The removal of denial provisions in utilization management for advanced diagnostic imaging won't result in increased imaging, according to a study recently published in the Journal of the American College of Radiology.
According to the authors--led by Jeffrey D. Robinson, M.D., of the department of radiology at the University of Washington--in an effort to control imaging costs, many health insurance plans have implemented broad-based utilization management systems whose process includes contact denial provisions, whereby the health plans will refuse to pay for requested studies, if performed.
The researchers looked at a health plan that used a no-denial pre-authorization system for CT, MRI, PET and nuclear cardiac imaging in all but four of its geographic markets, which became the experimental group. They retrospectively reviewed 247,117 advanced imaging requests 21 months before and 16 months after the elimination of the denial provision in the experimental group.
The researchers hypothesized that a collaborative consultation between a radiologist and ordering physician--without the threat of denial of payment--wouldn't result in in higher imaging utilization. They believe that an educational process that requires an imaging professional to provide a rationale for appropriate imaging "would counterbalance the natural tendency of people to get as much as they can until someone say "no."
Over time, the author wrote, the question becomes less about whether to image, but, instead, which imaging test is appropriate.
The researchers found that utilization decreased slightly more in the experimental group than in the control group after elimination of the denial provision. The concluded that relying on the collaborative nature of the radiologic consultation rather than potential denial of imaging requests does not increase utilization.
Education initiatives, such as Image Wisely and Choose Wisely, along with resources like the American College of Radiology's appropriateness criteria, have had an impact on MRI utilization, which hit a high of 189 per 1,000 beneficiaries in 2008, but decreased to 183 per 1,000 beneficiaries just two years later, according to research also published recently in JACR.
To learn more:
- read the study in JACR