Two key imaging groups--The Medical Imaging & Technology Alliance (MITA) and The Access to Medical Imaging Coalition (AMIC)—are prevailing upon Congress to reject the proposal by the Blue Cross Blue Shield Association (BCBSA) that Medicare use prior authorization for advanced imaging services.
BCBSA included the proposal in “Building Tomorrow’s Healthcare System: The Pathway to High-Quality, Affordable Care in America”, a plan it submitted to the Department of Health and Human Services (HHS) and Congress.
The intent of the plan is to transition the U.S. health care system to a patient-centered model from a fee-for-service one.
If adopted, the recommendations would, according to an economic analysis by Ken Thorpe, Robert W. Woodruff professor and chair of the Department of Health Policy & Management at Emory University in Atlanta, yield a savings of $319 billion over the next decade.
MITA and AMIC object to the suggestion, as outlined in the proposal, that Medicare “actively manage potentially harmful and costly technologies with a high risk of overuse or misuse, such as advanced imaging services."
“A proposal by an association of the health insurance industry to put medical decisions in the hands of the health insurance industry is simply a means to reduce access to medical imaging,” says David Fisher, executive director of MITA. “Medical decisions should remain in the hands of physicians and their patients, rather than the insurance industry.”
There currently exists no peer-reviewed health economic research demonstrating that prior authorization actually produces savings for the Medicare program. Rather, 63% of 2,400 respondents to a recent physician survey by the American Medical Association (AMA) say prior authorization delays “needed” medical procedures.
Meanwhile, HHS has previously deemed a prior authorization program “inconsistent with the public nature of the Medicare program,” due to the lack of transparency and reliance on private companies using proprietary systems to deny physician-prescribed care. The agency has also stated that the Medicare appeals process could overturn a “high proportion” of denials, rendering such a policy ineffective and highly burdensome.
“We know that these programs are highly burdensome and reduce access to care," Fisher asserts. "Policymakers should not place additional hurdles between patients and necessary diagnostic and screening services. Instead, healthcare providers should use evidence-based, physician-developed appropriateness criteria to ensure patients have access to the right scan at the right time.”
Meanwhile, AMIC cautions that prior authorization is not only an ineffective and unproven mechanism for encouraging appropriate imaging utilization; it will probably prevent senior citizens from accessing life-saving diagnostic and therapeutic services. In its communications with Congress, AMIC has noted that the BCBSA proposal closely follows the failed attempt by Blue Cross Blue Shield of Delaware (BCBSD) to impose prior authorization requirements on patients.
Intense scrutiny of the quality of BCBSD’s delivery of care under its prior authorization program for cardiac nuclear imaging spurred the Delaware Insurance Commissioner to order BCBSD to abandon prior authorization. BCBSD was instructed to replace that program with the American College of Cardiology’s (ACC) FOCUS program.
“It’s ironic that BCBSD was taken to task by the state insurance commissioner for denying patient care as a result of using prior authorization for imaging services, yet their national association chooses to advocate that Medicare adopt a similar scheme,” asserts Tim Trysla, AIMC’s executive director. "The Delaware Insurance Commissioner’s decision underscores the ineffectiveness and negative consequences of prior authorization and it would be irresponsible to enact these tools more broadly.
“There is not a single peer-reviewed, evidence-based study that shows prior authorization programs for medical imaging achieve any real cost savings. However, multiple studies have shown that alternatives to prior authorization like physician-developed appropriateness criteria and decision support tools effectively drive appropriate imaging use without compromising patient access. No matter how loudly private payers advocate for prior authorization, Congress and CMS cannot ignore the data: prior authorization for advanced imaging doesn’t work and will actually cost taxpayers more.”