Unmanaged Abuses in Advanced Imaging: MR, CT, PET, Cardiac

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Unmanaged Abuses in Advanced ImagingMR, CT,
PET, Cardiac

• NAMPI
• August 28, 2007

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Why focus on Radiology

• The number of Imaging procedures grew 40
  nationally from 2000 20051
• Projected to grow another 26 by 20081
• Radiology costs have quietly risen to be 10
  percent of the healthcare dollar and are growing
  at a rate of 18-20 a year, according to the
  HealthLeaders-Interstudy.
• Cost of high tech scans is growing faster than
  pharmacy2

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Waste is Expensive

• 26 billion in imaging is contributed by
  duplicative studies (Health Affairs 1/05)
• Medicaid usage trend growing at 20-25
• Overall, 30-40 of all high tech imaging is
  inappropriate

4
Expanding Capacity

• There are now more MRI scanners in the Pittsburgh
  area than in all of Canada.

5
Fraud Abuse in Radiology

• Little to no oversight or regulation for the
  provision of imaging services on federal or state
  levels
• Improper billing practices in imaging
• Misrepresenting or overcharging with respect to
  services delivered
• Outpatient imaging centers and medical office
  settings open to abusive practices if not
  monitored assiduously
• Result Unnecessary costs for the program
• Office of the Inspector General making plans to
  begin reviewing fraudulent practices related to
  imaging3
• Looking to identify systemic weaknesses giving
  rise to fraud, waste, and abuse

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Factors Contributing to Waste

• Patient Demand. Many procedures are ordered
  because the patient requests it, not because it
  will contribute to their care or diagnosis.5

• Ex.- Active person insisting on MRI for
  knee pain
• Ex.- Expectant mother requesting extra
  fetal US6
• Up to one-third of nations health care
  expenditures are consumed by the worried
  well7
• Direct to consumer marketing

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Factors Contributing to Waste

• Physician Uncertainty. Medical liability concerns
  drive defensive medicine.
• Repetitive or Duplicative studies ordered
• Patients dont share information on previous
  tests MDs dont ask the right questions
• Lack of knowledge regarding appropriate study
• More and more, Imaging is being used in place of
  physical exam
• Tendencies toward aggressive surveillance of
  incurable diseases

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Factors Contributing to Waste

• Fraudulent Claim practices
• Upcoding, unbundling
• Recognized, rampant issue in rapidly evolving
  cardiovascular imaging sector where new
  technologies such as CT Angiography have spurred
  creative new billing practices
• Providers frequently bill the same procedure many
  different ways for different payors, sliding
  under specific coverage policies and rules.
• Lack of defined coverage policies by CMS on new
  imaging allows discrepancies to develop

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Factors Contributing to Waste

• Screening studies. Multiple studies and repeat
  studies represent high costs that can be
  eliminated.
• False positives drive additional testing
• MA General Hospital study Whole-body CT scans
• 90.8 asymptomatic patients had at least one
  positive finding
• Only 2 actually had disease8
• Large MCO studies 1,087 subjects in a cancer
  screening trial 43 had at least one
  false-positive screening result. 83 received
  expensive follow-up care.9
• Less precise ordering.
• First test fails to arrive at accurate diagnosis
• Repeat testing ordered

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Factors Contributing to Waste

• New Technologies. MDs not trained specifically
  in how to order high tech imaging. Technology
  developed since they graduate medical school,
  with little to no training for most.
• 3D Software reconstruction as an enhancement for
  CT or MRI
• Unnecessary to provision of care in most cases

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Self-Referral Abuse

• No training required to purchase equipment No
  mandatory certification process
• Non radiologists performing their own imaging at
  least 1.7-7.7 times as likely to order imaging
  than non-self referring physicians in the same
  specialty who see patients with the same
  problems.10
• "Imaging increased up to 54 when a patient was
  sent to a facility in which a physician had a
  financial interest. ACR Study
• Patient Quality Issue
• "Deficiencies, such as image quality or patient
  safety are up to 10 times as common among
  non-radiologists as among radiologists.11

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Taking Advantage of Technology

• Areas to watch for significant waste potential
• 3D Software reconstruction as an enhancement for
  CT or MRI
• Unnecessary to provision of care in most cases
• Color Doppler, enhanced form of Doppler
  echocardiography, uses colors to designate
  direction of blood flow.
• Carries its own CPT code and charge
• Common knowledge that this add-on is used whether
  or not there is any indication to observe blood
  flow for the patient.
• Submitting bill for Contrast materials, and
  simply neglecting to provide the service

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• Seeking Solutions

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Time to Ask Questions

• Educate patients to become actively engaged in
  process
• Patients should ask their doctor basic questions
  when high tech imaging is prescribed
• Why do I need this test?
• What are the risks and side effects?
• How much will it cost? Is there a less costly
  alternative?
• Where should I have the test?
• How soon do I need it?

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Management Options

• Utilization Management (outpatient, elective)
• Prior Authorization or Notification with
  Education
• Evidence-based Medicine Best-practices
• Interactive, Educational process
• Reflect diagnostic thinking, with focus on
  patient outcomes
• Key Ensure tests are medically necessary,
  contribute to patient care
• Most effective approve to the CPT level match
  authorizations to claims

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Management Options

• Managing the Network
• Privileging and Assessment
• Assess technical and service quality of imaging
  providers
• Staff training, certifications
• Equipment maintenance, calibration
• Raises quality of imaging network through
  education
• Delivers savings by concentrating patients with
  those facilities most qualified to perform
  images, potentially eliminating serious patient
  safety issues.

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Strong ROI from Radiology Management
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Sample Reports
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Sample Reports
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Sample Reports
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MedSolutions Program Value

• In 2006, our average commercial radiology
  management customer saved 2.00 per member per
  month
• In 2006, we implemented a large Medicaid plan for
  CT and MR only
• Saved 48.8 Million first year
• Per member per month cost found to be 55 less
  than anticipated (3.39)
• Savings methodology validated by Milliman
  actuarial analysis

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What to look for in Radiology Manager

• Experience
• MedSolutions manages 25 Million Members overall
• Program in all 50 States for Commercial
• 3.5 Million total Medicaid Members
• Quality Certifications
• NCQA
• URAC
• JD Power Call Center
• Robust, Evidence-based Guidelines
• Average client impact rate 15 22

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• Questions?

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References

• Booz Allen Hamilton. Medical technology cost
  management strategy. Chicago BlueCross
  BlueShield Association 2003.
• Rundle, R. PET Scanners Become New Rx for
  Diagnostics. Wall Street Journal, May 2003.
• Department of Health and Human Services, Office
  of the Inspector General, Fiscal Year 2007 Work
  Plan
• Stein, Charles, Code Red Partners Program Aims
  to Rein in Skyrocketing Costs of Diagnostic
  Imaging Boston Globe, June 27, 2003.
• Wilson IB, Dukes K, Greenfield S, Kaplan S,
  Hillman BJ The patients role in the use of
  radiological testing for common office
  complaints. Arch Int Med 2001 161256-63
• Strasser, RP, Bass MJ, Brennan M. The effect of
  an on-site radiology facility on radiologic
  utilization in family practice. J Fam Practice
  1987 24619-23.
• Pennsylvania Healthcare Cost Containment Council,
  The Growth in Diagnostic Imaging Utilization,
  2005.
• Radiology 2005 234 415-422
• Cancer Epidemiol Biomarkers Prev. 2004 13
  2126-2132
• Kouri BE, Parsons RG, Alpert HR. Physician
  self-referral for diagnostic imaging review of
  the empiric literature. AJR Am J Roentgenol.
  2002179843-850.
• Verrilli MS, Bloch SM, Rousseau M, Crozier MM,
  Yecies SB. Design of a privileging program for
  diagnostic imaging costs and implications for a
  larger insurer in Massachusetts. Radiology.
  1998208385-392.