MGH Decision-support Study: A Shot Across the RBM Bow
A new study1 finding that radiology order-entry (ROE) and decision-support (DS) tools act to curtail utilization rates for advanced imaging is being celebrated as proof that a White House proposal to deploy radiology benefit managers (RBMs) as Medicare gatekeepers is unnecessary and ill conceived.
James H. Thrall, MD James H. Thrall, MD, FACR, chair of the ACR's board of chancellors and radiologist-in-chief at Massachusetts General Hospital (MGH), Boston, says, “I think this article is an important milestone in shaping the conversation nationally. Until this, we didn’t have scientific evidence of an alternative to RBMs, but now, we have clearly demonstrated that a less intrusive and more patient-friendly option exists. That is the point-of-care–decision approach.” The study, published this month in Radiology, describes how the use of a computerized ROE system, coupled with a DS system, effectively lowered or stabilized utilization rates for three categories of advanced imaging—CT, MRI, and ultrasound—at MGH between 2000 and 2007. Thrall, a coauthor of the study, says that it clearly shows that an upward-trending growth line for CT at MGH flattened after a computerized DS tool was installed to guide referring physicians on the appropriateness of ordering specific imaging studies for identified conditions. The ROE and DS systems analyzed in the study were developed at MGH, Thrall says. The DS system has since been licensed to a vendor and is available commercially. The ROE allows any physician cleared for access to order and schedule an imaging exam electronically. The imaging exam must be specified, along with the name of the patient and any patient information relevant to the exam, such as age, sex, metallic implants, pregnancy, or claustrophobia. When the exam ordered is high in cost (a category that includes all CT and MRI exams), a DS screen automatically appears. The ordering physician must then review information about the exam before proceeding. If the referrer elects to proceed, the DS software prompts an appropriateness score. A high score would indicate appropriateness; a low score would indicate that the exam is inappropriate, in most cases. The ordering physician would then be prompted to select a more appropriate exam (that would yield a higher appropriateness score) or write an explanation of why the original exam is appropriate, after all. Live consultation with a radiologist is a further option. According to Thrall, the DS system at MGH is built around appropriateness criteria developed by the ACR, but is structured differently. “They start with disease or condition and then go to relative appropriateness,” he says. “Ours starts with the imaging method and goes to the reason for doing the study.” While the ACR’s criteria and the MGH DS system are complementary, the latter is more detailed. “The ACR has 300 criteria sets, which we exploded into 12,000 very granular reasons for the imaging. We want to know which of the 20 different kinds of headache we are talking about, for example.” The Study The ROE–DS study analyzed outpatient imaging data at MGH between the fourth quarter of 2000 and the fourth quarter of 2007. MGH rolled out its ROE system between 2001 and 2003, and in the last quarter of 2004, it integrated the DS tool. According to Thrall, all the data for the study came from the MGH RIS. Counts of diagnostic imaging exams were obtained for CT, MRI, and ultrasound for periods before and after the implementation of ROE and DS. The usage volumes and growth rates of the three modalities were then compared to see whether changes occurred after ROE and DS were implemented. The assumption was that the computerized tools would act as gatekeepers and educators to curtail inappropriate exams, lowering volumes and cutting or stabilizing growth rates for the modalities studied. That is exactly what researchers found. Results For the entire length of the study, there were about 33 CT scans, 22 MRI exams, and 31 ultrasound exams per 1,000 outpatient visits. For CT, there was a decrease after ROE–DS of 274 exams per quarter in volume growth and a 2.8% reduction per quarter in growth rate. “After ROE and DS system implementation, the quarterly volumes for CT were essentially flat,”1 the study’s authors write. Thrall points out that a graph in the study “clearly shows that after several years of dramatic increase, when the DS was introduced, the trend line flattened dramatically.” For MRI and ultrasound, the declines weren’t as dramatic, but they were still evident. For MRI, there was no change in quarterly absolute volume, but the quarterly growth rate decreased by 1.2%. For ultrasound, researchers were unable to calculate DS impact because DS was never implemented for the modality, but a decrease in ultrasound growth rate of 1.3% quarterly was attributed to ROE alone. The researchers acknowledge that over the latter part of the study (after 2005), imaging volumes nationally may have been in decline, but they stand by their conclusion that ROE and DS were the major factors in MGH's ability to slow imaging-volume growth dramatically, to well below national averages. As the exams were tallied between 2000 and 2007, the study notes that a substantial reduction in the annual growth rate of CT was observed, with a drop from 12% to 1%. MRI’s growth rate declined from 12% annually to 7%, and ultrasound’s growth rate decreased from 9% to 4%. All those growth-rate declines followed the implementation of ROE and DS, the researchers note. They also took place when the number of outpatient visits was steadily rising. Clearly, according to the study, there were decelerations in the use of CT, MRI, and ultrasound attributable to the deployment of ROE–DS. Why the Study Matters “Anyone who is interested in reducing health care costs and eliminating unnecessary procedures should be very interested in this study,” Thrall says. “It demonstrates that computer-based DS can have a measurable and significant positive effect on costs.” Thrall says that the study is the ammunition that radiology needs to counter a proposal by the Obama administration to use RBMs to oversee and preauthorize advanced imaging exams for Medicare patients. According to an ACR press release² issued in February in response to the RBM proposal, the GAO estimated that the deployment of Medicare RBMs would save the government about $260 million over the next decade. For the ACR, though, the RBMs are anathema. “The ACR believes that instead of using a for- profit entity, whose only goal is to bring down costs, physicians themselves can be responsible for ensuring that the imaging they order for patients is appropriate,”² the college states. Thrall says that there are many reasons to be wary of RBMs. He adds that the MGH study shows that computer-based ROE–DS is more effective in controlling inappropriate imaging exams. "This fits right into the work process of the referring physicians. It’s done in conjunction with the actual scheduling of the exam, so there’s no slowdown,” he notes. “Every time they order something, they get immediate feedback on the appropriateness and comparative effectiveness of what they have ordered. If there’s a more appropriate method, they see that instantly—maybe CT instead of MRI, or vice versa.” ROE–DS doesn’t add work for the referring doctor; in contrast, RBM authorizations are time consuming, Thrall says. At MGH, when private insurers use RBMs, it is estimated to add 5 minutes to each exam order. Enterprise wide, the cost of this time adds up to about $7 million per year, he says. From that perspective, the $26 million per year projected to be saved by Medicare through RBMs will be far overshadowed by the cost to hospitals and clinics of getting approval from the RBM entities, Thrall contends. A Wedge Between Patient and Doctor Thrall also argues that the use of RBMs “devalues the knowledge of the attending physician.” The message to the patient is that the doctor is not trusted to make the decision. This drives a wedge between patient and doctor, Thrall says. With ROE–DS, the focus is never on telling the referrer that an exam can’t be ordered, but rather on educating the referrer about which exams are appropriate. “If we spot an outlier, then we work with that physician from an educational standpoint,” Thrall says. He uses the example of back pain. “If there are no neurological deficits or other indicators like fever, and it’s just back pain, imaging doesn’t have a lot to offer that patient. When we image patients who have no back pain, we see bulging disks and arthritis, so sorting out mother nature’s pathways versus something that’s causing pain is difficult. The vast majority of back pain resolves with conservative treatment, and imaging is not required, but when patients present, doctors feel that they have to do something, so they order a CT or MRI exam.” The referring physician using ROE–DS is educated over time, Thrall maintains, but when dealing with RBMs, the referrer only gets the slap in the face of a refusal, without explanation. “They just say yes or no,” Thrall says. Politics and More Politics Bibb Allen, Jr, MD, FACR, is a diagnostic radiologist with Birmingham Radiological Group, Birmingham, Ala. Allen is also chair of the ACR’s Commission on Economics. Like Thrall, he is an advocate of ROE–DS, and he opposes the use of RBMs. “We believe the referring physician wants the most appropriate study and to eliminate the unneeded exams, and we see opportunities—with the president’s touting of an electronic medical record (EMR) and all forms of electronic records—that a computer order-entry system operated by a hospital or an imaging facility could be used in conjunction with the ACR’s appropriateness criteria,” Allen says. He also says that deploying RBMs as Medicare gatekeepers interposes a third-party decision maker in the process and could adversely affect patient care. Taking fragile Medicare patients out of the physician’s control and putting them in the control of nonphysician gatekeepers is risky, he adds. He also questions the GAO’s estimate of saving $260 million over 10 years. Saving $26 million per year is not enough financial impact to prompt the implementation of RBMs, he argues. “If that’s all they’re expecting to save,” he asks, “why put the beneficiaries at potential risk in order to do that?” Furthermore, when the back-end costs to hospitals and clinics dealing with third-party RBMs are taken into account, the total cost to the health care system will probably increase, Allen argues. “It just turns the cost to the providers rather than the payors,” he says. Allen suggests politics as the driver of the RBM effort. “I would think these are some of the same companies that are out to improve market share and their own businesses, to make their stock prices go higher,” he says. “If they don’t grow, they retreat.” He also notes that some RBMs reportedly have risk-sharing capitated arrangements with their insurer clients. If the RBMs hold down the number of exams, they get paid more. From the point of view of patient care, Allen says, “This puts them in a conflict of interest.” When Thrall is asked about politics, he is even more pointed than Allen, saying, “They [politicians] are mounting it, because the RBM industry has absolutely lobbied the GAO to death.” Fighting Back Allen says that both he and Thrall will carry the message to CMS that deployment of RBMs needs to be reconsidered. They will cite the evidence in the MGH study of the reduction impact of ROE–DS. “It will be another piece that will say there are alternatives to RBMs in the Medicare program,” Allen says. “They just eliminate, and it’s not clear that the inappropriate imaging they eliminate is any less than the appropriate imaging they eliminate. We don’t consider RBMs transparent in how they decide.” Thrall notes a second avenue of attack. In passing the Medicare Improvement and Patient Protection Act of 2008, Congress authorized a demonstration program for physician-developed imaging-appropriateness criteria such as those demonstrated in the MGH study of ROE–DS. While the MGH study won’t suffice as a demonstration project, it can serve as a guide to the outside entity that eventually conducts such a demonstration, he says. That demonstration may be a year away, he estimates. Thrall also notes that other medical entities may get involved in challenging the deployment of RBMs. “There is now a new coalition being formed—an e-prescribing coalition,” he says, “that will be joining in this discussion.” Meanwhile, Thrall adds, the government has said that it will spend $19 billion to give physicians the computers they need to develop the EMR. “With that, installing computer-based DS for imaging nationwide would be an excellent use of those funds,” he says. “It would have a lasting effect on the reduction of health care costs.”
"This fits right into the work process of the referring physicians. It’s done in conjunction with the actual scheduling of the exam, so there’s no slowdown. Every time they order something, they get immediate feedback on the appropriateness and comparative effectiveness of what they have ordered. If there’s a more appropriate method, they see that instantly—maybe CT instead of MRI, or vice versa.” --James H. Thrall, MD
James H. Thrall, MD James H. Thrall, MD, FACR, chair of the ACR's board of chancellors and radiologist-in-chief at Massachusetts General Hospital (MGH), Boston, says, “I think this article is an important milestone in shaping the conversation nationally. Until this, we didn’t have scientific evidence of an alternative to RBMs, but now, we have clearly demonstrated that a less intrusive and more patient-friendly option exists. That is the point-of-care–decision approach.” The study, published this month in Radiology, describes how the use of a computerized ROE system, coupled with a DS system, effectively lowered or stabilized utilization rates for three categories of advanced imaging—CT, MRI, and ultrasound—at MGH between 2000 and 2007. Thrall, a coauthor of the study, says that it clearly shows that an upward-trending growth line for CT at MGH flattened after a computerized DS tool was installed to guide referring physicians on the appropriateness of ordering specific imaging studies for identified conditions. The ROE and DS systems analyzed in the study were developed at MGH, Thrall says. The DS system has since been licensed to a vendor and is available commercially. The ROE allows any physician cleared for access to order and schedule an imaging exam electronically. The imaging exam must be specified, along with the name of the patient and any patient information relevant to the exam, such as age, sex, metallic implants, pregnancy, or claustrophobia. When the exam ordered is high in cost (a category that includes all CT and MRI exams), a DS screen automatically appears. The ordering physician must then review information about the exam before proceeding. If the referrer elects to proceed, the DS software prompts an appropriateness score. A high score would indicate appropriateness; a low score would indicate that the exam is inappropriate, in most cases. The ordering physician would then be prompted to select a more appropriate exam (that would yield a higher appropriateness score) or write an explanation of why the original exam is appropriate, after all. Live consultation with a radiologist is a further option. According to Thrall, the DS system at MGH is built around appropriateness criteria developed by the ACR, but is structured differently. “They start with disease or condition and then go to relative appropriateness,” he says. “Ours starts with the imaging method and goes to the reason for doing the study.” While the ACR’s criteria and the MGH DS system are complementary, the latter is more detailed. “The ACR has 300 criteria sets, which we exploded into 12,000 very granular reasons for the imaging. We want to know which of the 20 different kinds of headache we are talking about, for example.” The Study The ROE–DS study analyzed outpatient imaging data at MGH between the fourth quarter of 2000 and the fourth quarter of 2007. MGH rolled out its ROE system between 2001 and 2003, and in the last quarter of 2004, it integrated the DS tool. According to Thrall, all the data for the study came from the MGH RIS. Counts of diagnostic imaging exams were obtained for CT, MRI, and ultrasound for periods before and after the implementation of ROE and DS. The usage volumes and growth rates of the three modalities were then compared to see whether changes occurred after ROE and DS were implemented. The assumption was that the computerized tools would act as gatekeepers and educators to curtail inappropriate exams, lowering volumes and cutting or stabilizing growth rates for the modalities studied. That is exactly what researchers found. Results For the entire length of the study, there were about 33 CT scans, 22 MRI exams, and 31 ultrasound exams per 1,000 outpatient visits. For CT, there was a decrease after ROE–DS of 274 exams per quarter in volume growth and a 2.8% reduction per quarter in growth rate. “After ROE and DS system implementation, the quarterly volumes for CT were essentially flat,”1 the study’s authors write. Thrall points out that a graph in the study “clearly shows that after several years of dramatic increase, when the DS was introduced, the trend line flattened dramatically.” For MRI and ultrasound, the declines weren’t as dramatic, but they were still evident. For MRI, there was no change in quarterly absolute volume, but the quarterly growth rate decreased by 1.2%. For ultrasound, researchers were unable to calculate DS impact because DS was never implemented for the modality, but a decrease in ultrasound growth rate of 1.3% quarterly was attributed to ROE alone. The researchers acknowledge that over the latter part of the study (after 2005), imaging volumes nationally may have been in decline, but they stand by their conclusion that ROE and DS were the major factors in MGH's ability to slow imaging-volume growth dramatically, to well below national averages. As the exams were tallied between 2000 and 2007, the study notes that a substantial reduction in the annual growth rate of CT was observed, with a drop from 12% to 1%. MRI’s growth rate declined from 12% annually to 7%, and ultrasound’s growth rate decreased from 9% to 4%. All those growth-rate declines followed the implementation of ROE and DS, the researchers note. They also took place when the number of outpatient visits was steadily rising. Clearly, according to the study, there were decelerations in the use of CT, MRI, and ultrasound attributable to the deployment of ROE–DS. Why the Study Matters “Anyone who is interested in reducing health care costs and eliminating unnecessary procedures should be very interested in this study,” Thrall says. “It demonstrates that computer-based DS can have a measurable and significant positive effect on costs.” Thrall says that the study is the ammunition that radiology needs to counter a proposal by the Obama administration to use RBMs to oversee and preauthorize advanced imaging exams for Medicare patients. According to an ACR press release² issued in February in response to the RBM proposal, the GAO estimated that the deployment of Medicare RBMs would save the government about $260 million over the next decade. For the ACR, though, the RBMs are anathema. “The ACR believes that instead of using a for- profit entity, whose only goal is to bring down costs, physicians themselves can be responsible for ensuring that the imaging they order for patients is appropriate,”² the college states. Thrall says that there are many reasons to be wary of RBMs. He adds that the MGH study shows that computer-based ROE–DS is more effective in controlling inappropriate imaging exams. "This fits right into the work process of the referring physicians. It’s done in conjunction with the actual scheduling of the exam, so there’s no slowdown,” he notes. “Every time they order something, they get immediate feedback on the appropriateness and comparative effectiveness of what they have ordered. If there’s a more appropriate method, they see that instantly—maybe CT instead of MRI, or vice versa.” ROE–DS doesn’t add work for the referring doctor; in contrast, RBM authorizations are time consuming, Thrall says. At MGH, when private insurers use RBMs, it is estimated to add 5 minutes to each exam order. Enterprise wide, the cost of this time adds up to about $7 million per year, he says. From that perspective, the $26 million per year projected to be saved by Medicare through RBMs will be far overshadowed by the cost to hospitals and clinics of getting approval from the RBM entities, Thrall contends. A Wedge Between Patient and Doctor Thrall also argues that the use of RBMs “devalues the knowledge of the attending physician.” The message to the patient is that the doctor is not trusted to make the decision. This drives a wedge between patient and doctor, Thrall says. With ROE–DS, the focus is never on telling the referrer that an exam can’t be ordered, but rather on educating the referrer about which exams are appropriate. “If we spot an outlier, then we work with that physician from an educational standpoint,” Thrall says. He uses the example of back pain. “If there are no neurological deficits or other indicators like fever, and it’s just back pain, imaging doesn’t have a lot to offer that patient. When we image patients who have no back pain, we see bulging disks and arthritis, so sorting out mother nature’s pathways versus something that’s causing pain is difficult. The vast majority of back pain resolves with conservative treatment, and imaging is not required, but when patients present, doctors feel that they have to do something, so they order a CT or MRI exam.” The referring physician using ROE–DS is educated over time, Thrall maintains, but when dealing with RBMs, the referrer only gets the slap in the face of a refusal, without explanation. “They just say yes or no,” Thrall says. Politics and More Politics Bibb Allen, Jr, MD, FACR, is a diagnostic radiologist with Birmingham Radiological Group, Birmingham, Ala. Allen is also chair of the ACR’s Commission on Economics. Like Thrall, he is an advocate of ROE–DS, and he opposes the use of RBMs. “We believe the referring physician wants the most appropriate study and to eliminate the unneeded exams, and we see opportunities—with the president’s touting of an electronic medical record (EMR) and all forms of electronic records—that a computer order-entry system operated by a hospital or an imaging facility could be used in conjunction with the ACR’s appropriateness criteria,” Allen says. He also says that deploying RBMs as Medicare gatekeepers interposes a third-party decision maker in the process and could adversely affect patient care. Taking fragile Medicare patients out of the physician’s control and putting them in the control of nonphysician gatekeepers is risky, he adds. He also questions the GAO’s estimate of saving $260 million over 10 years. Saving $26 million per year is not enough financial impact to prompt the implementation of RBMs, he argues. “If that’s all they’re expecting to save,” he asks, “why put the beneficiaries at potential risk in order to do that?” Furthermore, when the back-end costs to hospitals and clinics dealing with third-party RBMs are taken into account, the total cost to the health care system will probably increase, Allen argues. “It just turns the cost to the providers rather than the payors,” he says. Allen suggests politics as the driver of the RBM effort. “I would think these are some of the same companies that are out to improve market share and their own businesses, to make their stock prices go higher,” he says. “If they don’t grow, they retreat.” He also notes that some RBMs reportedly have risk-sharing capitated arrangements with their insurer clients. If the RBMs hold down the number of exams, they get paid more. From the point of view of patient care, Allen says, “This puts them in a conflict of interest.” When Thrall is asked about politics, he is even more pointed than Allen, saying, “They [politicians] are mounting it, because the RBM industry has absolutely lobbied the GAO to death.” Fighting Back Allen says that both he and Thrall will carry the message to CMS that deployment of RBMs needs to be reconsidered. They will cite the evidence in the MGH study of the reduction impact of ROE–DS. “It will be another piece that will say there are alternatives to RBMs in the Medicare program,” Allen says. “They just eliminate, and it’s not clear that the inappropriate imaging they eliminate is any less than the appropriate imaging they eliminate. We don’t consider RBMs transparent in how they decide.” Thrall notes a second avenue of attack. In passing the Medicare Improvement and Patient Protection Act of 2008, Congress authorized a demonstration program for physician-developed imaging-appropriateness criteria such as those demonstrated in the MGH study of ROE–DS. While the MGH study won’t suffice as a demonstration project, it can serve as a guide to the outside entity that eventually conducts such a demonstration, he says. That demonstration may be a year away, he estimates. Thrall also notes that other medical entities may get involved in challenging the deployment of RBMs. “There is now a new coalition being formed—an e-prescribing coalition,” he says, “that will be joining in this discussion.” Meanwhile, Thrall adds, the government has said that it will spend $19 billion to give physicians the computers they need to develop the EMR. “With that, installing computer-based DS for imaging nationwide would be an excellent use of those funds,” he says. “It would have a lasting effect on the reduction of health care costs.”