Computed Radiography Ltd. Under the agreement, which will likely close by the end of the first quarter of 2005, Kodak would acquire privately held OREX for approximately $50.5 million in cash. Kodak anticipates that OREX will add approximately $32 million to Kodak’s revenue in 2005…CompuMed Inc, Los Angeles, and Swissray International Inc, Elizabeth, NJ, signed a licensing agreement that authorizes Swissray to integrate CompuMed’s proprietary OsteoGram® software into its direct digital radiography ddR-systems. CompuMed signed a distribution agreement with SourceOne Healthcare Technologies Inc, Mentor, Ohio, under which SourceOne will market and distribute CompuMed’s DICOM OsteoGram software, enabling SourceOne’s customers to perform bone mineral density screening…SourceOne has signed a strategic national distribution agreement with Barco, Kortrijk, Belgium, under which SourceOne will offer Barco’s full line of medical display systems. Additionally, SourceOne signed a distribution agreement with PenRad Technologies Inc, Plymouth, Minn, giving SourceOne nationwide rights to distribute PenRad’s mammography information systems. The company also signed a distribution agreement with DeJarnette Research Systems Inc, Towson, Md, for DeJarnette’s dyseCT™ CT workflow engine. SourceOne also acquired distribution rights to DR solutions by Imaging Dynamics Company Ltd, Calgary, Alberta…CTI Molecular Imaging Inc, Knoxville, Tenn, announced that its subsidiary CTI Mirada Solutions has received FDA 510(k) clearance to market Scenium™, a new quantification tool for the analysis of neurological PET scans. CTI also announced that its subsidiary CTI PETNET will release and distribute PET.CONNECT, an application that includes IT products, educational programs, and service offerings for running a PET imaging practice. CTI has acquired ImTek Inc, Knoxville, Tenn, designer and manufacturer of the MicroCAT™ scanners for small animal CT imaging…TeraRecon Inc, San Mateo, Calif, announced the integration of its AquariusNET image-processing server with several PACS vendors, including Agfa, Mortsel, Belgium; AMICAS, Boston; Sectra AB, Linköping, Sweden; Delft Diagnostic Imaging, Delft, The Netherlands; and Intelerad Medical Systems, Montreal. TeraRecon strengthened its partnership in the development and distribution of advance ultrasound technology with Fukuda Denshi Co Ltd, Tokyo, with new research and development contracts for the joint development of portable and cart-based B-mode systems and a next-generation portable color Doppler system…Hologic Inc, Bedford, Mass, has entered into a private-label agreement with iCAD Inc, Nashua, NH, under which iCAD will manufacture film-based CAD systems for Hologic targeted to serve lower case-volume mammography clinics…iCAD and Vital Images Inc, Minneapolis, have signed a nonexclusive agreement to integrate iCAD’s Second Look® CT colon CAD application into Vital Images’ flagship software, Vitrea® 2…Cogent Medical Systems Inc, Mt Laurel, NJ, has become RamSoft USA Inc, the United States affiliate of RamSoft, Toronto. Cogent founder Paul J. Vilary will serve as national sales director of RamSoft USA.
