The Year of Utilization Management?

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While Congress hacks away at imaging reimbursement, radiology benefits management companies are chipping away at volume, and outpatient imaging is likely to feel the brunt of these efforts. An article in Managed Care Week reports Blue Cross and Blue Shield of North Carolina will begin requiring prior approval for for non-emergency CT, MRI, magnetic resonance angiography, PET scans and nuclear cardiology studies performed in all locations this month. In Minnesota—where MRI use is growing at twice the national average rate and CT and PET, three times as quickly—the state's three largest insurers announced plans to require pre-authorization of outpatient CT, MRI, and PET scans, beginning with Medica last month and HealthPartners, Bloomington, Minn, this month. Blue Cross and Blue Shield of Minnesota will join them in July.

In addition to controlling imaging costs, utilization management companies are moving into patient-centered services such as measuring radiation exposure and providing patients with provider price transparency, as patient co-pays for advanced imaging can be as high as 20%.

"You can see a swing [in patients' out-of-pocket costs] of $200 to $400."
— Pat Courneya, MD, medical director, American Imaging Management

But clearly the primary attraction of RBMs for insurers is the ability to slow the growth of imaging. The North Carolina Blues introduced an RBM program in 2002 that tracked without trying to control utilization, according to the article in Managed Care Week. Between 1999 and 2004, the insurer saw a nearly 160% increase in CT and MRI rates and also recognized wide variation in the cost of services, with CT unit costs ranging from $593 to $1,453. Outpatient diagnostic imaging exams rose 21% between 2003 and 2005, and now accounts for 10% of total health care costs, with expenses rising 18% to 25% annually.

Medica maintains that 10% to 15% of the 170,000 scans that it pays an average of $700 for each year may be unnecessary, potentially saving the company $12 million per year through the preapproval program. HealthPartners expects to save $7 million. The state medical association has objected to the plan because it requires more time from referring physicians, but does not compensate them, while the insurer gains the savings. The president of the state's largest radiology group called the new requirements punitive.

The challenge for radiology will be to keep the UM programs in the spotlight. As pressure mounts to control costs, it will fall to radiology to advocate for the patient if insurer' profit motive interferes.