Imaging gatekeepers: Another thing to slow down doctors

For some physicians, getting an imaging test for their patients means navigating an obstacle course. Before scheduling an imaging test, physicians increasingly have to call the patient's insurance company or its designated representative for approval. Insurers are using precertification strategies to address what they consider to be overutilization of high-tech tests, such as MRI, CT, nuclear imaging and PET scans.

Physicians see the trend as yet another clinical roadblock and a financial setback that trims their margins with extra overhead costs and lost productivity. At best, it can take longer to get a test scheduled, and some requests even can be denied.

The health plan strategy could especially affect medical groups that have purchased their own equipment in the interest of building ancillary revenue while offering patient convenience. With precertification requirements in place, physicians no longer can just end an appointment by sending a patient down the hall for a same-day imaging test. Instead, the physician's office must submit the relevant information, usually to a third-party imaging management company, and the patient must return at a later time.

Most preauthorization policies allow for immediate imaging tests in emergency, urgent care or inpatient settings, while focusing on tests conducted in outpatient settings.

"Nurses have many other things they need to do besides sit on the phone, like take care of patients," said Jim Wade, MD, a medical oncologist in Decatur, Ill. "But this is not just taking away from nurses' time. This is affecting patients' lives."

Preauthorization practices aren't new. But plans that once curtailed this procedure because of backlash from doctors and complaints from patients are reinstating them, in response to rapidly increasing costs.

For example, Medicare spending for imaging services paid under the physician fee schedule grew from $5.7 billion in 1999 to $9.3 billion in 2003, a 63% jump, according to a 2005 Medicare Payment Advisory Commission report. While physician services per beneficiary grew 22% between 1999 and 2003, imaging utilization grew 45% during the same time, according to the report. Usage of many high-tech imaging machines grew at an even faster rate; MRIs of body parts other than the brain, for example, grew 99%, according to MedPAC.

Meanwhile, a study by HealthLeaders-InterStudy, a Nashville, Tenn.-based health care research firm, says radiology costs are growing nearly 20% per year and now account for 10% of health care expenditures.

While health plans recognize how important a role imaging plays in clinical diagnosis and how powerful the new technology can be, they have to balance the need to provide good preventive medicine with "maintaining the value of the system," said Mohit Ghose, spokesman for America's Health Insurance Plans.

"Our members' point would always be there's a time and place," Ghose said. "What we need to be careful of in this arena is overuse."

Can this just be another health plan phase, one that will subside after enough public outcry?

"Not this time. It's too expensive," said James Borgstede, MD, a radiologist in Colorado Springs, Colo., and chair of the board of chancellors of the American College of Radiology. "It's incumbent on physicians to do what's best for physicians, but they need to look at the data and seriously question if all this imaging is necessary."

The college has called for federal standards putting more stringent requirements for ordering scans and limiting diagnosis to radiologists and other credentialed specialists who have had rigorous training, restrictions not supported by AMA policy. But, like the AMA, the college also is fighting efforts by Medicare to cut imaging payments.

AMA policy opposes efforts by any payer to control utilization of any medical service, imaging or otherwise, unless it can be proven that such control would improve quality without interfering with patient access. Also, AMA policy stands against any proposal to restrict payment for imaging services based on physician specialty, though it also says the AMA should review with specialty groups any criteria on patient care that might emerge from debate on the issue.

Physicians taking notice

Adoption of precertification policies among health plans still seems to be spotty. Doctors in some states may not have any preauthorization requirements, while others may have to deal with three or four different insurance plan policies. Physicians say that only adds to the confusion and hassle, as they have to cross-reference a patient's insurance plan with a list of insurers requiring precertification.

Illinois delegates at the AMA 2006 Annual Meeting in June proposed a resolution to oppose "efforts by third-party payers to require precertification for outpatient and physician office diagnostic imaging," based on experiences its members were having with Health Care Service Corp.'s BlueCross BlueShield of Illinois, which a few months ago implemented its "Radiology Quality Initiative." Delegates did not discuss the resolution because they said it was similar to already existing policy.

"Basically, the problem we see is it seems to be a cost-cutting measure," said Peter Eupierre, MD, president of the Illinois State Medical Society. "They're trying to put enough blocks along the line so the tests aren't done. Of course, they save money, but they're not doing any service to the patient."

The Illinois Blues program describes itself as being only consultative and educational, meaning no imaging orders are denied. But other precertification programs, such as ones run by WellPoint-owned Anthem Blue Cross and Blue Shield plans in the Midwest, are full utilization-management programs, with a denial rate between 2% and 3%, said John Jesser, vice president of health care management in Anthem Blue Cross and Blue Shield's northern and central Ohio office.

"A significant number of orders are withdrawn, or some are redirected," Jesser said. "Maybe the order was for a CT scan, but the patient needed an MRI instead."

The authorization process

The Anthem plans, including ones in Indiana, Kentucky, Missouri, Ohio and Wisconsin, run their own precertification programs with support from American Imaging Management, a utilization management company based in Deerfield, Ill. (The company also administers the Illinois Blues' program.)

Most other insurers simply outsource authorization duties to a utilization company like AIM.

The company, which has been known by a few different names since its start in 1989, contracts with 17 health care plans across more than 20 states, covering some 15 million lives.

Physicians who order a test would first either call AIM or visit the company's Web site to provide the relevant details about the case. Between 70% and 80% of orders are approved at that information intake stage, said Maureen White, MD, AIM's chief medical officer. Those that are not approved move on to a registered nurse review, and if not approved at that stage, they move on to a physician review, Dr. White said.

Health plans maintain that the precertification process is not burdensome, citing statistics such as those compiled by AIM. The utilization management company reports that its average intake time was 3½ minutes for those cases that could be approved with the initial phone call. Calls requiring a conversation with a nurse or a physician-to-physician discussion took more time, Dr. White said.

In the first quarter of 2006, physicians of all specialties contracting with Midwestern health plans had an average of 1.46 cases per month, according to AIM statistics. Some specialties, such as neurosurgery and cardiology, had more than the average, while others, like gynecology and pediatrics, had fewer.

But physicians argue that receiving authorization is never a quick process, and if a practice orders more than the average number of imaging tests each month, staff members could spend considerable time on the phone or inputting information online.

"Through a telephone interview, it can take up to 30 minutes," Dr. Wade said. "On the Internet, it takes 15 minutes to enter the data, but it may require clinical data that's not in the chart yet, and we don't have [electronic medical records]."

The issue that vexes physicians is why all doctors need to go through this process if the denial rate is so low and if health plans' primary goal is education. Insurers respond they want to collect data that will help them narrow down certain specialties or groups that might be ordering more than the average number of tests. Plus, the mere presence of a preauthorization process can deter some physicians from ordering a test they're not totally sure is necessary, and it helps steer doctors in the right direction, they said.

AIM, for example, measures the "impact rate," which is the percentage of total requests that are either voluntarily withdrawn, redirected or denied by the management company. In 2005, nearly 14% of requests made by internists and nearly 12% made by family physicians fit that category, according to AIM's figures.

"We believe it will most likely be more effective to have interaction at the time it's being ordered," said Kim Reed, MD, senior medical director for BlueCross BlueShield of Illinois. "With the rapid changes that are coming out in high-tech imaging, it's difficult for any physician to be up on the guidelines."

But if that's the case, why apply the policy only to tests ordered for outpatient settings, physicians ask. While there may be a few doctors who order tests inappropriately, the vast majority are acting responsibly in the interest of their patients, they said. The idea that they have to spend time seeking approval for an outpatient imaging test when the same patient could have gone to the emergency department and had the same test done with no questions asked seems counterproductive for many doctors.

"If there's urgency to the situation, hopefully the turnaround won't be slow," said David Olson, MD, a family physician in Brookfield, Wis. "If you think about it, in some situations, you might as well punt this and send them over to the ER and let them order the test."