Taking Back Imaging
Can radiologists keep imaging decisions within the specialty without interference from RBMs?
Many payers may see radiology benefits management (RBM) companies which analyze the appropriateness of high-tech imaging procedures, as tools to keep their costs down.
Others, however, including referring physicians and some radiologists, see RBMs as invaders that undermine radiology's ability and responsibility to select appropriate imaging and help reduce the amount of unnecessary imaging procedures. But how much say do radiologists have in the policies and practices of RBMs? Will decision-support systems, such as those based on ACR Appropriateness Criteria®, help keep imaging decisions firmly within the radiology community?
How RBMs Work
Before beginning to understand the influence radiologists have on RBMs, it's important to comprehend the relationship between the two. The interaction begins when a physician decides to refer a patient to an imaging practice for a specific high-tech procedure, such as CT or MRI. Before the patient can actually receive the designated imaging, however, the referring physician must get approval, or prior authorization, from a managed care organization (MCO) — usually an RBM hired by the payer. If the RBM, using its own criteria, concludes that the exam is appropriate, it approves the referral, and the patient can undergo the procedure.
"It is a three-tiered process," explains David C. Levin, MD, FACR, professor and chair emeritus of the department of radiology at Jefferson Medical College of Thomas Jefferson University in Philadelphia and consultant for HealthHelp, an RBM organization in Houston. According to Levin, the first tier usually consists of service representatives who check the referring physician's request against the RBM's criteria. If the request coincides with these criteria, the request is approved; if not, communication moves to the second tier, which includes nurses who contact the referring physician's office for further insight into the reasons a specific procedure is ordered. If the information is sufficient to satisfy these nurses, they can approve the request. If the nurses are still unsure, the request moves to the third tier: physicians. Like Levin, many of these third-tier professionals are radiologists. They contact the referring physician to discuss the case, and the RBM physician might suggest an alternative procedure. "Very often the requesting physician will go along with that change," explains Levin, who is also a member of the ACR Economics Commission and the co-chair of the Future Trends Committee.
Not Created Equal
Although RBMs use a seemingly simple approval process, each organization has its own procedures. For example, one RBM does not deny claims; it only consults and advises. A few other RBMs impose little or no consequences if a referring physician disagrees with the RBM physician's advice to change or abandon an imaging procedure. Other groups, however, have the power to deny coverage if the referring physician's request fails to meet the criteria. In other words, if the imaging procedure is done without prior authorization by the RBM, the payer will reject the imaging facility's claim for payment.
In addition, some RBMs may threaten to deny coverage unless the patient visits a specific imaging facility where a procedure costs less. The College and other radiologists argue against this practice, known as "steerage," because the cheapest facility may not always best meet the patient's needs. As a result, the ACR and other radiologists are concerned that some RBMs allow cost to weigh too heavily in the decision process and that other patient-centered factors — such as exposure to radiation dose — are possibly seen as a secondary consideration. "With steerage, it's not a question of quality ... it's all about the money," Levin says.
And as often happens with such intricate processes, challenges arise. In fact, some RBMs raise the "hassle factor" for certain procedures, according to Mark O. Bernardy, MD, FACR, chair of the ACR Committee on Managed Care. In essence, these groups make certain procedures so difficult to order that referring physicians simply stop ordering them.
Follow the Guidelines
The ACR does not approve of such practices as steerage and denial of coverage by RBMs and defines its official stance on RBMs on its website: "The College does not endorse RBMs or their approach to the marketplace, as there are better alternatives, but recognizes their current role in imaging utilization management and seeks to improve the strategies used by the programs regarding burdens created for providers and their patients."
The ACR Committee on Managed Care, together with the Radiology Business Management Association, released best practice guidelines RBMs should follow when implementing a preauthorization program. The purpose of the guidelines, Bernardy notes, is to benefit patients by helping the RBMs "play fair." The guidelines include clinical care, administrative processes, and transparency recommendations.
"If implemented, these guidelines will result in a uniform process that would ease the administrative burden on payers, MCOs, ordering physicians, and imaging providers," the College notes online. But do RBMs really listen to radiologists when presented with the issues mentioned in guidelines? "Most of the time, they do," Bernardy says. "What we've asked them to do is not rocket science, and it doesn't inhibit their ability to save money." Additionally, the guidelines inform the imaging community on appropriate RBM behavior, he notes.
When there are instances of inappropriate RBM behavior, we not have a rule book to hold them to, Bernardy says. Those RBMs that engage in behavior contrary to the guidelines, he says, pass the blame to the payer or MCO and claim that the payer mandates how they should function. "Even so, when the RBM steers the patient to a different facility, they will claim they are just trying to help the patient make informed choices and consider cost in the process. While this presents challenges for our present system, turning patients into consumers is a positive and necessary trend to get us out of the medical expense mess we're in," Bernardy states.
As radiologists continue to engage and converse with RBMs, the College is also assessing its own relationship with such programs. During the Board of Chancellors meeting in October 2011, for example, members became involved in a point-counterpoint discussion as to whether the ACR should modify its policy regarding RBMs. Although opinions varied, both sides agreed on the "need for radiologists to take a more active role in utilization management," explained John A. Patti, MD, FACR, then-BOC chair and current ACR president, in his From the Chair column in the March 2012 ACR Bulletin. BOC members also agreed on the need for a robust, digital order-entry system featuring decision support based on the ACR Appropriateness Criteria. The ACR IT Department along with Quality and Safety Department is incorporating the Appropriateness Criteria into web-based services that can be utilized by decision support vendors and health-care systems and it is expected to be available by the end of the year.
The development of this innovative system, however, does not guarantee that RBMs will fade away. Nor does it mean a repeat of the growth in imaging utilization as seen in the late 1990s and early 2000s, explains Levin. "I think radiologists need to basically accept the fact that the utilization of high-tech imaging is going to be controlled. It is not going to be able to grow unchecked anymore," he says. Bernardy agrees, "We find ourselves in a milieu in which medicine is expensive, and imaging has been the whipping boy for the past seven years." However, it is the ACR's goal to ensure that these cost-saving measures are implemented in a way that protects our patients and guarantees safe and effective imaging and diagnosis.
By Brett Hansen