Precertification for Advanced Imaging Takes a Toll

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Growth in outpatient advanced imaging has declined significantly from its peak in 2004. At that time, outpatient CT and MRI exam volumes were growing at approximately 10% each per year. From 2009 to 2013, however, imaging experts at The Advisory Board Co, Washington, DC, estimate that growth for these modalities will slow to approximately 5% annually. While still positive, this slowdown in growth means that there is less incremental volume to go around in a very crowded marketplace.
imageShay Pratt
The principal drivers of this deceleration in advanced imaging growth have been precertification programs implemented by private payors and their partners, radiology benefit management (RBM) companies. RBM-managed precertification programs are now estimated to penetrate more than 60% of the commercial-payor market. Insurers have been quick to adopt these programs because they are reliable and effective, guaranteeing a return on investment. Approximately 15% of scans are either denied outright or not covered later, after the service is complete, due to administrative challenges to the precertification acquisition. Precertification programs also decrease utilization through the sentinel or gatekeeper effect; the extra steps created by the precertification process often discourage referring physicians from even making the initial request. Precertification programs denied an estimated 1.6 million CT and 1.5 million MRI procedures in 2008 alone. A Door Opening for Decision Support An intriguing alternative to precertification now exists in the form of electronic decision-support systems, software-based tools that provide feedback on the appropriateness of an imaging exam for a specific clinical situation at the time of ordering. The two primary commercial decision-support options offer similar functionality. An ordering physician accesses the tool and enters some patient history and a reason for the exam. The tool then uses an appropriateness algorithm to generate a score of 1 to 9, with 9 meaning most appropriate. Decision-support vendors argue that ordering physicians prefer their tools to the more onerous precertification process. Decision-support adoption, however, has been limited. Imaging departments are cautiously evaluating these systems and whether payors will fully accept decision support as a viable alternative. On that front, early successes have already materialized. In Boston, Massachusetts, some of the largest payors have agreed to allow physicians to use decision-support tools in lieu of precertification. Meanwhile, a state law in Minnesota encouraging the use of decision support to manage imaging utilization has paved the way for widespread adoption of the model, and similar legislation is working its way through the Washington state government. The vast majority of private payors, however, appear reluctant to accept decision support as an alternative to precertification. In convincing payors of the benefits of decision support, vendors and providers face an uphill battle, given the deeply entrenched RBM–payor relationship. Payors probably are concerned that decision support might not provide the same return on investment as preauthorization. For now, it appears that the relationship between health-insurance companies and RBMs is growing stronger. RBMs are now offering precertification programs for areas of care such as cardiac devices and radiation therapy. More ominously for imaging, they have pioneered programs to steer patients to less-costly imaging providers via phone-based scheduling services and online cost-transparency portals, which shine a light on the differences in patients’ out-of-pocket costs and total costs across different imaging providers. Health Reform as a Potential Catalyst Whether decision support becomes a true alternative to precertification might hinge on the health reform bill now being crafted by Congress. RBMs gained momentum last year when the Government Accountability Office recommended that CMS adopt preauthorization to curb imaging costs, but DHHS administrators have since expressed reservations about creating an imaging preauthorization program for Medicare because of the significant administrative burden that RBMs could cause and the resulting impact on access. At the same time, the Imaging e-Ordering Coalition played a leading role in promoting decision support to Congress. Now, an early version of the Senate’s health reform bill includes a proposal to measure the appropriateness of the advanced imaging studies that physicians order for Medicare beneficiaries. This evaluation could also become an official part of the Physician Quality Reporting Initiative, and it might become the catalyst that decision support needs to realize widespread adoption. Of course, several questions remain unresolved. Would the new process call for determining appropriateness retrospectively, or at the time of the order? If the latter, how would the government facilitate introduction of decision-support technology across providers? Who would be on the hook for the cost? The future of utilization management for advanced imaging could well be decided during the next few weeks as Congress solidifies the final health reform package. Shay Pratt is managing director of the Imaging Performance Partnership, a membership program of The Advisory Board Co, Washington, DC, for hospital imaging departments;