All eyes are on the North Star state, as Minnesota physicians and hospitals embark on an ambitious program to self-manage their utilization of diagnostic imaging. Three major health plans, four large integrated delivery systems, and two leading Minneapolis-based radiology groups are participating, according to Jim Tierney, CEO, Suburban Radiologic Consultants, a 65-person radiology practice based in Bloomington, MN.

The participating payers — Medica, HealthPartners, and BCBS of Minnesota — require care providers to purchase or develop software that enables the referring physician to go through an automated decision-support process at the time of examination, eliminating the need for pre-certification calls. While radiology benefits management (RBMs) firms continue to be involved in managing the data produced by the utilization management program, their role has been greatly diminished.

Tierney estimates that through the four participating integrated delivery systems and the outpatient imaging centers owned by the two practices, 40% to 50% of the referrals in the Greater Metropolitan Minneapolis area are affected. Fairview Health Services, Allina Hospitals & Clinics, Park Nicollet Health Services, and HealthPartners health systems are all on board.

Tierney described how the program operates at Suburban’s seven imaging centers: “When a doctor’s office calls to order an exam, or a physician orders an exam internally in an integrated system, they are asked a series of questions. The answers to those questions regarding the patient’s history and the current signs and symptoms are plugged into a software program. This program runs the data through an algorithm and the exam order is given a score. The highest score results in the exam being scheduled, a lower score requires a radiologist or a nurse to follow up with the referring physician to make sure that he/she is getting what they want and what they need from the ordered exam. We then submit a report at the end of each day to the payor with the relevant data from each encounter.”

“So the front end is taken care of during the scheduling process and the back end is taken care of in an automated fashion at the end of the day with a computerized report,” Tierney continues. “That is how the requirement for the clinician to call a third party is eliminated. It still goes to whichever third party the payor is using, and that would be HealthHelp or AIM or a similar radiology benefits management company. The RBMs are still playing a role.”

The daily reports also enable the participating health care providers to review physician ordering patterns and identify outliers. “We get database reports that we can generate and do generate to assess whether or not there are referral patterns,” says Tierney. “And we use those reports to help educate referring physicians. It’s an educational process as well as a prior notification process.”

Why Minnesota?
In general, Tierney gives Minnesota physicians high marks for practicing high-quality medicine, partially explaining why this program could launch in Minnesota. “They order exams the way exams are supposed to be ordered,” notes Tierney. “So it seemed like there ought to be a way to do this without having long, drawn-out phone calls before they could even order an exam. Primarily, it is an effort to try to be efficient, expedite things, and try to get patients taken care of.”

Tierney also notes that the healthcare IT infrastructure in the city is fairly advanced. “Once the program started to roll out and it became apparent that groups would have to call a third party to get prior authorization, I think it seemed logical to everyone that a component of the EMR could be or should be a customized automated ordering system, including a decision support system, and that a third party really wasn’t required to work through that kind of a process,” he explained. “I think the process developed here because several of the large integrated systems were able to adapt their EMR process to handle what ends up being an extra layer of scheduling and ordering required to get the appropriate information prior to the exam being ordered. Then the radiology groups piggy-backed on that process to duplicate what the large integrated systems have done by acquiring software to do the same thing.”

Referring physicians have been particularly enthusiastic about the service in the outpatient setting because it eliminates the need to call a third party, reports Tierney. “They schedule the patient and go through a series of questions that expedite the order for them,” he explains. “So the referring physicians to our clinic were very pleased with what we were able to set up. For the integrated systems, it’s an added layer of overhead, so there is a cost to them. However, they also eliminate the costly phone calls to a third party.”

Although hospitals and radiology groups are bearing the cost of the program, there is currently no vehicle in place to compensate the providers for their efforts. “The providers cover the cost of development within the integrated systems, and the radiology groups are bearing the cost of developing our own electronic tools to provide this service,” Tierney explains. “But I think the jury’s out on how cost-sharing is finalized. In the long run, if everybody in town develops a program that allows this to be done internally or with a radiology group, the providers should be compensated by the health plans for these costs rather than paying the RBMs.”