Insurer tightening use of imaging tests
Harvard Pilgrim Health Care, one of the state's largest health insurers, said doctors are ordering so many MRIs, CT scans, and other expensive imaging tests that it is returning to a traditional style of managed care to control these soaring costs.
At Harvard Pilgrim, as at many health plans, radiology costs are growing faster than the cost of prescription drugs, which for years were the most explosive portion of medical budgets. Harvard Pilgrim patients underwent 130,362 advanced imaging tests last year, costing the plan $73 million -- an increase of 62 percent in just two years.
Harvard Pilgrim executives said some of these tests, particularly those for lower back pain and headaches, which are advertised heavily, may not be needed. They not only push up costs, but expose patients to unnecessary radiation and delay appropriate treatment for conditions that can be diagnosed without imaging, executives said.
As a result, starting April 15, the plan will require doctors to approve all nonemergency advanced imaging tests -- most radiology tests other than basic X-rays and ultrasounds -- with a company hired by Harvard Pilgrim to evaluate whether the tests meet "nationally-recognized, evidence-based guidelines."
If a doctor schedules a patient's scan without calling National Imaging Associates Inc., a New Jersey radiology management company, Harvard Pilgrim will not pay and the patient or doctor will end up with the bill. Until now, doctors ordered imaging tests on their own.
The changes to imaging are similar to old-style managed care, but slightly less restrictive, and they are not being applied to other treatments or patient care.
Under the call-in system for imaging, instead of saying no to unnecessary tests, National Imaging will require doctors to speak to employees to prove the tests meet guidelines. If the doctor doesn't agree with National Imaging's recommendation against a scan, the doctor can talk to a National Imaging nurse who may request additional medical information.
If the nurse and the doctor don't agree, the doctor can appeal to a company physician. A clinical review will happen in about 10 percent of cases, said Dr. Roberta Herman, Harvard Pilgrim's chief medical officer. But if the prescribing doctor remains firm, he or she can still order the test, Herman said. The program, she said, will operate by power of persuasion.
"What concerns us is that the cost of radiology is outpacing the cost of pharmacy," Herman said. "It's a call to action."
Health plans generally spend more money on prescription drugs than on imaging tests.
Despite Herman's assurances that physicians ultimately will make the final decision about whether to order a scan for the plan's 750,000 commercial members, physicians are not happy.
"The doctors are up in arms about this," said Dr. Richard Parker, a primary care doctor affiliated with Beth Israel Deaconess Medical Center. "We have to call someone, which means immediate hassle, time, and aggravation. I'm in full agreement that radiology costs need to be controlled, but this not the answer."
Health maintenance organizations required physicians to get prior approval for many types of medical care during the height of managed care in the 1990s, but doctors and patients rebelled and plans cancelled many of the stricter requirements.
Many doctors and health care policy specialists say prior approval programs discourage not only unnecessary tests, but necessary ones as well because "it makes it an incredible hassle for doctors to order them," said Dr. David Himmelstein, a physician affiliated with Cambridge Hospital.
Tufts Health Plan saw a 48 percent rise in imaging tests between 2000 and 2003. Plan executives said they slowed the growth by initiating education programs for doctors and negotiating contracts that allow doctors to earn financial incentives by controlling radiology costs. At Blue Cross, Blue Shield of Massachusetts, members underwent 20 percent more MRIs last year than in 2002 while the number of CT scans shot up 25 percent. Blue Cross has not settled on a strategy to control costs.
Parker said some of the increases in scans are warranted: Images are clearer and more sophisticated, allowing doctors to use MRIs and CT scans to better diagnose conditions like spinal stenosis and appendicitis.
But John Donahue, president of National Imaging, which has doubled its clients in the last 18 months, said doctors sometimes can rule out serious illness with a more thorough physical exam and questioning. A patient who has had a headache for two weeks may want a scan, but a tumor, stroke, or concussion is very unlikely unless the patient has other symptoms such as dizziness and nausea, he said. But instead of eliciting this information first, doctors sometimes order an MRI, which can cost up to $900.
Herman said at the very least the new program will require a doctor to have a conversation with a National Imaging employee about why the doctor is ordering a scan. Most interactions, she said, will end there. She said patients should not be kept waiting because even a clinical review will take an average of just 4 1/2 minutes, she said. National Imaging can earn more if it cuts down on the number of tests but also by meeting service standards.
Liz Kowalczyk can be reached at kowalczyk@globe.com. 