Saying that the use of high-end medical imaging is “out of control,” Blue Cross & Blue Shield of Rhode Island is considering several ways to curb costs – from “educating” doctors who order a lot of MRIs or PET scans, to a blanket preauthorization requirement.
The insurer hasn’t decided yet how far it wants to go, spokeswoman Kim Keough said, but it is determined to do something because imaging costs are rising rapidly, at a rate of about 10 percent per year. In 2004, Blue Cross spent $45 million on MRIs alone, she said.
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“That’s a lot, and that clearly is a reason to look into it,” Keough said.
Blue Cross wouldn’t be the first New England insurer to crack down on high-end imaging. In Massachusetts, Harvard Pilgrim Health Care and Health New England have required prior notification – administered by National Imaging Associates – for a while, and on Oct. 1, Tufts Health Plan began requiring it as well.
On Dec. 1, Blue Cross & Blue Shield of Massachusetts will implement its own imaging review system, with preauthorization required for doctors with a record of particularly high usage, and prior notification required for most others.
In Rhode Island, however, health plans until now had been reluctant to restrict imaging. They stayed out of a debate over proposed legislation to curb the proliferation of MRIs – as of this spring, the state already had 51 magnets, or one per 20,000 people, twice the national rate – even though Health Insurance Commissioner Christopher F. Koller argued that they, more than anyone, could control costs through their payment policies.
Blue Cross, it turned out, hadn’t even been enforcing a legal provision that allowed only MRIs done on machines certified by the American College of Radiology to be covered by insurance. United, for its part, has tended to avoid utilization review.
Asked whether United is considering policies to control imaging costs, spokeswoman Debora M. Spano said she didn’t expect one this year, “but we’re always concerned about utilization and cost and looking at better ways to manage it.”
If United did go in that direction, Spano added, it would most likely focus on “evidence-based medicine” and what research shows are the best uses for high-end imaging.
At Blue Cross, meanwhile, Keough said four possible strategies are under consideration:
*An “educational series” for all physicians to help them better understand when high-end imaging is appropriate, and when less-costly procedures are enough
*A targeted “educational” effort for “outliers” – doctors who order an “exceedingly high” number of MRIs and such – to steer them into more moderate imaging use
*A preauthorization requirement for the “outliers” only
* A preauthorization requirement for all doctors
“The thought is maybe doing it for a year,” Keough said, “and then those who were outliers or who were denied frequently, would have to continue, and those who didn’t wouldn’t have to get preauthorization.”
Blue Cross of Massachusetts worked closely with that state’s medical society to craft its imaging policy, and Keough said Blue Cross of Rhode Island is doing the same. “We’re talking about options, because when we told them about (the $45-million MRI tab), they were just as shocked,” she said.
Steven DeToy, director of government relations for the Rhode Island Medical Society, said local doctors are hoping to work out a plan with Blue Cross that avoids preauthorization requirements and minimizes the limits on patients’ access to care.
“Preauthorization punishes everybody,” DeToy said. “It makes it more difficult for patients, it increases the hassle factor in medical offices, and it may reduce utilization, but not in proportion to what is appropriate.” He called it a “slash-and-burn” approach.
“What we would like to see is a collaborative approach where we try to find those places, those physicians, those hospitals, whatever, that are high utilizers, and try to find out why,” DeToy said. Maybe for some, those above-average usage rates are actually appropriate, he said. For others, this could be an opportunity to provide guidance. The Medical Society has done this kind of outreach before, DeToy said, and it made a “pretty dramatic” impact.
Dr. John J. Cronan, chair of the department of diagnostic imaging at Rhode Island Hospital, said preauthorization has a record of reducing usage, but across the board, and mostly in the first few months. “After six to 12 months, it goes back.”
Profiling “outliers,” on the other hand, would be a new approach, Cronan said, and it could be effective. But ultimately, the problem goes much deeper, he said.
“It’s a skewed system,” he said. Medicare has set the tone by making MRIs and CT scans highly profitable while underpaying for mammograms and pediatric radiology, for example. And changing the status quo “is going to be difficult,” he said, because radiology equipment vendors “aggressively” resist any such efforts. “The insurance companies don’t want to get caught in this crossfire,” he said, so instead they try things like preauthorization.
Koller agrees that a better-structured payment system would make the biggest difference, but he said utilization review, when developed in close collaboration with doctors, does work, both to save costs and to help standardize care.
“The benefits are very real,” he said.
