A few weeks ago, the federal government’s Government Accountability Office (GAO) issued a report on the rapid rise in the cost and use of high-end radiology services (CT Scans, PET Scans, MRIs and the like). In a nutshell, the report said three things: first, the use and cost of imaging services to Medicare beneficiaries went up dramatically from 2000 through 2006, second, the use patterns suggest wide variation in treatment protocols and the possibility of inappropriate utilization. And finally, that CMS and Medicare should implement some kind of front-end prior approval process to deal with the potential overuse and misuse of these services that came through in their data.

Well, well, well. If it isn’t deja vu all over again. Several years ago, Harvard Pilgrim noticed a similar problem with imaging services for its members in MA, NH and ME. We did some analytics, concluded that the explosive growth in utilization (and expense) couldn’t be mapped to any predictable pattern of evidence based practice, and decided to pursue a front-end approach to managing non-emergency imaging services.  Our approach wasn’t even a prior authorization process. Prior approval processes require physicians’ offices to call the plan, review the clinical circumstances with the plan, and then the plan renders a decision on whether or not it will pay for the procedure. We didn’t make a payment decision. We said we would pay for  the procedure whether we thought it made sense or not — but we did require physicians to call us and discuss the clinical circumstances surrounding the desire to order the test. We then planned to take that information, organize it by specialty, and meet with the various specialty societies to discuss order and use patterns.

In retrospect, it’s possible to think we were just ahead of the curve. Today, every health plan we compete with in MA, NH and ME has a front-end process in place for managing imaging utilization — some more aggressive than others. And it sounds like Medicare will soon be heading in this direction as well.

But back then, when we first proposed implementing this program, you would have thought we were committing a crime. We were called in front of several major medical groups, brought before key public officials, scrutinized and criticized in the media, and demonized by many factions of the medical community. During one particularly noisy exchange, our Chief Medical Officer was told by another physician that, “she would never work anywhere else in Boston if she didn’t back off on this.”

But she and we stood our ground, made some modest adjustments to deal with real issues that were raised, and implemented the program — which remember, was notification/consultation only. Twelve months later, we’d seen no increase in imaging utilization. None. Same thing was true for the following 12 months — and only recently have we seen much uptick at all. And in the meantime, we’ve been sharing the utilization and order pattern data with the physician groups we do business with and with the various medical and specialty societies we work with. That, not surprisingly, has led to some useful and interesting conversations about the use of new and evolving technologies between our medical staff and the clinicians we work with. With no payment denials.

All in all, a pretty good story — once we got past the first five or six months. I suspect CMS and Medicare, due to the political nature of their business model — will run into some trouble as they pursue some kind of front-end option. But I hope they stick to their guns and implement. These programs work, and we need a hundred more just like it.

Posted by Charlie Baker in Harvard Pilgrim, Health Care Costs, Medicare