By Kate Madden Yee, staff writer

October 19, 2011 -- A new report commissioned by the Access to Medical Imaging Coalition (AMIC) found no evidence that requiring physicians to receive prior authorization before ordering advanced medical imaging exams would provide meaningful cost savings in the Medicare program. In addition, prior authorization could hurt patient access to imaging.

"We've seen prior authorization being proposed as a cost-cutting policy, but it's an unproven mechanism, and it carries patient-access implications," said Tim Trysla, AMIC executive director, in an October 18 press call.

Curbing costs

The U.S. government has been examining both prior authorization and decision support as tools for curbing runaway healthcare costs in the Medicare program. In 2008, the U.S. Government Accountability Office recommended that Medicare adopt prior authorization as a means of tamping down inappropriate utilization. However, the Department of Health and Human Services had several objections to the recommendation, noting the lack of data on the success of prior authorization programs, the administrative difficulty of implementing such programs in Medicare, and the potential for reduced savings if prior authorization denials in Medicare were appealed.

The new analysis, from the Moran Company, comes on the heels of recent research illustrating a downward trend in imaging use: A study conducted earlier this year, also by Moran researchers, found that in 2009 the overall volume of imaging services delivered to Medicare beneficiaries declined for the first time in 11 years, Trysla said. In light of this trend, AMIC cautioned that prior authorization by radiology benefits managers (RBMs) will only further hinder access to life-saving diagnostic imaging services.

In fact, the report showed no evidence in peer-reviewed health economics literature that prior authorization works. And government agencies have noted this, according to Don Moran, the company's president, who was also on the call.

"Our assignment was to look over the existing literature, and we found two approaches to managing diagnostic imaging utilization: developing evidence-based guidelines for ordering physicians, and prior authorization, which has typically been applied in managed care settings," Moran said. "Computerized decision support is beginning to spread. But when we looked for evidence that prior authorization is cost-effective, we found nothing to support this. Prior authorization is not going to end up saving taxpayers a bunch of cash."

So what would be more effective in cutting costs? Perhaps programs that give providers incentive to order appropriate exams and penalize those who don't, the report suggested.

Overutilization of advanced imaging obviously exists, but the point is not to curb utilization completely, said Dr. Bibb Allen Jr., of Trinity Medical Center in Birmingham, AL, and a member of the American College of Radiology's Board of Chancellors.

"We're very aware that there's overutilization in our specialty," he said during the press call. "But what is needed is an approach that curbs inappropriate imaging use rather than all imaging use."

Prior authorization disrupts the flow of healthcare in a population of people who tend to be more fragile and sicker than the general population, according to Allen -- and it doesn't help referring physicians learn what is actually appropriate in a given clinical situation.

"Decisions about a patient's diagnosis and treatment should be by a physician and not by someone in a remote location who is following a money-saving algorithm," he said. "Prior authorization doesn't educate referring physicians about what is the appropriate exam in the situation, but rather enforces a 'hard stop,' a yes or no answer. That's not decision support. We've also seen that any cost savings radiology benefits management firms using prior authorization programs demonstrate are costs shifted to referring physicians -- or radiologists."

Will preauthorization delays affect patients?

Preauthorization protocols delay care -- and this delay can negatively affect patients, said Andrew Spiegel, chief executive officer of the Colon Cancer Alliance. Spiegel also participated in the October 18 press call.

"People with colon cancer need regular scans to see if disease has progressed," he said. "If their doctor has to take time from the practice to talk to a benefits manager to get approval for a scan, their treatment is delayed. What's so bothersome [about prior authorization protocols] is that somebody who doesn't know the patient or the patient's history is making a healthcare decision for this person. It interferes with the doctor-patient relationship. Do we want someone in Washington making healthcare decisions for patients?"

Copyright © 2011

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