Creating Shared Value in Imaging

Developments in Health Care IT Offer Promise for Members, Providers and Payers

Managing the Growth in High-Tech Imaging

The evolution of diagnostic imaging has been one of the most significant developments in modern medicine. A 2001 survey of physicians published in Health Affairs identified high-tech imaging as the most important clinical innovation in the last thirty years by a wide margin. Given the dramatic advances in imaging technology that has occurred since that article was published, it is likely that this margin would be even higher today.

Diagnostic imaging is fundamentally changing the way that medicine is practiced. High-tech imaging can produce high resolution, cross-sectional, three-dimensional pictures that offer an unprecedented and dramatic view of the human body. Sophisticated information systems allow images to be transferred around the world and shared in leading medical centers at the press of a button. Imaging’s potential is increasing as uses for current technologies expand, and as new technologies, such as molecular imaging and nanotechnology, become reality.

While advances in imaging use have received significant press, the rapid escalation of imaging costs has received equal, if not greater, attention. Driven by spiraling utilization and high unit costs, imaging has become one of the fastest growing components of health care spending in the United States. With a growth rate double the average of all other services, imaging was the fastest growing physician service cost in Medicare between 1999 and 2004. For private health insurers, imaging costs have been increasing at annual rates approaching 18 to 20 percent-- easily eclipsing trends in other segments such as prescription drugs and inpatient care.

While technology advances and broadening clinical application account for part of the growth in imaging, it is clear that some portion of the increased spending is due to inappropriate use. A 2004 article in the Journal of the American College of Radiology estimated that the annual cost of inappropriate imaging could be as high as $16 billion. In addition to cost considerations, inappropriate imaging also creates patient safety issues, primarily due to high levels of radiation exposure during certain high-tech imaging studies. For example, one of the most ordered high-tech imaging studies, a CT of the abdomen, exposes patients to the radiation equivalent of 500 chest x-rays. In response to growing patient safety concerns, the American College of Radiology now recommends tracking cumulative radiation levels from imaging at a patient level in order to avoid excessive radiation exposure. Inappropriate imaging can also lead to sub-optimal treatment due to false positives or incorrect findings due to the use of the wrong imaging modality.

Multiple reasons have been cited for inappropriate imaging including: the need for better physician education regarding the evolving uses of imaging, system inefficiency resulting in waste and duplication, and the growing issue of self-referral that occurs when providers purchase, operate and control referrals to their own equipment.

As the primary healthcare payers in the United States, both Medicare and private health insurers have implemented mechanisms to decrease inappropriate imaging. Congress attempted to lower imaging spending by Medicare through reimbursement reductions contained in the Deficit Reduction Act of 2005. The five-year impact of this proposal was estimated to be between $2.8 billion and $6.0 billion. Predictably, this legislation was opposed by a coalition of provider organizations and imaging equipment manufacturers, resulting in the implementation of far more modest cuts than those originally proposed.

Private health insurers have taken a different route by introducing prior authorization requirements, primarily through the use of third-party radiology benefit management companies (“RBM”) such as American Imaging Management (“AIM”). Imaging prior authorization programs focus on high-tech services such as CT, CTA, MR, MRA, Nuclear Cardiology and PET delivered in an outpatient setting. These services comprise a high proportion of total imaging spend and are particularly good candidates for prior authorization as they are discrete and readily definable and are often performed on an elective rather than urgent basis in the outpatient environment. Prior authorization in imaging is also facilitated by the presence of widely accepted clinical guidelines and appropriateness criteria issued by sources such as the American College of Radiology.

Prior authorization for outpatient high-tech imaging is similar to the process used for other clinical services. Physicians ordering high-tech imaging studies are required to contact the RBM before the study is performed. During this interaction, which may be through the phone or the Internet, the physician is asked to submit clinical information to allow the RBM to compare the rationale for the order against the generally accepted clinical guidelines used by the RBM. If necessary, the comparison process may also require interaction with nurse and/or physician reviewers. In most programs, RBMs will either approve or deny the request based on the cumulative information collected during the process. If the request is denied, the health plan will not reimburse the performing provider or facility if the study is done.

The use of prior authorization programs has had a direct impact on imaging utilization. Health plans realize an immediate reduction in utilization, which is augmented by an on-going reduction in growth trends. Despite tepid acceptance by the physician community, RBM use has grown dramatically and over 60 million health plan members are now covered under these programs.

While prior authorization has reduced inappropriate imaging use and added an additional quality component through the application of clinical guidelines and review to the ordering process, rapid developments in imaging and healthcare information technology are creating the opportunity for a broader vision for imaging quality improvement.

A New Vision and New Opportunity for Quality Improvement in Diagnostic Imaging

As one of the largest imaging management companies in the United States, AIM has taken advantage of the changing environment to evolve its own programs. AIM is focusing on attaining complete data capture to identify inappropriate and unsafe procedures and to perform more comprehensive analysis. Through information system development, AIM has created a clinical review process that efficiently gathers and evaluates relevant clinical information and generates a valuable data stream for analytical review. AIM’s extension of prior authorization capabilities onto the Internet has resulted in over 60,000 registered users and over 1 million prior authorizations submitted through the web annually.

AIM’s data shows that the utilization reduction that accompanies its programs is not driven by high denial rates, but rather through improved awareness in the physician community. The presence of a prior authorization program, intensive data analysis to identify physicians potentially ordering inappropriately, and the use of provider education and information sharing create a greater impact on utilization than denials. The primary value of an imaging management program is clinical data, analytical tools to assess the impact of that data and a feedback mechanism for providers. The value of clinical data is the key driver for AIM’s vision for the next phase of quality improvement in imaging.

Prior authorization covers one aspect of the imaging process: determining whether an order is appropriate based on clinical criteria. While the question of whether a study should be performed is important, it is only one aspect of quality management. A comprehensive approach would not only focus on whether a study should be done, but would also determine where the study should be done, what the results of the study were, and how the study impacted patient care.

For example, a physician’s decision to order a coronary CTA may be clinically appropriate and may receive an authorization from an RBM. However, the complexity of a coronary CTA procedure requires unique equipment and staff competencies. Requiring sub-millimeter slices, 0.5 to 0.75 mm reconstructions, multiple simultaneous images and cardiac gating—coronary CTA should not be performed on a CT scanner with less than 16 slices, and preferably should be done on machines with at least 32- or 64- slice capability and a high signal-to-noise ratio. Additionally, the imaging center’s staff must be able to precisely slowdown a patient’s heartbeat and accurately time contrast injections. Most health plans lack information on the imaging facilities in their networks to be able to ensure that all of these standards are met.

Once a study has been completed, there is no feedback mechanism to detail the outcome of the study and the positive or negative impact that it had on the overall process of patient care. Most health plans receive minimal data in the claim that is sent by the imaging facility and the interpreting physician, and usually not enough data to understand the longitudinal impact of the exam on the patient’s care.

Developing a comprehensive approach to imaging quality management-- ensuring that the right study has been done, that the study was delivered in the right setting and that the study produced a quality outcome-- has been challenged by an inability to gather, integrate and interpret the right data. However, developments in imaging and healthcare offer new promise for creating a new approach to imaging quality management:

• Through AIM, health plans have gained an increasingly rich stream of clinical data regarding high-tech imaging ordering. AIM provides its clients with appropriateness information on modalities, individual procedures, specialties and individual physicians, along with analytical support to interpret this information. AIM’s clients are using this information to identify educational opportunities and create network strategies.
• More sophisticated network management tools are being developed. Previously, facility information was gathered through cumbersome paper-based assessment processes. These processes produced incomplete results, were difficult to update, and provided little opportunity for meaningful data comparisons. AIM has recently launched its OptiNetSM application to improve network management. OptiNet is a multi-faceted assessment program that allows imaging providers to submit and update facility information using an easy-to-use web interface. OptiNet collects the information and uses a quality-scoring algorithm to calculate a provider value score, creating meaningful comparisons between facilities based on key quality attributes. Health plans are using the information from OptiNet to support network and consumer awareness strategies. Through OptiNet, health plans can begin to ensure that imaging services are delivered at the facilities that are most appropriate from a quality perspective.

The final step of matching services to outcomes remains a challenge. The lack of connectivity between health plans and providers has created a barrier to transmitting the information necessary to match services to outcomes. While challenges remain, several developments are breaking down this barrier.

Through PACS, hospitals and imaging providers are already facile in sharing and transmitting images and radiology reports. The continued integration of imaging and the web, combined with the digitization and miniaturization in imaging, is creating a readily accessible environment for sharing images and clinical information.

In order for imaging management to become an integrated quality improvement program, health plans will need to embrace the interoperability movement that is taking place within the provider community. Interoperability between health plans and providers is a key component to creating a more integrated health management value proposition. Additionally, health plans and their vendor partners will need to create stronger analytical tools to assess the new data that will be received, and to develop solutions based on the data. Finally, health plans will need to develop a new relationship with providers to create a partnership on how data should be gathered, evaluated and used for quality improvement. With a richer data stream and a commitment to partnering with providers, health plans can create a comprehensive approach to ensuring imaging excellence.

Full integration of clinical information will enhance imaging management by delivering a broader focus on imaging’s impact on the care process. For providers, this type of solution will simplify care management by creating a streamlined process that is integrated with care delivery and comparison data to improve their own practices. For members, integrated imaging management will ensure the appropriate provision of imaging services, and will provide the information needed to make more informed choices. Health plans will benefit by creating a new source of value for their key constituencies.

The evolution of diagnostic imaging is changing the way that medicine is practiced. An integrated approach to sharing and evaluating information will increase the value that all of the constituencies of our health care system will gain from these advances ensuring excellent quality and patient safety.

(reproduced with permission)