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Insurers Question Costs and Safety of Advanced Imaging Scans

Posted on: Monday, 24 March 2008, 14:30 CDT

Citing soaring costs and safety concerns, many health insurers are beginning to question the necessity of the large number of advanced medical scans, such as CT and PET scans that are being prescribed for patients.

Emerging evidence even has some doctors agreeing the scans may be over-prescribed.

"Costs are soaring in this area, quality concerns are mounting and safety concerns are mounting," Karen Ignagni, CEO of the trade group America's Health Insurance Plan, told the Associated Press.

Health insurers have started requiring more pre-authorizations before patients can receive the scans, and have added other restrictions such as mandates for credentialed staff and equipment.

The concern is that some patients are being over-exposed to dangerous radiation levels from repeated CT and PET scans. These scans use many times the radiation of a regular chest X-ray, and sometimes repeated scans are required because the initial scan was conducted improperly, possibly due to outdated equipment or poorly trained technicians.

Doctors are also concerned about overexposure to radiation in patients who receive unnecessary scans, often ordered as “defensive medicine” to protect doctors against possible lawsuits.

And there also is fear that a small number of unethical doctors with inadequate expertise are referring patients for scans in their own offices or affiliated imaging facilities in which they have a financial interest.

"There is a definite concern that in-office imaging could lead to scanning for dollars," said Dr. Robert Hendel, a heart specialist who sits on American College of Cardiology panels focusing on the appropriateness and quality of imaging tests.

But some experts say the larger issue with medical imaging tests is the insurance red tape required to get them.

"Is this a preauthorization process or are these (insurance) companies practicing medicine?" asks Dr. Arl Van Moore, American College of Radiology board chairman.

Moore cited another explanation for rising costs is a practice doctors often perform by ordering tests that don’t require preauthorization, even if the tests provide less helpful information that the one they’d prefer. The doctors then move forward with approval for an advanced test when the initial one shows it is needed.

Even worse, occasionally patients end up getting even riskier, more invasive tests than required, Hendel said . For instance, cardiologists who want to examine blockages and blood flow in a patient's heart arteries would prefer a nuclear cardiology test, in which small amount of a radioactive substance is injected in the blood and tracked using a camera.

But instead some doctors will order a cardiac catheterization that doesn't require advance authorization, Hendel said. This test involves threading a catheter through a blood vessel up into the patient's heart, and carries a 10-times higher risk of complications such as a heart attack or stroke, according to Hendel.

To combat the improper use of the scans, specialist groups are supporting accreditation of the machines and doctors using them and publicizing appropriateness and quality criteria for various imaging tests.

"There is substantial evidence that these types of techniques, when used appropriately - and I want to emphasize the word 'appropriately' - can keep the lid on expenses and improve outcomes," such as by finding cardiac problems early enough to prevent a heart attack, Hendel said.

Hendel said patients who are inconvenienced often blame the doctor and office staff.

"They (patients) show up expecting a test to be performed. We've booked a slot," and then discover the problem, Hendel said. "We have no choice but to reschedule. Are they upset? Yes!"

He said strategies to reduce imaging costs were minimal until last year, after which it became more of a priority and even set off the growth of a new industry of insurance consultants called radiology benefit managers.

A recent study by the Center for Studying Health System Change, funded by the nation's biggest health care charity Robert Wood Johnson Foundation of Plainsboro, N.J., also found that limitations on use of MRIs, CT scans, PET scans and nuclear cardiology imaging became prevalent last year.

The report, based on interviews with hospitals, doctors, health plan officials, major employers and others in 12 metropolitan areas during 2007, found the use of CT scans in the U.S. nearly doubled between 2000 and 2005, from 12 scans per 100 people to 22 per 100. The increase was due in part to improved technology that made the imaging machines, which can cost $1 million to $2 million a piece, useful for diagnosing a wider range of medical problems.

"The hospitals and physicians purchase it, and then there's a strong incentive to use the equipment," said Ignani, the insurance trade group CEO.

Ignani added that manufacturers aggressively market the machines.

The tests, which can run $500 to $1,000 or more apiece, are a tempting revenue stream for struggling hospitals and doctors facing shrinking reimbursements from commercial insurers and government health programs.

Indeed, at least one medical education firm is marketing a training conference called, "Practice Expansion for Primary Care Physicians: How to Grow Your Income by Adding In-Office Imaging!"

But for now, the insurer restrictions seem to be working. In fact, one health plan that implemented a preauthorization program after it noticed a 20 percent annual increase in advanced imaging saw the growth rate plummet as a result. This despite only 1.5 percent of requests being denied, which indicates doctors were ordering fewer tests.

"Most health plans believe it's been successful," said Ann Tynan, the study's lead author.

Some insurers are also putting in place similar restrictions for other high-cost areas, such as stomach-reduction surgery and very expensive medications, Tynan said.

After passionate arguments by physician groups reversed changes they were fighting, some doctors see some hopeful signs in finding an effective middle ground. For example, Medicare is looking to hold down its spending on imaging after the annual costs increased from $6 billion in 2000 to $12 billion in 2005. It had originally proposed no longer paying for cardiac CT scans unless patients were enrolled in an effectiveness study, but in mid-March, it decided to continue covering the scans.

Horizon Blue Cross Blue Shield of New Jersey, the state’s biggest insurer, recently discontinued its initiative to require preauthorization for relatively inexpensive echocardiograms, or EKGs, even though it is beginning to require advance approval for expensive cardiac imaging.

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On the Net:

America's Health Insurance Plan

American College of Radiology

American College of Cardiology

Medicare

Horizon Blue Cross Blue Shield

Center for Studying Health System Change

Robert Wood Johnson Foundation

Associated Press

Source: redOrbit Staff and Wire Reports

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