Partnership for Success
Wisconsin radiologists team up with other specialists to demonstrate the benefits of point-of-service decision-support technologies.
Medical practitioners don't always agree with the rules imposed on them by government agencies.
So when Wisconsin's Department of Health Services (DHS) mandated that such imaging services such as CT, MRI, and PET be preauthorized by a radiology benefit management (RBM) company, radiologists and other stakeholders decided to inform DHS of the decision-support technologies already in place to ensure appropriate imaging. These computer-based clinical tools rely on a set of criteria, such as the ACR Appropriateness Criteria®, to demonstrate whether a particular test or therapy is right for an individual patient. (ACR Select™, a decision-support product, utilizes the appropriateness criteria. Visit www.acrselect.org to learn more.)
By partnering with the Wisconsin Medical Society and DHS, Wisconsin radiologists successfully influenced the creation of the ForwardHealth Alternative Pathway prior authorization exemption for CT and MRI. In doing so, participants perfectly exemplified the mission of ACR's Imaging 3.0™ initiative by using a collaborative approach and capitalizing on advanced decision-support tools to implement a more cost-effective, stream-lined system of care.
The first step in this process, according to Gregg A. Bogost, MD, FACR, president of Madison Radiologists in Madison, Wis., was simply talking to others around the state about the requirement. Spreading the word about the new policy led to many partnerships with local health systems, as well as vital connection with the Wisconsin Medical Society. "It became a collaborative effort between multi-disciplines and different clinicians, who all came together with the state radiological and state medical society," says Tim Bartholow, MD, family practitioner and chief medical officer of the Wisconsin Medical Society.
Indeed, for those health systems or practices with electronic decision-support tools, the RBM preauthorization process appeared redundant. "What DHS was asking is that we call on RBM that has the same guidelines as site-of-care decision support tools, replicating the imaging-order approval process," says Bartholow. Because of the obvious duplication in processes, and the resulting waste, it wasn't difficult to gain support from the Wisconsin medical community and, ultimately, DHS.
Once Bogost realized that there was significant support among all of the stakeholders for an exemption from the RBM imaging approval rules, he and other physicians, including Bartholow, initiated conversations with Medicaid. The next challenge was technical. In order to successfully implement an alternate pathway, "Medicaid would have to create a whole separate electronic pathway for institutions to provide Medicaid with information in a way that was structured to save money and give appropriate care," he says. Fortunately, DHS was on their side, a partner also supporting the need for an RBM exemption.
Ultimately, on May 1, 2013, Wisconsin DHS rolled out the ForwardHealth exemption for decision-support technologies, including ACR Select. DHS works with applying health systems to evaluate their tools and get them approved. Only CT and MRI were approved for exemption because of their more widespread use. DHS is hopeful that PET will be approved for exemption in the future, when it is more widely available in Wisconsin. Visit http://bit.ly/PriorAuth for specific details about how to apply for an exemption.
Bogost touts the benefits of using decision-support tools. "With decision support, approvals are all done while the patient is right there, before they leave," he says. "The other big advantage is that some decision support tools, like ACR Select, are based on the ACR Appropriateness Criteria (www.acr.org/Quality-Safety/Appropriateness-Criteria), which are vetted by 20+ person subspecialty working groups, experts from within and outside of radiology who meet, discuss, and use literature to revise the criteria every three years. It's a high-quality, living document," he says, adding that RBMs do not employ such a large and skillful team to evaluate each imaging request.
1. “Decision Support for Ordering Appropriate High-Tech Diagnostic Imaging Scans at the Point-of-Order,” Institute for Clinical Systems Improvement. Available at http://bit.ly/13EWaux. Accessed Aug. 1, 2013.
By Alyssa Martino