No need for RBMs: In-house efforts cut imaging rates

By Kate Madden Yee, staff writer

September 5, 2017 -- Radiology practices can reduce the use of inappropriate high-cost imaging exams such as CT, MRI, nuclear medicine, and PET by establishing an in-house imaging utilization management program, thus avoiding external oversight from a radiology benefits management (RBM) firm, according to a study published in the September issue of Radiology.

Researchers from Massachusetts General Hospital (MGH) found that a simple use management program that offered decision support via the hospital's radiology order-entry system reduced unnecessary high-cost imaging by 21%. The system outlined indications for imaging exams and provided physicians with an appropriateness score for each exam.

The findings demonstrate that it's possible to cut unnecessary imaging from the inside rather than using an outside service, wrote the team led by Dr. Jeffrey Weilburg.

"[The decrease] in outpatient high-cost imaging use rates at our medical center was achieved without the use of any external mechanism (i.e., we were exempt from radiology benefits management oversight) and was equal to or greater in magnitude than national and statewide rates," the group wrote.

An inside job

For a number of years, insurers have been using RBMs to try to contain imaging costs by implementing preauthorization programs to avoid the ordering of unnecessary exams. But providers tend to chafe under the restrictions of such efforts, saying that they emphasize cost over all other factors that go into clinical decision-making.

Weilburg's group sought to investigate whether an autonomous imaging utilization management program could be successful in decreasing the utilization rate of high-cost imaging. Data for the study came from MGH and outlying practices serviced by its providers.

In 2006, the hospital instituted a program that produced reports distributed to primary care doctors and selected specialty care physicians that showed the rates of high-cost imaging use and order appropriateness; the researchers used information in these reports taken from the years 2007 to 2013 (Radiology, September 2017, Vol. 284:3, pp. 766-776).

They assessed the number of outpatient high-cost imaging exams per patient per year ordered by the patient's primary care provider or by any other specialist, and they then determined the probability of a patient undergoing a high-cost imaging procedure during a study year and the number of exams per patient per year in patients who underwent high-cost imaging. The group compared results of the utilization management program with outpatient laboratory studies conducted during the same time frame -- because these studies were not subject to the program -- as well as statewide high-cost imaging data taken from a private insurer.

Weilburg and colleagues found that the internal program reduced use among both primary care and specialty physicians. It also reduced the probably of a high-cost imaging exam being ordered by both types of physicians (after adjusting for the disease risk of patients).

Effect of internal MGH program on high-cost imaging use, 2007-2013
Category Change in high-cost imaging use
Overall use -21.3%
Use by primary care physicians -32.3%
Use by specialty physicians -16.5%
Probability of order by primary care physicians -24.3%
Probability of order by specialty physicians -10%
All data are statistically significant.

For point of comparison, routine laboratory study use decreased by 9.4% during the period, less than half the 21.3% MGH rate for imaging. In addition, based on data unadjusted for risk, MGH's outpatient high-cost imaging use fell by 28% during the research time frame, compared with a decrease of 20% from a statewide local payor.

All for autonomy

The fact that MGH's own utilization management program reduced the use of high-cost imaging more than a private payor's program shows promise, Weilburg and colleagues noted.

"The observation that the reduction in high-cost imaging utilization in our system was significantly greater than that for the population of one of our large local payors (which had engaged an external radiology benefits management company to conduct imaging utilization management for most of its insured patients during this time) raises the suggestion that internal [use management] may have a greater impact than external [programs]," they wrote.

Of course, further studies are needed to confirm this finding, according to the researchers. But they hope the results will motivate other practices to institute their own use management programs.

"Comprehensive provider-led imaging utilization management in our urban academic health center produced a substantial, consistent, and sustained reduction in ... [the] use of outpatient high-cost imaging," the group concluded. "Autonomous imaging utilization management (sponsored and run by the healthcare system by and for its own clinicians) can be successful."

Copyright © 2017

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