Editor's Note: This is part one of a two-part series.
As new treatment modalities become available, it has become more difficult to know the right test. Diagnostic imaging tests are ordered for more than 830 different clinical conditions. The latest developments in imaging technology have created a plethora of complexity. These advanced tests (MRs, CTs and PET-CTs) are also the hardest to match appropriately to each patient's diagnostic needs.
Imaging has expanded its role and is no longer used only for the identification or confirmation of a patient's condition. Imaging is intertwined with therapy for oncology patients and used at every stage of care: screening, diagnosis and staging, treatment, and monitoring. It is a tool for lifelong follow-up. In fact, according to an article by Christopher Farr of Sg2, the expanded utility of these applications will increase utilization by 189% by 2016.
Imaging also continues to be one of the fastest growing areas of spending for health plans, with costs expected to double over the next four years to $200 billion by 2011. As a response to this increase, many payers have contracted with radiology benefit managers (RBMs), who utilize various utilization management techniques.
The challenge for health plans, radiologists, and referring physicians is how to reduce the use of unnecessary or inappropriate imaging while ensuring access to clinically valuable imaging, especially in a period of rapid technological advancement and increased use.
History Repeats Itself
Prior to the introduction of RBMs several years ago, pharmacy benefit managers (PBM) arrived on the scene for much the same reason: help in controlling escalating costs.
In 2007, PBM spending was reduced to 6-8% of premium from a 18.2% increase in 1999. Comparatively, the radiology expenditure was 2% of benefit in 1999 and is currently 18-20% of premium today. This increase is driven by advances in imaging technology, advertising directed at patients, physician self-referrals, a wide disparity in appropriateness, and an aging population. This growing complexity has led to wide variation in the appropriateness, pricing, and quality of imaging services.
Imaging Sharpens Disease Identification and Management
Successful care management strategies offer payers many opportunities for reducing costs and improving patient outcomes. Care management tools help payers integrate data from various sources into a patient's medical record with financial and clinical data. Combining that information with laboratory, radiology, and pharmacy data provides an optimal longitudinal view of the patient's care history.
These eight dimensions of radiology management identify shifts leading managed care organizations have made as they've adapted to industry changes and consumer expectations:
1. Wellness and prevention. includes screening and programs targeted at keeping the member population at the healthy end of the care continuum. Programs are designed to address issues before they become problematic, so patients stay well and employers and payers spend less money on treatments. One of the best-of-breed options is screenings. Screenings use a test to check people who have no symptoms of disease, to identify people who might have that disease, and allow it to be treated at an early stage when a cure is more likely.
In 2008, 182,460 new cases of breast cancer were be detected in women. Nearly 41,000 will lose their lives to breast cancer. Many of these lives can be saved by early detection. Mammograms are capable of finding breast cancer two to three years before it becomes manifest as a palpable lump. These early tumors are typically curable by local removal and radiation treatment without the need for mastectomy.
Mammography has shown that early detection of disease can improve the chances for successful treatment. In the next decade, according to Christopher Farr of Sg2, imaging's role in screening will evolve beyond mammography to include such applications as CT lung screening of high-risk patients, virtual colonoscopy, and even rapid whole-body MR studies.
2. Targeting and segmentation. stratifies a population, identifying members and matching with the right program and interventions.
Market-leading organizations link data into the member's medical record and use the information as triggers for preventive, condition, and disease management programs. For example, women can be identified who meet the American Cancer Society guidelines for a mammogram. In addition, family history can identify a member in need of a screening study for cancer.
3. Reach and engage. opens up two-way communication via multiple channels to make use of the health information that members provide. This includes personal health records (PHRs), Health Risk Appraisals and patient portals. Payers encourage behavior changes through increased connection points with members via Web-based programs and multi-channel campaigns.
Market leading organizations include diagnostic images and reports into the consumer oriented tools: PHRs and Member portals for patients with cancer, PET images can help with disease tracking and availability to the patient helps with their battle.
4. Condition management. includes the use of disease management programs, clinical pathways, biometric devices, return on investment compilation, and outcomes. The ultimate goal is to create and utilize the longitudinal member view and apply this information to the needs of the member. Market leading organizations tie the integrated member information into care managers' workstations. This includes the diagnostic images, results, and reports. Only by having the member's complete information, can an optimal care plan be created.
Market leading organizations incorporate appropriateness criteria American College of Radiology (ACR), American College of Cardiology (ACC), and National Comprehensive Cancer Network (NCCN) for high-tech radiology into the care management process. The objective is ensuring a patient receives the right test at the right time in the right facility.
This includes establishing best practices/standards of care with quarterly internal review and acquiring accreditation through ACR.
- Exceed training requirements for clinical staff
- Clinical equipment is current, well maintained, and regularly upgraded to remain technologically competitive
- Clinical standards/guidelines are established and routinely followed
- Conducts annual satisfaction surveys from referring physicians and patients to measure quality standards
Not only can the patient move on with a diagnosis, but the cost of identifying the problem is streamlined, long-term costs are lowered, and member satisfaction is increased.
5. Care coordination capability. focuses on utilization management, concurrent review, and case management. The output is included into the longitudinal view of the member. Information from every phone call, every member interaction and all other forms of communication should be included along with lab results, radiology images, and reports and pharmacy information.
With the introduction of RBM companies, the old school type of prior authorization filled with the mantra, "just say no" has unfortunately come back to care management. According to Cherrill Farnsworth, president and CEO of HealthHelp, other methods are successful such as an advocacy and continuing education/mentoring approach.
Marybeth Regan, PhD, is an expert in disease and care management. She has written numerous articles on strategies for care and disease management. She may be reached at Drmarybethregan@aol.com.
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