Douglas Tardio, CEO of CareCore National, recently wrote an article, A Case for Prior Authorization of Imaging Services, discussing the pros and cons of CDS (Clinical Decision Support) versus Prior Authorization. As CEO of one of the largest RBMs (Radiology Benefit Managers) in the country, it is not surprising Mr. Tardio would end up siding with prior authorization.
While I am not a big fan of prior authorization nor am I on the CDS bandwagon, he makes a valid point. Mr. Tardio states that with both approaches, "data comes from vast archives of patient outcomes, clinical trials and other scientific data, eliminating the guesswork about how best to address the clinical needs of a patient." Most RBMs and CDS software systems use ACR (American College of Radiology) guidelines as the basis for their criteria.
Mr. Tardio describes the benefit of prior authorization as, it "ensures that the patient receives the appropriate test based on their unique medical history and situation, physicians subject to prior authorization are only reimbursed for services that are deemed medically necessary based on very specific evidence-based pathway criteria." In other words, the health insurance company will not pay for advanced imaging that does not meet "very specific evidence-based pathway criteria". The last time I looked (today, actually), ACR has guidelines, not "very specific evidence-based pathway criteria." So who develops this "very specific evidence-based criteria"? Health insurance companies and radiology benefit managers do.
The second and last benefit of prior authorization, Mr. Tardio states, "Prior authorization for radiology alone, on average, can reduce health care costs by more than $60 per insured each year ($60 million/year for a million-member health plan) while reducing patient exposure to unnecessary radiation from inappropriate diagnostic testing. Okay, for arguments sake, let's go with the savings of $60 per insured per year figure. I would bet the farm that $60 is not going to be passed on to the patient. And, it is highly likely the medical office pays out a large portion of that $60 per month per insured on health insurance administrative costs.
In regards to the cons of CDS, Mr. Tardio states, "Criticism of prior authorization systems tends to revolve around the fact that physicians must obtain authorization via phone or online, which critics say can be more time consuming than decision support systems. In fact, the tools used in both systems are virtually identical — and equally time-consuming from a pure administration standpoint." Yes, it is a known fact, they are both equally time consuming. That is the reason most medical offices hire staff to specifically perform prior authorization. As with the Prior Authorization process, the CDS process will also require someone (aka medical office staff) to input the clinical to spew out a rating of appropriate versus less appropriate. One of the differences with CDS is a medical office staff person will not have to wait on hold for the next available representative and the software is easily accessible to them in their own office. Another difference is if the clinical does not match evidence-based guidelines, the physician can choose an alternate study or proceed with the study he/she requested.
In my opinion, there has to be a hybrid system, a cross between CDS and the RBM process. Of course, the system has to use evidence-based medical guidelines not strict pathway criteria designed by health insurance companies and radiology benefit managers. It has to be easy to use by all medical staff, hold the physician accountable and ensure the patient gets the right test at the right time. The CDS system is a good model. To use it efficiently, there should be a discussion with a radiologist or specialist in that field if the CDS system offers an alternative study and the physician declines. I don't believe we can drive down the costs of advanced imaging or health care in general by giving physicians carte blanche when it comes to advanced imaging.
In my experience as a former senior nurse reviewer, most often physicians do request appropriate advanced imaging. But with all the changes in technology and usage, advanced imaging is rapidly changing. It is very difficult for any medical provider to keep up to date on the current uses for advanced imaging. It's a given, we are all going to have to live with the regulation of advanced imaging in order to curb health care costs. I choose CDS with a little tweaking.