ACR criteria help Israeli HMO cut high-tech imaging use

An Israeli HMO has reduced its high-tech imaging costs with the help of American College of Radiology appropriateness criteria that guide CT and MR use for its 1.6 million members.

Maccabi Health Care Services, the second larges HMO in Israel, implemented preauthorization in 2002 after observing substantial increases in CT and MR use. According to Dr. Arve Blacher, a radiologist with the health plan, Maccabi radiologists performed 12,000 MR and 84,000 CT procedures in 2001. Costs associated with those procedures represented 1.4% of the provider's healthcare budget.

CT use dropped 33% to 57,204 exams, and MR use fell 8.7% to 11,070 procedures in the 23 months after preauthorization for the two modalities was linked to the ACR criteria in February 2002. Lower utilization has saved the HMO more than $3.6 million, said Blacher, who presented the results Wednesday at the RSNA meeting.

Physical indications most likely to lead to deferred CT service included vertigo, neck pain, and musculoskeletal pain. Denials for MR were most often associated with neck or abdominal pain, she said.

Before the adoption of ACR criteria to guide utilization, preauthorization for CT was not required, and the policy governing authorization of MR use varied from district to district.

Referring physicians are now required to phone in MR and CT imaging requests to a central site for authorization. All imaging is performed on the HMO's equipment. The call center staff responds to requests for CT and MR with either an immediate authorization or a deferral followed by a written explanation. A phone discussion with a radiologist to explain the decision is available on demand. In disputed cases, the referring physician may still order CT. MR imaging may not be performed during disputes but only after the disposition of an appeal.

Blacher identified a correlation between the MR utilization rates and district office compliance with the preauthorization policies. MR utilization was lower in districts that readily adopted the policy compared with those that were slow to implement the plan.

Blacher has seen CT use continue to fall in 2004, while MR and ultrasound use has risen modestly. She associates this pattern with ongoing efforts at Maccabi Health Care Services to encourage physician to reduce patient radiation exposure.