November 16, 2009

RBMs — Study Examines Their Impact on Utilization

By Kathy Hardy
Radiology Today
Vol. 10 No. 18 P. 28

Imaging utilization drops significantly during RBMs’ first year after implementation but then less (or not at all). The reasons why aren’t clear.

Exactly how do radiology benefits managers (RBMs) affect utilization, especially for advanced imaging modalities such as CT, MRI, and PET? How much do they reduce soaring medical costs?

Answers to those questions were sought during a recent study conducted by Georgetown University public policy professor Jean M. Mitchell, PhD. R. Robert LaGalia, who was chief financial officer of RBM company National Imaging Associates (NIA) when the study was done, is the study’s coauthor. The study examined managed and unmanaged Medicare costs and shows how three health plans reduced advanced diagnostic imaging costs by implementing NIA’s RBM protocols. It examined claims data from three insurers who used NIA services.

Initial Drop
The research found the greatest reductions occurred during the first year after implementation.

“The introduction of RBMs does seem to cause a drop in advanced imaging utilization,” Mitchell says. “The concern is does it really work in the long run?”

Mitchell notes that although RBMs were implemented as early as the 1990s, little information has been published on the topic of what effect, if any, their involvement in the preauthorization process for imaging services has had on ensuring appropriate utilization of imaging and in reducing costs, although it’s safe to presume that insurers would not keep using RBMs if they didn’t save them money.

“Private insurers have been reluctant to relinquish data on the effects of RBMs,” Mitchell says.

Financial data have been readily available, coming from the ledgers of insurance providers and governmental bodies in Washington, D.C. Close scrutiny of advanced imaging spending stems back to the 2005 Medicare Payment Advisory Commission (MedPAC) report to Congress on the increased utilization of imaging exams. The Centers for Medicare & Medicaid Services (CMS) adopted some of MedPAC’s recommendations beginning in 2006. The U.S. Government Accountability Office (GAO) reported in 2008 that Medicare Part B imaging spending increased from $6.89 billion to $14.1 billion between 2000 and 2006.

Popular With Insurers
The Deficit Reduction Act of 2005 cut Medicare’s imaging spending by $1.8 billion when the law’s regulations were implemented in 2007. President Obama’s proposed 2010 budget included a line item calling for Medicare to implement RBMs as a way of promoting “efficiency and accountability.”

“Given what’s occurred in imaging, the private insurers are increasingly adopting RBMs,” Mitchell says. “Although more empirical analysis is required before drawing definitive conclusions, these trends suggest that RBM prior-authorization initiatives may be a viable approach to addressing concerns about appropriate use of advanced imaging.”
NIA is one of six major firms currently providing RBM services. The others are HealthHelp; CareCore National; American Imaging Management (AIM), which is now part of WellPoint; Care to Care; and MedSolutions. According to the study, an estimated 88 million people had private health insurance plans that included RBM oversight in 2007. The three largest firms—CareCore National, NIA, and AIM—each reported more than 20 million enrollees.

The study included data from three health plans: a commercial healthcare insurer that covers several western states, a commercial carrier from a midwestern state, and an East Coast Medicare Advantage managed care plan. Imaging procedures were performed in hospital outpatient departments, physicians’ offices, and freestanding centers. The modalities included in the study were MRI, CT, PET, and nuclear cardiology.

RBMs’ Own Data
That data came from two years before and two years after RBM implementation. Each insurer contracted with NIA for mandatory imaging prior authorization programs from early 2004 to February 2005.

“It is important to examine trends before and after implementation of the prior authorization initiative to determine if more detailed analysis is warranted,” Mitchell says.

In the year prior to the implementation of RBMs in each of the three plans examined, imaging utilization experienced double-digit increases. Following implementation, the most significant changes in the imaging utilization pattern for each insurance provider were found in the first year the program was implemented.

Utilization rates with the western states’ insurer for CT dropped 12% after the first year under RBM protocols; MRI decreased by 10% in that same time period. In the second year under RBMs, use rates for CT declined another 5%, while MRI utilization dropped by another 8%.

Down and Then Up
In the midwestern states, usage rates for CT, MRI, PET, and nuclear cardiac imaging were increasing at rates varying from 13% for MRI to as much as 75% for PET in the years prior to RBM implementation. One year after RBMs were implemented, demand for CT dropped 9%, while MRI utilization dropped 15%. Much of that benefit was lost by the end of the second year, when CT use increased 11% and MRI use increased 8%. Nuclear cardiology utilization in this group was reduced by 22% during the first year of required preauthorization, with an additional 2% decline during the second year.

Age and its related need for increased advanced imaging services in general played a role in creating slightly different results with the Medicare Advantage group. The demand for PET was up to nine times higher for this group than with the other two plans. In addition, CT and MRI utilization rates were more than three times and 1.2 times higher, respectively. However, with the implementation of RBMs in early 2005, CT utilization dropped 14% in the first year and MRI utilization fell 8%, with an upward spike in the second year.

Mitchell considers several factors for the spike in utilization in the second year, including self-referral, defensive medicine, technology advances, and new imaging applications for modalities.

“Self-referral with or without RBMs continues to play a role in increased imaging costs,” she says. “Some physicians use self-referral to expand their practices. Addressing self-referral would help deal with that.”

The ACR continues to promote the self-referral issue, seeking industrywide adoption of appropriateness criteria for ordering imaging as a way to ensure that exams are ordered for appropriate reasons. Diagnostic radiologist Bibb Allen, MD, of Birmingham, Ala., who chairs the ACR’s commission on economics, sees a variety of causes of inappropriate imaging and refers to attempts by physicians to make up for lost reimbursements by providing ancillary services as one. Physicians may use economically motivated self-referrals as a “way to make ends meet,” he says.

“Eliminating economically motivated self-referral isn’t the whole answer, but it will help,” he adds.

Gaming the System?
Another possible explanation for the second-year spike in imaging is that physicians learned how to game the system by listing the diagnostic codes they know will result in the approval of the imaging requested. Allen reiterates that in this situation, educating physicians on the proper criteria for determining appropriate imaging, rather than on how to beat the preauthorization process, will result in good, patient-appropriate medicine.

“It’s better to have physicians learn how to order the appropriate imaging than how to trick the system,” he says.

The study also addresses the issue of defensive medicine playing a role in imaging rate increases during the second year after RBM implementation. Physicians use diagnostic imaging to rule out the most serious potential causes of a patient’s symptoms because they are concerned that if something is missed, patients will sue them for malpractice.

However, it is not just defensive medicine that leads to ordering imaging examinations when patients have potentially life-threatening illnesses. Allen uses the example of a patient who arrives at an emergency department with head trauma. Most often, a head CT is ordered on the suspicion that the patient might have a life-threatening hematoma. While clinical decision criteria may suggest there is only a remote possibility of such bleeding in the brain, imaging can eliminate the most serious possibilities from consideration. In addition, fear of a lawsuit from that small chance leads to the exam being ordered to protect the doctors as much as the patient.

“The patient could be discharged and then die at home if we don’t check for it,” Allen says.

Allen notes that imaging in situations such as this may also save money in the long run. For instance, another patient comes to the hospital suffering from abdominal pain; a CT scan will most often reveal whether that patient needs surgery for appendicitis or can be discharged.

“If you don’t do the scan, you won’t know whether or not the patient needs surgery,” he says. “The patient may need further tests or even hospitalization to determine the cause of the abdominal pain. Any costs incurred by not knowing the diagnosis can be mitigated by imaging the patient.

“Even in patients without disease, you still have to monitor them if you don’t do any imaging,” he continues, “and monitoring is money spent. With all aspects of medicine increasing in cost, you can’t say that patient’s treatment would have cost less without imaging.”

The study also notes that increased imaging could also be influenced by the advancement of new technology. According to Allen, 20 new imaging modalities have been introduced since 2006. Study results relating to PET utilization demonstrated that fact. PET had low procedural demand both before and after the RBM was implemented by non-Medicare insurers. However, there were increases in PET scans reported after RBMs were implemented, demonstrating that as PET became more of a mainstream modality, it was used more often, even with RBM preauthorization review.

Mitchell adds that an expansion of applications for existing modalities such as breast MRI, where advanced imaging is determined to be appropriate, could contribute to the increase. In 2007, the American Cancer Society criteria for breast cancer screening included MRI along with mammography as appropriate for women at high risk of breast cancer.

Further Study
Mitchell sees this study as just the first step in truly learning how RBMs can affect advanced imaging usage. The next steps include empirical analysis with a control group and allowances for other potentially confounding factors. One approach would be a comparison of frequency of use for each type of advanced imaging during a specific time period for individuals enrolled in plans that are subject to the RBM preauthorization initiative and a control group of individuals who are not enrolled in the RBM program.

“There was no control group with this study,” she explains. “This was more about looking at trends before and after implementation. A control group is needed so that you can identify if the program had an impact on those enrolled.”

— Kathy Hardy is a freelance writer based in Phoenixville, Pa., and a frequent contributor to Radiology Today.

Insurers Bringing RBMs In-House
The recent Georgetown University study did not consider changes in the radiology benefits management (RBM) companies themselves as influences in the study. However, one strategy that has hit the radar is health insurance providers acquiring RBM service companies and bringing the work in-house. While this practice isn’t new in the industry—Magellan Health Services purchased National Imaging Associates in 2005 and WellPoint purchased American Imaging Management in 2007—this trend suggests that radiologists and referring physicians can expect to keep working with RBMs.

“The act of internalizing RBMs only slightly impacts radiologists, as they still have to deal with the RBMs whether they fall under the payer or act as a separate entity,” says Ron Howrigon, president of Fulcrum Strategies, a provider advocacy company. “The main thing to think about is that when an insurance company spends money to acquire these companies, it sends a message that RBMs aren’t something that’s going to go away.”

Howrigon notes that as external companies, RBMs would “simply disappear” if insurers believed the concept of benefit management didn’t work.

“Now, if insurance companies are acquiring RBMs, they’re not going anywhere,” he adds. “With these acquisitions, utilization management is going to expand. I expect that within the next five years, other RBMs may be gobbled up by other payers.”

With the anticipation of more similar acquisitions of RBMs by insurers, Howrigon suggests that radiologists educate themselves about each major insurer. As RBMs become internal entities to insurers, there could be territories or regions covered exclusively by different insurers and, with that, their respective RBMs will cover those areas as well. Mergers such as these could lead to accreditation and credentialing standards, across the board or specific to those respective regions.

“Radiologists need to learn as much as they can about each of the insurance companies,” he says. “If the radiologist is hospital based, they need to talk to their hospital and make sure they’re keeping up with what’s going on in the industry. You need to keep your ear to the ground as to the next steps insurers are taking.”

— KH