The Usual Suspects

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As I read the cover story on radiology benefit managers (RBMs) in this month’s Diagnostic Imaging (DI) magazine, I ruminated on the (metaphorical) similarities between the mug shots of what the author described as imaging’s new decision makers (the five reigning RBM CEOs) and the ensemble cast of Kevin Spacey’s classic film of intrigue. Which of these suspects, though, is cultivating the mystery? Which is perpetuating the myth? Which is the one most feared? Which is the inventor of the much-maligned concept of prior authorization? It’s interesting that the Wall Street Journal (WSJ), in its November 6 edition, ran a similar prior-authorization story, Insurers Hire Radiology Police to Vet Scanning, in which the author went even further in opening up, for full view, the business model of utilization-management companies, which are exerting significant control over the medical imaging profession. The irony of the radiology police moniker in the WSJ piece, and the DI command-and-control positioning for RBMs in its article, is worth contemplating, considering the impact of these watchdogs’ revenue model on the business of radiology. Whose business do they care about most? Although the WSJ article did discuss the fact that payors are concerned (rightfully) about overutilization and inappropriate utilization of imaging, the basic theme of the piece can best be summed up in an opening paragraph: “Some doctors say the RBMs’ review procedures can result in delays or rejections that sometimes pose risks for patients. Doctors also complain that the procedures waste their staffs’ time and force physicians to justify decisions to reviewers who haven’t seen their patients.” The article goes on to outline some cases where patients have suffered as a result of this preauthorization process, which one person characterized as a whole bureaucracy. The DI story included interviews with the chief executives of some of the RBMs—who explained their objectives and reason for existence—along with some prominent people in the profession, not least of whom is James Thrall, MD, president of the ACR. Thrall criticized the prior-authorization requirement “for oversimplifying the practice of medicine.” Other radiologists quoted were even more dismissive of the prior-authorization system as being, as one put it, a punitive way to discourage physicians from ordering diagnostic imaging. Here we are: The patients don’t like prior authorization. They are afraid that they will not get the diagnoses that they need in time to save their lives. The referring physicians don’t like it because it is a bureaucratic layer that must be dealt with, on top of everything else that they try to figure out in their harried existences. They are getting tired of fighting bureaucrats at every turn in their practices. Their office staffs don’t like it because they are often put on hold for long periods of time as they attempt to navigate the preauthorization bureaucracy. Radiologists don’t like it because it slows the entire process and puts them at risk for delivering poor customer service to their referrers and patients. Imaging center executives bemoan the fact that prior authorization adds so many layers to the referral system that it quite literally clogs the referral arteries in ways that simply overwhelm them. They spend many hours of each day just trying to help close the loop for their referring physicians, so that they can get authorization to order the scans that their patients need. This takes valuable time and resources away from other (and more pressing) issues facing the center’s staff. In many cases, they have been denied payment from the insurer because of some glitch in this prior-authorization system. Radiologists are eating significant costs, between this lost revenue and the FTEs that they have added to deal with the prior-authorization requirements, mostly to help their referrers find a smooth pathway to exam approval. The RBMs’ customers are the insurance companies themselves, and in at least the case of American Imaging Management (WellPoint) and National Imaging Associates (Magellan Health Services), they are actually subsidiaries of large insurers. They are not just the radiology police, but rather the in-house secret service, protecting, first and foremost, the interests of these large payors. It is clear that the RBMs are doing a good job of pushing back against utilization and, in theory, it is appropriate that those who write the checks keep a watchful eye on how the money is spent. I understand why RBMs are a part of the radiology landscape. There is little argument about that—until the restrictions encroach on the medical decision-making process and the judgment of the referring physician, or the medical team’s ability to act with urgency. What is not so clear, however, is the efficacy of prior authorization as a tool to accomplish efficient and fair management of the radiology benefit. In many cases, radiologists themselves have developed methods for helping the referring physician identify the appropriate exam for the patient, and in this way, the radiology profession can find its own way through the maze of utilization management. This has historically been a hallmark of the consultative relationship that radiologists have had with their referring colleagues. Radiology, at its best, can police itself. Systems and processes exist in which best practices can be modeled into the authority to advise referring physicians on how best to use the imaging spectrum as they do their diagnostic work-ups. Accreditation and other mechanisms should be more fully accepted by the insurance companies as stamps of approval for the imaging practice to be viewed as grownups in the delivery of care. Practices that I have visited around the country are more than capable of becoming their own utilization/quality/appropriateness gurus. They really don’t need a police force putting the handcuffs on their referring physicians in the form of prior-authorization requirements. That, I think, is the best opportunity to bridge the obvious need for insurance companies to control costs and the equally obvious need for physicians to practice uninterrupted medicine, with the patient’s best interests in mind. There is no doubt that the reimbursement system is flawed. There is also no doubt that there are providers who would just as soon commit fraud as do medicine the hard way. These realities, however, do not warrant the creation of a back-breaking bureaucracy that seems to add costs at one end while trying to control them at the other. I am not sure where the cost–benefit ratio stands on the RBM model, but it is clear that the addition of prior authorization to its managed care arsenal has truly changed the face of medical imaging referrals. It is something that all imaging providers are dealing with as they try to figure out whether the term applies to the benefit piece or the management piece. In an era of consumer-driven health care, the RBMs will be under increased scrutiny to demonstrate their benefit to the patient. As their cornerstone model, RBMs will find prior authorization to be a tough sell. It’s time to round up the usual suspects.