Wake-Up Call

What radiologists can learn from Hawaii's preauthorization fight and how CDS can help.wake up call

Ho'ohiki. In Hawaii, that little statement means something big: that you will deliver fully on your promise.

In an open letter to all physicians in the state, Elizabeth A. Ignacio, MD, president of the Hawaii Radiological Society (HRS), and Christopher D. Flanders, DO, executive director of the Hawaii Medical Association (HMA), urged the medical community to join forces to thwart an insurer-imposed radiology business manager (RBM).

"HRS and HMA are completely committed to working with Hawaii's insurance carriers to build and support sustainable health care systems for the people of Hawaii," the letter stated. "Our goal is ho'ohiki — keeping our solemn promise as physicians to fully deliver the highest quality of health care that we can provide."

The letter came in response to a mandate handed down in December 2015 by Hawaii's largest insurer, which requires physicians to obtain preauthorization for all advanced diagnostic imaging exams. The effort to reduce unnecessary costs is having unintended consequences, says Ignacio, including extra administrative burdens, delays in critical imaging tests, and potential impacts on patient outcomes. What's more, physicians and radiologists are increasingly frustrated that their training and professional expertise are being pre-empted by the RBM's drive to save money.

In the struggle to ensure appropriate imaging in Hawaii, leaders from the HRS, HMA, and the ACR have come together with patients, physicians, corporate executives, and quality bodies to combat the challenges of dealing with what the authors of the letter call "preauthorizations via third-party reviewers who are thousands of miles away." As an alternative to the onerous RBM process, the letter also issued a clarion call for all physicians to deploy clinical decision support (CDS) — based on the evidence-based ACR Appropriateness Criteria® — at the point of care.

Moments Matter

In addition to physician education and a public awareness campaign, the coalition took the battle over preauthorization to Hawaii's state legislature. House Bill 2740 (which cleared the House and Senate, but died in the legislature's final review committee), sought to "prohibit health insurance preauthorization requirements that cause undue delay in receipt of medical treatment or services."

The bill would have held insurers, rather than health care providers, liable for civil damage caused by preauthorization delays. And it would have mandated that evidence-based guidelines or appropriate use criteria be consulted for prior authorization approval.

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In advocating for the legislation in front of the Senate committee, HMA president D. Scott McCaffrey, MD, said, "In health care, moments really do matter," especially when it comes to timely and accurate diagnoses. Ignacio says the gravest impact of the insurer mandate is frustrating and, often, frightening delay patients must undergo as they wait for authorization for imaging. "And the longer we wait, the worse the patient's condition will get," she emphasizes.

The leaders in Hawaii are continuing the fight on many fronts. "We want the insurance companies to know we're all on the same side," Ignacio stresses. "We're all trying to deliver care and to do it in a thoughtful, careful, cost-efficient way that gives patients the health care they need. We were disappointed the legislation didn't pass, but we're going to keep plugging away. I am optimistic that things are going to move to CDS and better preauthorization for our patients in Hawaii, because this issue got so much publicity in the legislature and more people became aware of the problems."

CDS Solutions

According to both the HRS and HMA, clinical decision support will reduce inappropriate imaging and help cut costs — without compromising patient care or adding to the burden on overworked physicians and staffs. "We understand the importance of creating a sustainable health care system. You can't spend money for inappropriate care," declares Ignacio. "CDS is a masterful consolidation of national standards and guidelines, so we can say, 'Our experts agree this is what's needed for a particular clinical problem.' That elevates everyone's comfort level. Insurance companies know they're spending money on something that is relevant and effective, and physicians know they're giving the best care they can."

She adds, "We believe CDS is a great tool to use in lieu of RBMs for preauthorization. Even more than that, it is a valuable tool for physicians to use to hone their craft, to improve their quality, and to keep track of themselves. With CDS, we know how we measure up and where we can improve."

To move the ball forward in Hawaii, the ACR and the American College of Cardiology are providing all HMA members with free access to their appropriate use criteria for advanced imaging via the ACR Select® Web Portal. "HMA leaders see the value of CDS as an educational tool for their physicians, with all the latest literature and guidelines on imaging techniques," says Mick Brown, vice president of business development at National Decision Support Company (provider of the ACR Select® CDS tool). "We are putting this evidence-based information at their fingertips — right when they're ordering an imaging study.

Intense Scrutiny

Hawaii isn't the only state where discussions about preauthorization and the role of CDS are taking center stage, says Brown. Today, there is widespread national focus on managing imaging utilization, along with federal legislation that will soon mandate the use of CDS for Medicare reimbursement.

The Protecting Access to Medicare Act (PAMA) was initially supposed to go into effect Jan. 1 2017, but CMS has delayed implementation, possibly until Jan. 1, 2018. However, many providers are not waiting for the mandate to kick in before they deploy CDS. What's more, says Brown, many state medical societies and professional organizations are heeding the Hawaii wake-up call and are taking action to encourage ubiquitous use of CDS to reduce inappropriate imaging and, possibly, head off or replace insurer-mandated preauthorization by RBMs.

"Washington State is a step ahead of most when it comes to embracing initiatives like Choosing Wisely®, reducing inappropriate tests, and delivering evidence-based guidelines natively within the electronic medical record workflow," Brown notes. "Like everywhere else, there's a lot of angst over the burden of prior authorization. The medical communities in Washington, as well as some employers and quality bodies, are all getting aligned and trying to do the right thing. They're also working on crafting legislative solutions and on being involved in rule-making processes by the insurance commissioner."

Action Plan for Radiologists

Under PAMA, radiologists will be hit with a financial penalty if providers don't consult CDS when ordering imaging, so radiology practices have a vested interest in advocating for such tools to provide timely, appropriate imaging for their patients. Brown says that PAMA opens the door to alternative forms of prior authorization beyond RBMs. "It was effectively an endorsement of decision support as a new way to manage utilization based on transparent, evidence-based criteria," he notes. "And it's got the backing of the country's largest payer — CMS."

"Now more than ever, radiologists need to be front and center in driving their health system or their practice to adopt clinical decision support, Brown says. We need to help referring physicians understand how decision support can enable them to participate more fully in value-based payment models. CDS can impact quality metrics and drive increases in payments under new federal programs."

Ignacio agrees, explaining that the first step for radiologists is "to do your job well and present for your physician colleagues as a consultant." She adds, "When you're interacting with your referring physicians as part of a team, you all begin to understand what is necessary to get the big job done, not just your little piece of it. At that point, it will be much easier to introduce CDS to your provider colleagues, because they will know you and will be receptive to how you can use the tool to collaborate on appropriate imaging to improve patient care."

One of the best ways radiologists can introduce their ordering physicians to CDS is via the ACR Radiology Support, Communications and Alignment Network (R-SCAN™). More information is available at rscan.org. "R-SCAN allows physicians to get their feet wet and see how CDS tools are used in real-world scenarios," says Ignacio. "For those who might be a bit reluctant to dive into CDS head first, this is a zero-cost, risk-free path to introduce clinical decision support. And it gives radiologists the opportunity to work more collaboratively with specialists and general practitioners."

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By Linda G. Sowers, freelance writer for ACR Press

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