RBM Standards: Too Much of a Good Thing?

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Most providers of quality diagnostic imaging welcome more stringent quality standards invoked by payors in the belief that higher standards will eliminate inferior providers from their markets. But as payors increasingly resort to employing radiology benefits management companies (RBMs) to help control escalating imaging costs, outpatient-imaging providers are encountering a bewildering array of standards to meet. And projections from the Advisory Board suggest that the influence of RBMs will only grow. Many RBMs are requiring compliance with equipment specifications that are not encountered in the accreditation standards of respected accrediting bodies such as the American College of Radiology (ACR), the Intersocietal Commission for the Accreditation of Nuclear Laboratories (ICANL), the Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In addition, various RBM standards that have emerged ask outpatient imaging centers to divulge financial ownership interests, keep a minimum 40-hour work week, and have a board certified radiologist on-site full-time. Consider the following requirements found within the standards used by competing RBMs: Each center providing CT or MR/MRA must be staffed on-site by a board-certified or board eligible radiologist during general business hours (8AM to 4 PM), Monday through Friday, during which time all contrast-enhanced procedures must be performed. For centers offering MRI, it is preferable that the facility have a maintenance agreement with the company that manufactured the MRI equipment. Service agreement must coincide with the hours of operation. Practices must divulge financial ownership interest about the facility. All devices must be owned or leased on a permanent basis. One RBM requires that a minimum of five modalities be offered to become a credentialed imaging provider. Yet another requires only those providers of MRI and CT, the high-ticket imaging payors are most interested in controlling, to offer a minimum of four modalities chosen from an approved list. If an imaging center operation happens to fall within the jurisdiction of more than one RBM, it is highly likely that the center will have that many different standards with which it must abide. The following standards for providers of CT were culled from the credentialing standards of three different RBMs. CT software must be upgraded within 5 years of purchase. CT software may not be older than 4 years Single-slice CT will no longer be considered. CT equipment must employ a minimum of 4 slices. But imaging centers offering MRI are encountering an even more diverse set of standards: Only MR systems of 0.5T and greater will be considered. All providers of MRI must have a device that is ACR accredited and DICOM compatible Devices of field strength of less than 0.3T will not be permitted. MR studies performed at less than 0.4T will be reimbursed at a different rate than 0.4T or greater; Devices with field strength of 0.3.T to 0.6T will be limited to the examination of brain, spine, knee, and extremities. Any device to be used for breast MRI must be 1.0T or greater and have bilateral capabilities. Inconsistencies Abound The equipment standards have generated considerable concern in the outpatient imaging community, impacting many with FDA-approved, high performing low-tesla magnets. In his presentation at the Maximizing Managed Radiology for Health Plans conference in San Francisco, February 26-28, Sheldon I. Schaffer, VP & General Manager, MR/CT Hitachi Medical Systems America, Twinsburg, Ohio, noted that the company supports the application of appropriateness criteria and equipment performance standards, but noted that the standards imposed are often inconsistent in applying appropriateness criteria and may or may not apply equipment standards. "Failure to act on consistent standards has resulted in payment initiatives (capitation and the DRA), steerage to low-cost providers, provider privileging programs that are often inconsistent, pre-certification, and post-procedure denials," Schaffer said. Sharing a series of images obtained on magnets that would not meet some RBM equipment standards, Schaffer called for the standardization of criteria to accomplish delivery objectives, clearly defined appropriateness criteria, and clearly defined equipment standards. Paul A. Larson, MD, FACR, chair of the ACR (link to: http://www.acr.org) Commission on Quality and Safety, provided conference attendees with a detailed review of the ACR's appropriateness criteria and accreditation programs, and attempted to demonstrate how those programs can impact quality. The ACR offers a wide range of quality and safety products including: Appropriateness Criteria. First introduced in 1995 and reviewed annually, criteria have been developed for 170 clinical conditions with more than 900 variants, with the input of more than 15 medical specialty societies. This summer, the criteria will be converted to a relational database to provide more powerful search capabilities and to incorporate CPT and ICD code mapping, as well as incorporate a relative dose index. Practice Guidelines & Technical Standards. Diagnostic modality accreditation programs good for 3 years are available for mammography, MRI, nuclear medicine, breast ultrasound, CT, ultrasound, stereotactic breast biopsy, radiation oncology, and PET. Mammography accreditation is mandatory as per the Mammography Quality Standards Act, but the others are voluntary. However, Larson noted that 32 Medicare carriers require certification in vascular ultrasound, 7 states require one or more accreditation programs, 23 carriers require one or more accreditation programs, and UnitedHealthcare will require accreditation on freestanding facilities and physicians offices for CT, MRI, PET, nuclear medicine, and echocardiography by March 2008. While the ACR accreditation program does not specify equipment requirements, Larson stated that an important aspect of the program is the assessment of clinical images for: exam identification, exposure, position and anatomical landmarks, anatomic coverage and display, artifacts, filming technique, and technique parameters. Other quality assessment products offered by the ACR include RADPEER, a clinical peer review tool, the BIRADS Atlas, quality control manuals, contrast media manuals, a Guide to Continuous Quality Improvement, and radiation safety documents. In addressing conference attendees, Hitachi's Schaffer suggested that equipment use be based on FDA clearance and accreditation by governing bodies qualified to judge performance, such as the ACR, the IACMRL, JCAHO and the ICANL, and urged payors to go beyond product specifications to consider image quality.