Insurers want 2nd opinion before scans

By David Phelps, Star Tribune
http://www.startribune.com

Worried about the rising number of CT scans, MRIs and other high-tech imaging procedures showing up on medical bills, Minnesota’s largest insurers now want doctors to get permission from a third-party evaluator before ordering such procedures for their patients.

As medical imaging centers and expensive machines proliferate, insurers say this is a way to reduce the number of tests wrongly or unnecessarily prescribed.

Medica instituted the requirement Monday; HealthPartners will do so in February, and Blue Cross and Blue Shield of Minnesota will follow suit in July.

For patients, this will mean another set of eyes evaluating whether an imaging test is appropriate for their conditions. But doctors are lukewarm about the new requirement, saying the rules will mean more work for them without more pay.

But the health plans say they expect it to result in big savings. “We pay for 170,000 scans a year, and if 10 percent to 15 percent are wrong scans or unnecessary, that’s a lot of scans,” said Dr. Charles Fazio, Medica’s chief medical officer. “And that’s a lot of health care costs.”

At an average of $700 per scan, Medica estimates that it will shave its imaging expenses by at least $12 million this year. HealthPartners says it expects $7 million in savings.

The new rule applies only to outpatient scans and will not affect inpatient care, urgent care or emergencies. Nor will it affect low-tech imaging, such as X-rays.

Computerized tomography (CT) scans use special X-ray equipment to show a cross-section of body tissue and organs, and can be used to look for conditions such as cancer or cardiovascular diseases. Magnetic resonance imaging (MRI) is used more for soft-tissue examinations, such as the brain. Positron emission tomography (PET) scans can be used to trace the results of therapy on cancers.

Rising numbers

Minnesota has virtually become the land of 10,000 imaging scans in recent years. According to the American College of Radiology, MRI use in doctors’ offices, as opposed to specialized imaging centers, grew at twice the national average between 1998 and 2003. CT and PET scans grew at a rate triple the national average.

A report by the Minnesota Council of Health Plans recently found that insurers paid $188.9 million for CT and MRI scans last year, up 13 percent from 2004.

“This is one of those things that everyone acknowledges is an issue that we have to address,” said Dr. Pat Courneya, associate medical director for HealthPartners. “With the right information, people will work to make good decisions.”

According to Medica, the average cost of different scans range from $646 for a pelvis CT to $3,175 for a skull PET. Fazio said that the cost of high-end imaging paid by Medica jumped 27 percent this year, after a string of 20 percent increases in recent years.

Under the new requirement, physicians treating Medica patents must call the insurer’s third-party consultant when ordering a high-tech scan to make sure it is the appropriate test for the appropriate condition.

The evaluator — a radiology management consultant who is not necessarily a medical doctor — can agree with the doctor’s decision or recommend another procedure. The telephone call, on average, should take five minutes, Medica says, although physicians question whether a response can be made that quickly.

After March 1, health care providers will not be paid by Medica if they do not get authorization for a procedure.

Doctors not happy about rule

The medical community is not enthusiastic about the rule.

“I’m not unaware of the problems [health] plans are facing with the rising cost of imaging,” said Dr. Joseph Tashjian, a radiologist and president of St. Paul Radiology. “The authorization process is a punitive process and not as helpful in furthering the goal” of creating a more uniform system for decisionmaking.

St. Paul Radiology is the largest of its kind in the state, with nearly 90 radiologists who work at five imaging centers and 11 hospitals.

In the HealthPartners and Medica programs, individual doctors will have final say on the imaging procedure, and HealthPartners will reimburse them even if their decision is not the same as the one advised by the consultant.

Dr. Robert Meiches, chief executive of the Minnesota Medical Association, said doctors follow test guidelines the majority of the time, but they also need leeway in prescribing scans “because each situation has to be individualized.”

Meiches said the new requirement takes time from doctors’ busy schedules without any financial returns.

“Medica is addressing an important issue but is placing an extra burden on physicians without extra reimbursement,” he said.

In a six-month pilot project by Medica, 10 to 15 percent of doctors treating Medica patients agreed to change tests they ordered after talking to a consultant, Fazio said. For example, instead of an MRI, a patient with lower back pain might be treated with anti-inflammatory drugs or the use of physical therapy.
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