Blue Cross imaging rules aim to reduce utilization

A policy instituted in January by Blue Cross & Blue Shield of Rhode Island that requires “precertification” for MRIs, CT scans, PET scans and two other high-end radiology procedures has cut down substantially on utilization, a key official for the insurer said last week.
Dr. Gus Manocchia, chief medical officer for Blue Cross, said about 9 percent of imaging studies requested under the new policy – which applies to outpatient procedures, but not to hospital inpatients or to emergency rooms – are being denied each month.
In addition, Manocchia said, there has been a bit of a “sentinel effect,” with requests for MRIs and other high-end imaging down slightly overall, though by how much he couldn’t say yet.
For Blue Cross, that reduction is a welcome change from the steady increase in high-end imaging – and the accompanying costs – the insurer had been seeing for years.
Utilization had been rising by about 8 percent per year, and in 2006 Blue Cross spent about $78 million on outpatient CT scans and MRIs alone, for almost 150,000 procedures, Manocchia said. (For perspective, that’s about one MRI or CT scan for every five Blue Cross members.)
Across the nation and in other countries, insurers have been limiting access to high-end imaging for years to try to stem the growth; as of late last year, 28 of the 39 plans that are members of the Blue Cross Blue Shield Association, including Blue Cross Blue Shield of Massachusetts, had “radiology management” programs of some kind in place.
But providers in Rhode Island had resisted previous attempts by Blue Cross to do the same here, and the Rhode Island Medical Society had urged the insurer to instead try educational efforts in collaboration with doctors, said Newell Warde, executive director of the society.
“We said to them, ‘Please don’t do this, because it’s hard enough to schedule these tests now for patients, and if you put this extra hurdle in the way and you’ve got people sitting on the phone lines and delaying the tests people need, it’s really going to create a burden, especially for primary care practices,’” Warde said in an interview.
The society encouraged Blue Cross to identify “outliers” – doctors who were ordering more high-end imaging than their peers – and target them first, Warde said, but the insurer didn’t have the data to do that; it could only fully track who was performing the imaging.
Asked how much inappropriate imaging was being done, Manocchia acknowledged in an interview that Blue Cross didn’t really know when it put the policy in place.
But others’ experience, Manocchia said, suggested that needless high-end imaging was being done. In a Blue Cross newsletter, Dr. Gregg Allen, chief medical officer of the contractor hired by the insurer to handle the precertifications, MedSolutions Inc., cited estimates that more than $16 billion is spent each year on unnecessary high-tech imaging. He also noted that while in 2006, such tests cost about $120 billion nationwide, this year, it’s expected to be $161 billion.
MedSolutions uses national guidelines to determine when a procedure is considered medically necessary. Doctors who want to order, say, an MRI for their patient have to call or fax the company or else go online to request the procedure; if the request is denied, there’s an appeal process as set out by the R.I. Department of Health, Manocchia said.
Manocchia said most denials involve situations where no imaging is called for at all, or where it’s premature, but perhaps a patient is eager to get an MRI right away. If someone injures his back doing yard work, for example, he may fear he has serious damage and want to have it checked out right away, but national guidelines say he should wait four weeks unless there are neurological symptoms, Manocchia said.
Asked how many appeals there have been, Manocchia said that through May (the program began Jan. 1), there had been “about 400,” and a fair number of those were successful. That’s a low number, however, given the “tens of thousands” of imaging requests, he noted.
Matthew Stark, spokesman for Health Insurance Commissioner Christopher F. Koller, said it’s too soon to evaluate the impact of the program on health care, insurance affordability and provider finances, but Koller’s office is reviewing the program quarterly to ensure it is simple to administer and isn’t unfairly hurting providers.
But providers do report noticing a decline in imaging, and for those who do imaging themselves, an accompanying decline in revenue.
Jeanne LaChance, chief financial officer of The Westerly Hospital, said outpatient high-end imaging is down about 10 percent, though it has started to rebound, “because they’re just performing other tests first before they get an MRI.”
Edward J. Quinlan, president of the Hospital Association of Rhode Island, said each hospital has been affected to a different extent, but they all have seen some reduction in procedures.
However, both Quinlan and Warde, of the medical society, said that while the initial implementation of the program was burdensome, Blue Cross has made changes that made things easier – most notably, agreeing to let radiologists, rather than the doctors who order the imaging, go through the precertification process.
Asked whether Blue Cross considers the program a success, Manocchia said “it’s too early to say right now,” but he added that he expects the insurer to reach its anticipated savings goal of about $7 million for the year. &#8226