Data casts doubts on effectiveness of radiology benefits management, experts say
An exhaustive comparison of diagnostic imaging use between Medicare patients and the commercially insured may cast doubts about the effectiveness of radiology benefit managers, two radiology experts assert.
That’s one of the key takeaways from a new analysis of trends in diagnostic imaging, published Dec. 31 in Radiology. Comparing utilization rates across several modalities in the two insured populations from 2003 to 2016, University of Texas Southwestern researchers noted that usage trends seemed to mostly mirror one another. For both Medicare fee-for-service patients and the commercially insured, imaging use grew rapidly up until the mid-2000s, followed by a slowdown around 2010.
In a corresponding Radiology editorial, experts pondered whether these similarities should serve as an indictment of benefit managers, deployed by private payers to curb the use of imaging services and a well-known source of headaches for providers.
“The lack of substantial difference in imaging utilization between these populations—including CT, PET and MRI otherwise expected to require preauthorization—raises the question of effectiveness of radiology benefits management to control non-Medicare utilization,” wrote Keith Hentel and Michael Wolk, both MDs From the department of radiology at Weill Cornell Medical College. “This lack of effect on utilization trends further suggests that cost savings realized by payers through radiology benefits management are being achieved through alternate mechanisms, such as steerage to lower-cost providers and cost shifting,” they added.
For the original study, UT Southwestern researchers analyzed data from 35 million-plus Medicare beneficiaries, along with more than 9 million commercially insured individuals covered by one large national payer. The latter was separated into two study groups—those ages 18 to 44, and the rest ages 45 to 64. Lead researcher Arthur Hong, MD, and colleagues concluded that all three populations saw similar peaks and valleys over those dozen years. However, Medicare enrollees had the highest utilization rate for almost every modality, followed by the older commercially insured group (noncardiac ultrasound among ages 18-44 was one exception, likely driven by pregnancy imaging). The study incorporated individuals treated across all care settings including inpatients, emergency departments and private offices.
One notable exception in the data was a “significant” upward swing in CT imaging among both older populations beginning in 2012, Hong and colleagues wrote. Future research could explore this outlier, and whether such studies were clinically appropriate.
The authors noted that higher imaging utilization among Medicare beneficiaries is easily attributed to the greater burden of disease among older patients. However, reasons for the overall slowdown in imaging across both public and private payers are less obvious.
Possible drivers among the commercially insured could include preauthorization requirements from radiology benefit management companies, a movement toward more high-deductible health plans and other new forms of cost sharing. Meanwhile among Medicare beneficiaries, drivers could include accountable care organizations meant to control healthcare spending, along with the growing popularity of Medicare Advantage plans.
“These potential explanations do not account for some of the overall similarities in trends across the three groups,” Hong and colleagues wrote. “Because Medicare fee-for-service uses neither preauthorization nor high-deductible health plans, it is of interest that the imaging slowdowns and subsequent trends among its enrollees were similar to those in the commercially insured population. A host of other factors may potentially explain these similarities, including commercial alternative payment programs that mirror the Medicare accountable care organizations, bundled payment programs, overall concerns about radiation exposure and costs, reimbursement cuts, or greater adherence to appropriate use criteria by ordering clinicians,” they added.
In their corresponding editorial, Wolk and Hentel believe this study provides a springboard to further explore whether prior authorization is actually improving care quality for patients, or just steering them to cheaper options.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.