Health plan looks to doctors to steer patients' imaging business

WellPoint's Anthem Blue Cross and Blue Shield divisions in Indiana, Ohio, Missouri, Kentucky and Wisconsin have launched a program the company says is intended to direct patients to better-quality, lower-cost imaging facilities. But some physicians say the program is likely to be more of a hassle than a help.

Like many of its peers, Anthem had already put in place prior authorization to try to limit imaging tests, which it had identified as one of its fastest-growing costs. The WellPoint division handling those prior authorizations, American Imaging Management, then developed OptiNet.

When a doctor calls or goes online to obtain prior authorization for an imaging procedure, that physician hears or sees a list of local imaging facilities that, along with listing the distance from the patient's home, shows letter grades for quality and average cost for the procedure being ordered.

OptiNet bases the letter grade on reported hours of operation, qualifications of staff and physicians, and type and age of equipment, said Paul Danao, vice president for business development at American Imaging Management, based in Deerfield, Ill. It started OptiNet in November 2007.

He said if the facility adds a technician, buys new equipment or hires a new physician, the quality information can be changed, and the facility's quality score will be updated on the following business day.

Imaging facilities don't have to participate in OptiNet, and physicians don't have to take it into account when suggesting facilities to their patients. In any case, physicians aren't welcoming its presence.

Christopher G. Ullrich, MD, a Charlotte, N.C., neuroradiologist, is chair of the Managed Care Committee of the American College of Radiology. He said he doubts a program like OptiNet will do much to change referrals, and it could end up being a hassle for referring physicians.

"It's another layer of burden to the ordering physician that isn't funded," he said.

Linda Abels, MD, an Indianapolis internist, said getting prior authorization is already time-consuming without throwing OptiNet into the mix. She said she didn't think a program like OptiNet would help direct patients.

"Generally I refer to a place I would go to as a patient and a place where I have access to the radiologist reading the study," Dr. Abels said.

Jeffrey Thomasson, MD, a radiologist from St. Louis, is president-elect of the Missouri State Medical Assn. and serves on the physician consultative committee for Anthem. He said radiologists support quality and cost transparency -- if those measures are truly about quality and not cost. He and others are not sure Anthem is really measuring quality.

"We worry this would be kind of an economic credentialing thing," he said. "Whenever you start talking about price as an incentive, at the forefront it kind of de-emphasizes the quality, and the two are not always linked. You can have high-quality, high-cost and high-quality, low-cost care."

WellPoint spokeswoman Jill Becher said the company knows that physicians who refer may do so based on long-standing relationships rather than a quality grade and cost data.

"However, it is our hope that as providers gain familiarity with OptiNet and as members become more engaged in their health care choices, the information that we provide will be utilized by all providers," she said.

OptiNet is voluntary for Anthem-contracted imaging centers, but if a facility does not participate, it won't show up when a physician calls for prior authorization. About 60% of the 2,000 imaging facilities Anthem contracts with in the five participating states have chosen to participate, said John Jesser, vice president of health care management for Anthem Blue Cross and Blue Shield of Ohio.

American Imaging Management also provides OptiNet services to BlueCross BlueShield of Florida, which is in the midst of surveying its imaging facilities to put together the system for its physicians.

Anthem has no dollar savings goal for OptiNet, Jesser said. OptiNet will be a success, he said, if there is a reduction in use of the highest-cost, lowest-quality facilities and an increase in traffic where the highest-quality, lowest-cost tests are performed.

"Some of this is going to have to take time as people with high-deductible plans, consumer-directed plans, who have their own money on the line, get more interested in these things -- if you have a $10 co-pay, you don't care about the price," he said.

Other plans have focused on making quality and cost information available to patients in the hopes it will help them make better decisions about where to have a test done.

Cigna, in 58 markets, provides cost and quality information about MRI, CT and PET scan facilities to its members. This year, the company plans to upgrade its online Health Advisor to give its members cost estimators for hundreds of procedures.

"One of the fundamental tenets of cost transparency is helping educate the member about the alternatives, choices and costs associated with those choices and fostering a more robust dialogue with their physicians about those choices," said Paul Thompson, Cigna's vice president for product development and director for quality and cost transparency.

Jesser said Anthem felt it would be more useful to give information to physicians than hand it to patients.

"The goal ... was to get the most appropriate test ordered for the patient and make sure the test was needed," he said. "That's not really something the patient can answer."