Automated prior authorization combined with evidence-based clinical guidelines, as well as "physician engagement" can significantly reduce overutilization of advanced imaging services, according to a study published in the September issue of the Journal of Managed Care Medicine.
In the article, Anthony Akosa, M.D., vice president of medical affairs and informatics at Indianapolis-based provider-owned health plan Advantage Health Solutions, Inc., and assistant professor in the department of family medicine at Indiana University School of Medicine, argues that since physicians make decisions that control the bulk of healthcare costs, "the level of physician engagement could directly affect the level of achievement of the triple aim--better care for individuals, better health for populations and lower growth in expenditures."
For the study, three groups of providers were exposed to a program in which they were incentivized based on their individual performance on three utilization metrics, including the utilization of advanced imaging (CT, MRI and PET). Each provider received a quarterly report of his or her performance on these metrics, the incentive payout for the quarter, as well as a report comparing them to their peers.
As part of the program, a health navigator worked with providers; one of the navigator's primary responsibilities was to educate provider offices on the use of a provider portal, particularly for prior authorization requests, which were approved or declined based on Milliman Care Guidelines.
One group of providers (highly engaged) had multiple meetings explaining the program and quarterly results, while the second group (moderately engaged) had just one meeting. The third group was unengaged in the program and served as the control group.
According to the study, advanced imaging utilization decreased on average by 39 percent for all three groups, with the larger increase in the third group "probably due to the precertification requirement rather than provider engagement."
Overutilization "is not just a cost issue. It's also a patient safety and care quality issue, particularly for scans emitting ionizing radiation," Akosa said in an announcement. "Our study strongly suggests that pairing automated authorization with evidence-based clinical guidelines--as the MCG solution does--can ensure delivery of safe, effective care while also reducing medical costs by 39 percent or more."
To learn more:
- see the study in the Journal of Managed Care Medicine
- read the announcement