Faced with rising costs for diagnostic-imaging scans, some insurers are turning to radiology management companies for preauthorizations-much to the chagrin of physicians who fear additional red tape and compromised patient care.In the first quarter of 2007, Blue Cross and Blue Shield of North Carolina will become one of the state's first insurers to contract with a radiology management company, says Debra MacClennan, vice president for member health partnerships. MacClennan declined to identify the company that will perform the preauthorization services, but such firms generally share a common goal: identifying unnecessary tests. One company, American Imaging Management based in Deerfield, Ill., claims to reduce imaging utilization for its clients by 15 percent to 40 percent.The North Carolina Blues' preauthorization push comes amid a steady rise in diagnostic-imaging services. The plan recorded a 21 percent hike in such services from 2003 to 2005, MacClennan says. Nationally, many insurers and radiology management companies point to a report in Imaging Economics that contends 30 percent to 40 percent of diagnostic imaging is inappropriate or noncontributory.Not everyone agrees with that assessment, however. Robert W. Monteiro, M.D., serves on an advisory group that provides feedback to Blue Cross about its preauthorization project. Monteiro, a physician with Eastern Carolina Internal Medicine headquartered in Pollocksville, says officials at Blue Cross and the radiology management company have convinced him that the preauthorization program will dramatically reduce the amount of diagnostic imaging ordered by the state's physicians-even though he remains unconvinced that physicians are really ordering inappropriate tests to begin with. "If you talk to any internist who does a regular schedule, he'll be able to tell you a story about a patient who had a diagnostic-imaging test that made a difference in that patient surviving because it was done at an early point in time," Monteiro says. When another insurer in the state instituted a program that required preauthorization of diagnostic imaging, 40-physician Eastern Carolina Internal Medicine dropped the insurer rather than deal with the administrative hassle. But dropping a payor like Blue Cross would be considerably more difficult, he says. "There are a lot of patients we see from them, so they have a lot more leverage."Blue Cross has promised physicians the program will use Web-based technology to limit their administrative burden. Officials have told Monteiro that the radiology management company approves 70 percent of the orders up front and typically responds in less than five minutes.Yet physicians remain skeptical. According to the North Carolina Medical Society, 70 percent of its physician members report that radiology management programs reduce productivity and add unnecessary costs to the practice of medicine. Sixty percent say the programs negatively impact patient care and compromise the patient-physician relationship."I've gone through extensive training to know what to order and how to order it, so I take exception to this program a little bit in that somebody's looking over my shoulder," says Monteiro. "The physician-patient relationship is becoming more adversarial because we have all of these other people in the room with us."Monteiro and his physician partners are also concerned about the financial impact preauthorizations could have on their group's bottom line; the group has invested millions of dollars in advanced imaging equipment that includes a 64-slice CT scanner. "We're not real excited about the prospect of not being able to use our equipment when it's appropriate," he says.MacClennan says Blue Cross regards high-tech imaging as an important part of medical practice, but adds that the insurer needs to get a handle on the services' escalating costs. "It only stands to reason that focusing on the right test at the right time for the right patient would improve the appropriate utilization of these services and thus improve affordability of healthcare for our members."
-Rick Johnson
Magazine
