Patient Steerage Could Harm Radiologists, Confuse Patients

As implementation of the Affordable Care Act continues, all sectors of the healthcare industry are being called upon to increasingly rein in costs. For many insurance providers, patient steerage has proven to be an effective strategy. But the impact on radiology has been largely negative, industry experts said.

Patient steerage in radiology occurs when outside forces - usually insurance providers - actively direct patients or physicians to lower-cost radiology practices. And, this strategy is becoming more prevalent nationwide, said Geraldine McGinty, MD, chair of the American College of Radiology’s (ACR) Commission on Economics. 

“Our feeling is that as radiology benefit managers have maxed out on the initial imaging volume savings they can offer to clients, so they’ve started participating in programs to drive patients to facilities where the payers have negotiated lower reimbursement rates,” she said. “Recently, it’s been more aggressive due to increasing involvement of patients as they take on more responsibility for their care through higher-deductible plans.”

In fact, according to an informal survey by the Radiology Business Management Association (RBMA) in September 2012, 65 percent of respondents reported experiencing active patient steerage from either radiology business management (RBM) groups, payers, or both. With active steerage, payers give patients incentives, such as gift cards, for choosing lower-cost providers. In addition, 47 percent confirmed the presence of passive steerage - simply making cost differential data available to patients and providers.

However, patients are also driving a certain level of steerage. A recently-published joint ACR-RBMA paper credits high-deductible insurance plans and patient cost awareness with some patient redirection.

What Payers Are Doing

While not all payers have patient steerage programs, many do. For example, in September 2011, Anthem Blue Cross Blue Shield in Ohio implemented a steerage program for imaging services through which company representatives called patients in attempts to redirect them toward lower-cost providers. Within nine months, more than 3,500 patients had been called and steered to different imagers.

In addition, WellPoint launched a passive steerage campaign with OptiNet, an Internet portal through which referring physician were encouraged to schedule patients with lower-cost imagers. When referrers largely ignored this resource, however, WellPoint enlisted RBM company American Imaging Management (AIM) to call patients directly. According to AIM marketing director Ana Perez, nearly 20 percent of patients chose lower-cost imagers in response to the phone calls.

Other payers, such as UnitedHealthcare, also provide radiologist cost information, but they do not actively contact patients. Still other payers successfully steer patients by classifying certain providers as out-of-network in a patient’s insurance plan.

The Impact of Patient Steerage

The increasingly prevalence of patient steerage can potentially impact practices and departments on a variety of levels, McGinty said. According to the ACR-RBMA paper, she said, radiologists should be aware of the three main ways patient steerage can affect everyday practice.

1. Daily operations: When payers redirect patients, providers can lose any time they’ve already spent in the pre-authorization process. They can also experience productivity dips , and if they don’t know patients have been steered elsewhere, they  could face vacant or missed appointment slots. Imagers could  also be asked to answer patient and provider questions about any steerage and why it occurred. Overall, up to 82 percent of RBMA survey respondents indicated steerage decreased their patient volume. However, some respondents - about 14 percent - actually saw volume increases due to patient steerage.

“The big item will be the loss of business, and virtually every practice is looking at a decrease in volumes,” said David Levin, MD, a radiologist with the Center for Research on Utilization of Imaging Services at Thomas Jefferson University. “It’s not like in the early 2000s when volumes were growing like crazy and it wasn’t a problem if we lost a little business because insurance steered our patients elsewhere. No one feels that way anymore.”

2. Legal issues: When payers actively steer patients to lower-cost imaging centers and away from a referring physician’s initial suggestion, they open themselves up to potential medical liability if findings, such as a lung cancer, are missed. In addition, legal action can also be launched against the chosen imager, the imager’s corporation, and the RBM. It’s also possible, especially with active steerage, that these activities violate the federal anti-kickback law that forbids any payments or solicitations that influence patient health decisions.

According to the ACR-RBMA paper, radiologists could also assert payer-directed steerage impedes their legal right to practice, defames their professional reputations by listing them as lower-tiered providers, or violates any existing contracts they have with facilities to receive a certain amount of referrals.

3. Provider relationships: Any payer-directed steerage can disturb existing healthcare relationships, McGinty said. Referring physicians often have a small cadre of imaging providers, chosen for their levels of quality and service, to whom they send patients. Redirecting patients to different imagers can damage long-term provider partnerships and can impose on referrers the additional cost of transferring all patient records to a new imager. Any instances of incomplete reads prompt the need for a second radiological opinion. And, the radiologists providing the second read do not receive reimbursement.

Impact on Patients

While survey data exists to support the negative effect steerage has on providers, the verdict is out on how much payer redirection influences patient care.

The ACR’s biggest concern, McGinty said, is that steerage can confuse patients.

“Patients build relationships with their physicians over time, and they value their doctor’s advice and guidance,” she said. “We don’t want to see those relationships disrupted or see patients’ confidence shaken when it’s suggested they see an imager their doctor didn’t recommend.”

It’s also paramount, she said, to make it clear to patients that payer recommendations are only cost-based suggestions. Many patients are unaware they have a choice to simply pay a higher fee for seeing the imaging provider chosen by their referring physician.

Payer steerage also increases the risk that patients will be sent to a facility without ACR accreditation. But that risk is small, Levin said, adding that ACR accreditation ensures a certain level of service quality.

“I don’t think steerage will impact patient care that much. People will get scans if they need them even if insurance companies steer patients to places they think are more affordable,” he said. “It’s not as if there’s a huge variation in quality so that if you go to my hospital you’ll get a great scan, but if you go to the hospital down the street, you’ll get a lousy one.”

Protecting Your Practice

Although your practice or department can’t control payer steerage, there are ways you can protect your bottom line, Levin said.

“Take every possible step to maximize your quality. You have to develop quality metrics and make sure your quality is absolutely first-rate in everything you’re doing - scan quality, turnaround time, communication with referrers and patients,” he said. “Be at your absolutely peak level so if you’re threatened with steerage and can’t control charges, you can point to excellent level of service you provide as a reason to receive cases.”

McGinty also emphasized the need for practices to become more actively engaged with both the physician and patient communities. The more you discuss what you do with referrers and patients, the more they will understand the value you bring to healthcare, she said.

In fact, the ACR recently launched Imaging 3.0, a toolkit that educates radiologists, patients, and referring physicians about the steps that go into creating high-value, high-quality imaging. The goal, McGinty said, is that patients will be better informed and have more reasonable expectations about imaging services when they are confronted with payer-directed steerage.

Positive Practice Experience

Not every practice has suffered from patient steerage, however. Over the past few years, Carolina Regional Radiology (CRR) in Fayetteville, NC, has seen its patient volume blossom due to an increase in self-pay insurance plans and a clinic redesign that created a one-stop-shop experience for patients. CRR serves 10 counties and completes roughly 500,000 scans annually.

In early 2011, CRR launched a women’s imaging clinic within its existing office. The key to success, said Sheryl Jordan, MD, former CRR director of women’s imaging and current associate professor of radiology at the University of North Carolina at Chapel Hill, was designing the clinic to be both patient- and referring provider-centric, a model that followed McGinty’s recommendation.

Although CRR is considered to be a low-cost provider, Jordan said, many patients were directed to the practice or opted to go there for treatment because of its unified approach to patient care.

“People want a turn-key approach - a continuum of care,” she said. “They want the benefit of saved time and money that comes with receiving additional interventional or therapeutic procedures in one location.”

Based on this continuity, transparency of service, and active engagement with referrers and patients, Jordan said, the practice has maintained an annual patient volume growth rate of 25 percent in all modalities except one: mammography. Since 2011, CRR’s mammography business - which charges patients about $240 per scan - has skyrocketed 126 percent, she said. Conversely, the average cost for a mammogram at Cape Fear Valley Medical Center, also in Fayetteville, is $480. Jordan also credited extensive technology adoption for a portion of the patient steerage.

Ultimate Result

There’s no doubt, according to both Levin and McGinty, that payer-directed steerage is here for the long term. Over time, private practices could fare better than hospital departments, they said, because they have more control over their charges, but steerage will likely create some problems for nearly everyone.

The biggest concern, they said, is that price will continue to outweigh all other factors when deciding where patients should receive imaging.

“It’s a timely problem, and it’s clearly been a successful model for RBMs,” McGinty said. “But it’s a bit of a bait-and-switch for patients who either don’t or can’t understand that they do have a choice.”