Clinical Decision Support or Prior Authorization?

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.

Radiology Benefit Managers are Shifting Cost!

The Journal of the American College of Radiology reported in June 2011, "It is estimated that 28% ($182,066/$640,263) of the projected RBM-related savings are shifted to providers." Ask any medical provider and I am sure they will tell you that this was no surprise to them. The burden of cost to hire and train staff to perform prior authorization for advanced imaging is placed on the medical provider. This cost is even shifted to radiology centers. If the test or procedure scheduled did not have prior authorization or a test requires upgrading, it is up to the facility to obtain that prior authorization. We all know it is extremely difficult to get reimbursement for a test or procedure for which prior authorization was not obtained first. And what about the cost to the patient in the delay of treatment or denial of a test or procedure? All costs that someone had to burden.

So how do you cut those costs that you have now been burdened with? You train your staff to become better informed about the prior authorization process, become more efficient in the way you perform prior authorizations and properly train your staff to provide accurate clinical to the RBM to reduce delays and denials.

Appropriateness in Advanced Imaging

As a former clinical reviewer for one of the largest Radiology Benefit Managers in the country, I often witnessed inappropriate requests for advanced imaging. After collecting patient clinical to include the type of test ordered, if it didn't match up to our criteria, it was sent for further medical review by an RBM physician. At which time, it was either approved, denied or a request for additional information was sent to the ordering medical provider. There are other reasons advanced imaging is ordered inappropriately, this post will focus mainly on education.

For example, there was one obstetrician, who only ordered non-urgent CT scans for his pregnant patients. Even after I recommended MRI, he refused. Of course, these were always sent for further medical review to the RBM physician. We received many requests for spine MRIs, especially lumbar spine MRIs for acute low back pain without injury. Of course, most of these were sent for further medical review, having lacked proper conservative treatment.

So whose responsibility is it to make sure the patient is getting the right test at the right time? Originally, it must rest on the medical provider. He/she is the one who has initial contact with the patient and should make an educated decision about what test is the right test and when. If they are not sure, they should speak with a specialist or radiologist to determine the proper test. There is nothing wrong with that. It is impossible for medical providers to know what test is the correct test for all diagnoses. As a clinical reviewer, a large part of my job was educating medical providers and staff in regards to the appropriate test.

Secondly, the next person responsible for getting the right test is the radiologist. As an example, when an order is received for a brain MRI without contrast and it includes the pituitary gland, it is the radiologist's responsibility to make sure the test is done with contrast. A brain MRI without contrast will not visualize the pituitary gland. Sure, that may mean a phone call to the RBM, health insurance company or the ordering physician, but it means the patient will get the right test. Many times, I saw brain MRIs being performed without contrast (as ordered by the physician) to visualize the pituitary gland. This is a waste of time and money. Because that means the patient has to return to redo the MRI with contrast.

If the first two lines of responsibility are neglected and the ordered study is presented to the RBM or the health insurance company for prior authorization (precertification), it then becomes their responsibility to educate based on evidence-based guidelines and safety. Sure, there will always be some physicians who disagree with the RBM or health insurance company's guidelines. That happens.

I will get to my point here as I could go on for days about the over-utilization and inappropriate requests for imaging I witnessed. And not that I am on the RBM bandwagon, because I think there are better ways to handle requests for advanced imaging.

There are good evidence-based guidelines out there. Most RBMs and health insurance companies use ACR (American College of Radiology) based guidelines. Those guidelines are posted on their websites. There are advanced imaging basics that all medical providers should know. And if they don't, they should consult with a specialist, radiologist or RBM clinical reviewer/medical director. There are many resources out there. And yes, the patient must also take responsibility to get educated about their health issue and the proper testing that accompanies it.

There is a shared responsibility that must take place among medical providers, radiologists, RBMs, health insurance companies and the patient when ordering advanced imaging to make sure it is the right test at the right time. No longer can an advanced imaging study be requested without regard for its safety and potential to improve patient outcome.

Will RBMs Go Away?

I was recently asked if I thought 'middlemen' like CareCore National will go away? And the answer is "no".

The reason for this is simple. Medicare and Medicaid costs are putting great strains on state and federal budgets. Health insurance companies are making smaller profits now because of health care reform. Costs have to be contained somewhere. Advanced imaging is expensive. If you look at the health care cost pie, advanced imaging is the second highest expense behind prescription drugs.

In 2009, Med Solutions stated 90% of health insurance companies use RBMs. They also stated, "Radiology Benefit Management Could Save Medicare Up To $18 Billion Over 10 Years".  Like most RBMs, they proclaim their management of advanced imaging saves money. With RBMs already in place and saving money, it is highly unlikely they will go away. Add to the fact that Medicaid/Medicare costs is a highly charged political and economical issue, it is even more doubtful RBMs will go away. 

Yes, I believe RBMs save money for the actual imaging. But who pays the price? For one, medical offices, hospitals and radiology centers burden the cost of hiring staff to sort through the red tape in getting a study or procedure approved and following through until it gets paid. Second, the patient may have their study or procedure delayed or denied because of the red tape.

It can be frustrating, as the process for obtaining prior authorization (precertification) for advanced imaging is not transparent. Most office staff learn the prior authorization process as they go along. No one is teaching them, especially not the RBMs. And that can be costly to your bottom line and the patient.

If you would like a free consultation on how I can teach you or your staff to become more efficient at prior authorization for advanced imaging, email me at: randrbizassociates@gmail.com. I would love to talk with you! Terri

10 Things an RBM(Radiology Benefit Manager) Won't Tell You

1. What their criteria is. Guidelines are posted on most RBM websites but criteria for decision making is not that transparent.

2. If the health plan will actually pay for the test or not. You can get prior authorization but the health plan has the final say as to whether or not they will pay for it.

3. The best way for you to submit clinical(telephonic, web or fax). They won't tell you what is the fastest way to get a response.

4. How to provide clinical. They will ask you questions about the patient but won't teach you how to do it.

5. The most common mistakes medical office staff make. There are a lot of common mistakes that staff are not allowed to share with you.

6. How to make sure your fax gets processed properly. There are key facts to know about properly faxing your prior authorization request.

7. They get frustrated too when callers are not prepared or faxed/internet requests are incomplete.

8. The medical provider can speak with a medical director at any time during the prior authorization process.

9. How to make your charting prior authorization friendly. It is easier for clinical reviewers to approve studies when medical office notes are complete.

10. The medical provider can write on the Rx, “add IV contrast if required”. For most health plans, the test must first be approved without IV contrast. It can be upgraded later if it can be justified.

Controlling Medical Costs

In January 2010, Dr. Howard Brody, MD, PHD wrote an article, Medicine's Ethical Responsibility for Health Care Reform — The Top Five List. He prescribes taking the top 5 tests and treatments that are the most expensive and commonly ordered for each specialty and creating universal guidelines(developed by clinical epidemiology, biostatistics, health policy, and evidence-based appraisal) . Once these guidelines were agreed upon by each specialty, there would be an implementation of that particular specialty to discourage the use of these tests, etc. by their members to help lower health care costs.

This solicited many responses from physicians across the country. Some physicians said, "yeah, this a great idea" and some commented, "you have got to be crazy". Someone described it as "Utopia".

Correct me if I am wrong, but is that not what RBMs claim they are doing? RBMs state their guidelines are based on the American College of Radiology, physician specialties, clinical practice and research. Of course, there is debate among some (ACR, for one) that they are actually using evidence-based guidelines but they are not as transparent as some would wish them to be.

I agree with Dr. Brody. I believe specialty societies should take the lead. They should be the ones creating evidence-based guidelines, implementing a system to support those guidelines and supporting their members when they use them.

I also believe in tort reform. Physicians should not be punished for using those guidelines and they need someone to cover their backs.

Unfortunately, as it stands now, physicians are at the scrutiny of health insurance companies and RBMs for most tests and procedures they order. If specialty societies would take a more proactive stance when it comes to evidence-based guidelines for all tests and procedures, it would show they actually care about being a part of health care reform. They are the ones best suited for the job not the government, health insurance companies or RBMs.

The Future of Health Care

Ten years from now where will health care be? Will all Americans have health insurance? Will health care be delivered in the best way possible? Will costs be contained? No one knows for sure. But we can be the ones who shape the future of health care delivery. Right now we can be the ones who can make sure that our children and grandchildren will have fair and competitive health insurance rates, high-quality health care and the peace of mind that comes with it. I say we stop blaming and start finding solutions.