April 6, 2009
RBMs Are Part of Obama Plan
By Kathy Hardy
Vol. 10 No. 7 P. 18
President Barack Obama’s proposed budget for fiscal year 2010 joins a number of documents coming out of Washington, D.C., within the past year calling for the use of radiology benefits managers (RBMs) to reduce imaging costs within the Medicare program. In one line item, the budget seeks the promotion of efficiency and accountability by ensuring “that Medicare makes appropriate payments for imaging services through the use of radiology benefit managers.”
In a $3.6 trillion budget that is looking to set aside $634 billion for healthcare reform in 2009, the preauthorization proposal is projected to save $260 million over 10 years.
The ACR addressed the topic of RBMs following the release of a June 2008 Government Accounting Office report, noting how an increase in spending on imaging services in the private sector was successfully managed by the use of preauthorization and RBMs. This report corroborated a 2005 Medicare Payment Advisory Commission (MedPAC) study that identified high-end imaging such as MRI, CT, and PET as the fastest-growing imaging services covered by Medicare. The Centers for Medicare & Medicaid Services (CMS) adopted some of MedPAC’s recommendations, adding further restraints on imaging services spending after the Deficit Reduction Act was issued.
ACR Appropriateness Criteria
John A. Patti, MD, FACR, vice chair of the ACR’s Board of Chancellors, believes the inclusion of RBMs in the president’s budget stems from an option in the December 2008 Congressional Budget Office report that calls for the implementation of preauthorization for advanced imaging services, specifically Medicare. Based on trends in imaging service costs among private insurance plans that employ RBMs, the budget office estimates a reduction in net federal spending of $220 million between 2010 and 2014 and about $1 billion between 2010 and 2019 by implementing preauthorization criteria.
The ACR, however, believes that the adoption of appropriateness criteria would better address the issue, leaving the treatment decision-making process in the hands of physicians and their patients. The ACR established its own appropriateness criteria and encourages its use by medical professionals nationwide. The criteria list approximately 300 evidence-based guidelines that provide guidance for referring physicians and other providers to determine the best methods for imaging a patient. The guidelines, which are updated regularly, link the disease process to different methods of imaging. They utilize a scoring process of 1 through 9, with 1 being the least applicable method and 9 being the most appropriate. Ultimately, physicians review the criteria and determine the best method for the patient.
“The ACR is certainly hopeful that evidence-based quality initiatives will continue to gain support, instead of for-profit brokers, as a preferred methodology to ensure appropriate utilization of imaging,” Patti says.
He goes on to point out that language in the Medicare Improvements for Patients and Providers Act of 2008 calls for Health and Human Services to establish a demonstration project on the appropriate use of advanced imaging services by January 1, 2010, without the use of preauthorization to collect data under the demonstration. This causes a potential conflict, Patti says, as it was Congress that established these guidelines without the involvement of RBMs in the medical decision-making process.
An alternative to preauthorization that the ACR has discussed with the CMS is the adoption of a computerized physician order entry system with embedded decision support that utilizes all of the ACR’s appropriateness criteria. With this system, referring physicians enter their order, with information that includes the patient’s medical condition, and they receive a score for the test that was ordered, as well as scores for alternative methods.
CPOE and Decision Support
“This system provides instant feedback on the exam that was ordered and also instant feedback on alternative exams,” Patti says.
The system also tracks physicians’ ordering patterns. In addition, once a decision is made on the course of imaging, the physician is able to send the patient to any hospital or imaging facility to undergo the exam.
“This allows the ordering physician to directly interact with the database that we know was derived from the ACR appropriateness criteria,” he says. “There are other order entry systems in use, but only a few of them have the embedded decision support.”
This system was developed at Massachusetts General Hospital, where Patti practices radiology, and is used throughout the Partners HealthCare integrated healthcare system, which also includes Brigham and Women’s Hospital in Boston. He says all major insurance payors in Massachusetts accept the system and allow its users to bypass the RBMs’ preauthorization process.
Ensuring Access to Imaging Exams
Focusing on reducing imaging costs as a way to offer healthcare to all Americans is not the approach the Medical Imaging and Technology Alliance (MITA) would like to see the president take. Ilyse Schuman, managing director of the MITA, believes that relying on RBMs to reduce costs would ultimately undermine access to imaging services and therefore would limit access to exams.
“We’re very concerned by his approach but not the goal,” Schuman says. “Giving all Americans access to healthcare is good, but every patient should also have access to the right scan at the right time. Preauthorization interferes with the patient/doctor relationship. We’re concerned with having a third-party step into that process.”
The MITA, part of the National Electrical Manufacturers Association, agrees with the ACR that relying on appropriateness criteria is the better option when it comes to approving imaging services, as outlined in the Medicare improvements act. The next step, Schuman says, is to “educate other stakeholders and policy makers” that there is a better approach than with RBMs.
As for ways to approach preauthorization policy efforts, industry organizations are working to educate government and industry alike about alternative methods of ensuring that appropriate testing is available for everyone. A joint task force of the Radiology Business Management Association and the ACR is preparing a white paper on appropriate imaging utilization management, which will contain a section that addresses RBM performance standards.
“RBMs are not a perfect option, but they’re participants in the process, so we felt the need to establish guidelines for them,” Patti says.
Other industry organizations, including the AHRA, are watching the marketplace before weighing in on the potential impact of RBMs.
“The president’s budget proposal is a complex document which addresses healthcare reform,” says Penny M. Olivi, CRA, FAHRA, president of the AHRA. “As the professional organization representing medical imaging managers, AHRA will be closely watching this issue, as it could greatly affect our members and the institutions for which they work.”
— Kathy Hardy is a freelance writer based in Phoenixville, Pa., and a frequent contributor to Radiology Today.