If only specialists could order MRI and CT exams of the joints, would primary care doctors refer more patients to them? Would costs then rise? Would quality of care suffer? Apparently not, according to Dr. Andrew Litt from the New York University School of Medicine.
In a two-year, 100,000-patient utilization study that Litt presented at the November RSNA meeting, the restriction reduced the number of exams in both modalities significantly, without increasing referrals to orthopedists and rheumatologists.
The patients’ imaging was covered by a network of about 50 radiology groups across New York state, which contracts with managed care payors to provide radiology services under varying financial arrangements, Litt said. The study group of non-Medicare capitated patients came from a total of about three million covered lives in the network, about half of whom fall under financial-risk agreements and half under non-risk contracts.
"Rather than having third parties come in and do managed care, when dealing with radiologists it's better if they take the burden on themselves, despite the difficult challenge," he said. "Obviously we want to keep quality and service parameters up where they should be, but unfortunately we are in a risk environment in many situations, and we have to manage costs."
The goal of the study was to determine the consequences of limiting access to high-cost MRI and CT exams to specialists. For that reason, lower-cost x-rays were not included in the restriction.
Orthopedists and rheumatologists were more than happy to cooperate, Litt said. "In our discussions with various specialists we learned that they are often frustrated when the patient comes to them with imaging studies, sometimes ordered inappropriately by primary care doctors. They're interested in having a little more control."
The group's main concern was that the restriction would result in more visits to specialists, and ultimately increase costs. On the other hand, the researchers posited, maybe most of these patients were seeing the specialists anyway -- after visiting the primary care physician.
Comparing total exams for one year before the restriction began and for one year following implementation, overall CT use dropped 23%, while MRI use dropped 26%, with no overall change in specialist utilization. In fact, total orthopedic consultations dropped from 1,971 pre-program to 1,817 post-program, Litt said. On a RVU (relative value unit) basis, CT use dropped 24%, and MRI use again fell by 26%. Overall specialist utilization remained at 0.019 consultations per 1,000 patients, both pre-and post program.
"Requiring the orthopedist to see the patient didn't change the number of referrals, and overall you would assume a good impact on patient care," Litt said. "We're thinking now about how to take this further, looking at neurologic consults and that sort of thing."
But before expanding the study, the group will streamline the precertification process to make it easier for specialists to order exams, which they presumably will do with more discernment than the primary care physicians. However, Litt noted that data suggest there is also wide variability in exam-ordering behavior among individual specialists.
An audience member asked Litt to explain why he thought orthopedic consultations didn't increase. "That would imply that a negative examination didn't stop the referral to an orthopedist by the primary care physician," he said.
"That's the answer to the question," Litt said. "It's our belief -- and this part we can't prove -- that the primary care doctors are actually sending most of the patients for discussion to the orthopedist anyway. They just want to do something up front before they send the patient. And if they're concerned enough about what they're finding, they're going to send the patient regardless of whether they get the MRI before or after."
By Eric BarnesAuntMinnie.com staff writer
January 11, 2001
Related Reading
Localized practices: another look at orthopedic referral, January 31, 2000
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