Utilization management, computer decision support square off at RSNA

Alternative strategies for controlling imaging utilization, radiology benefit managers and computerized decision support, squared off in a scientific session Sunday.

Advocates of computerized clinical decision support said their strategies are emerging as a more clinician-friendly alternative to controlling inappropriate imaging utilization. A representative from one radiology benefit management company said data supporting the computer-based approach benefits from progress already made by the RBMs, and it remains to be seen whether new strategies for controlling imaging utilization will be all that successful.

RBMs emerged earlier in this decade as the front-line strategy by commercial insurers for controlling inappropriate imaging utilization. Using internal protocols, the RBM companies operate prior authorization programs for high-end imaging scans. Statistics show they have been successful in reducing imaging utilization, but at the expense of complaints from clinicians and radiology practices upset by another layer of authority and procedures.

In the last three years, elite institutions such as Massachusetts General Hospital and Brigham and Women’s Hospital have developed “point of care” decision-support programs that use appropriateness algorithms to guide clinicians to better imaging exams at the time they are ordered. Systems developed at those facilities have been commercialized and are now entering the market.

A computerized approach has been tested in a five-facility, three-year pilot program in Minnesota and is now being offered to all facilities in the state, said Cally Vinz, an administrator in the pilot program who presented data from the pilot at Sunday’s scientific session. The pilot started with ACR criteria applied to electronic health record requests that did not require prior authorization. The number of high-tech scans did not increase in 2007 compared with an 8% increase in the prior year, Vince said. In addition, the diagnostic quality of the scans increased 10%, radiation dose was reduced, and increased efficiency shaved $84 million off of healthcare costs.

Time savings alone were substantial, Vince said. RBM approval took approximately 10 minutes. Computerized decision support took just 10 seconds.

The case for the RBM approach was made by Dr. Mark Hiatt, chief medical officer for HealthHelp, an RBM. He maintained that RBMs are a proven way to reduce excess utilization, something that will be important as more people are added to the insurance rolls under healthcare reform.

Using charts and graphs, Hiatt argued that high-tech imaging utilization flat-lined and then turned negative in both commercial and Medicare lines as a result of RBM controls. In the case of the five million patients covered by one of HealthHelp’s customers, utilization management yielded $90 million in savings over the course of five years.

“Getting the test right the first time is good medicine and saves money in the end,” Hiatt said.

In the question and answer session, Dr. David Levin, a medical director of HealthHelp and a longtime critic of self-referral, said utilization growth of high-tech procedures started to decline in 2005 and that Minnesota may have benefited from RBM controls even before their pilot started.

Vince agreed that the RBMs had an effect, but countered that computerized decision support offers a more patient- and clinician-friendly approach to utilization management.