Readers Write: Radiology Benefits Managers: An Inelegant Method for Managing the Use of Medical Imaging

Radiology Benefits Managers: An Inelegant Method for Managing the Use of Medical Imaging
By James A. Brink, MD, FACR

Doctors, lawmakers, and regulators are supposed to work together to make healthcare better. So why put a process in place that takes medical decisions out of the hands of doctors and patients, may delay or deny care, and often results in longer wait times to get care?

That is what insurance companies do by requiring preauthorization of advanced medical imaging (such as MRIs or CT scans) ordered for beneficiaries. A better way to ensure appropriate imaging is widely available and already in use.

In most cases, if your doctor thinks an imaging scan can improve your health, he or she has to ask a radiology benefits management company (RBM) whether the scan will be covered or not. This process can take days or even weeks. You may not be able to get the scan at all if the RBM says no, which happens a lot.      

In fact, a Patient Advocate Foundation (PAF) study found that in people who challenged coverage denial for scans, 81 percent were denied by RBMs and 90 percent of reversed denials were in fact covered by the patient’s health plan. The U.S. Department of Health and Human Services (HHS) says there are no independent or peer-reviewed data that prove radiology benefit managers’ effectiveness. HHS also warned against the non-transparent coverage protocols that RBMs use. 

What’s more, ensuring appropriate imaging is already being done in a more modern and efficient way. Clinical decision support (CDS) systems, embedded in electronic health records systems, allow providers to consult appropriate use criteria prior to ordering scans. American College of Radiology (ACR) Appropriateness Criteria, for instance, are transparent, evidence-based guidelines continuously updated by more than 300 doctors from more than 20 radiology and non-radiology specialty societies.

CDS systems — easily incorporated into a doctor’s normal workflow — reduce use of low-value scans, unnecessary radiation exposure, and associated costs. The systems educate ordering healthcare providers in choosing the most appropriate exam and suggesting when no scan is needed at all.

An Institute for Clinical Systems Improvement study across Minnesota found that such ordering systems saved more than $160 million in advanced imaging costs vs. RBMs and other management methods over the course of the study. A major study by Massachusetts General Hospital and the University of Florida showed that these systems significantly reduced advanced imaging use and associated costs. This was done without delaying care or taking decisions out of the hands of patients and doctors.

In fact, the Protecting Access to Medicare Act — passed by Congress with the backing of the ACR and multiple medical specialty societies — will require providers to consult CDS systems prior to ordering advanced imaging scans for Medicare patients starting as soon as next year. This makes image ordering more transparent and evidence-based than any other medical service. The law would require preauthorization only if a provider’s ordering pattern consistently fails to meet appropriate use criteria.

In short, preauthorization is an antiquated approach to utilization management that disconnects doctors and patients from learning systems designed to improve patient care. Patients. together with the providers and legislators who serve them, should be demanding a more modern approach to prior authorization through the delivery of EMR-integrated imaging CDS.

James A. Brink, MD, FACR is vice chair of the American College of Radiology, radiologist-in-chief of Massachusetts General Hospital, and Juan M. Taveras Professor of Radiology at Harvard Medical School.