In this Wednesday session, researchers from Thomas Jefferson University in Philadelphia will present data showing that RBMs -- with the help of radiologists -- can in fact halt the upward trends in advanced imaging utilization rates.
Dr. David Levin and colleagues evaluated the decision process of an RBM and how it affects advanced imaging utilization. They focused on HealthHelp, a Houston-based RBM that offers prior authorization services to commercial payors, using a three-tier decision support system. Levin is national medical director at HealthHelp.
"RBMs have attracted lots of attention recently and are very controversial. If you go to the Web sites of most of them, you find many unsubstantiated marketing claims about what they can accomplish," Levin told AuntMinnie.com. "But there has been very little published in the peer-reviewed literature to document this. We wanted to present some hard data from one of the RBMs on how their call center applies computerized clinical rules in its prior authorization program and what the effect of that program has been on utilization of high-tech imaging."
During 2008, HealthHelp's first-tier service representatives recorded 404,612 requests for CT, MRI, and PET exams; these representatives used clinical rules to ascertain appropriateness of the orders. Of the requests, 74%, or 299,961, met the rules and were approved; ordering physicians decided to withdraw 4,164, or 1%. The remaining 25%, or 100,487, could not be resolved and were referred to second-tier nurses.
Of this 100,487, the second-tier representatives approved 82,598, or 82%; changed or withdrew 8,053, or 8%; and referred 9,836, or 10%, to the third tier, a group of approximately 40 subspecialty radiologists.
These third-tier radiologists approved 6,406 of the 9,836, or 65%, after phone consultation with the referring physician. In another 2,881 cases (29%), the ordering physician agreed to withdraw the request. In 397 (4%), the procedure was changed to a more appropriate one. In 152 (2%), there was no consensus, but these orders were not denied.
The entire process resulted in cancellation of 13,362 studies (3.3%) and the changing of 2,133 (0.5%) orders to a more appropriate exam, Levin wrote.
Preliminary data from HealthHelp showed that while the utilization rates of CT, MRI, and PET had been projected to increase 10%, 10%, and 45%, respectively, the rates actually remained flat or dropped after the program was instituted in 2005.
"The data show that prior authorization can in fact reduce the rapid growth of advanced imaging," Levin said. "Although radiologists and referring physicians generally dislike prior authorization, it's crucial that something be done to slow utilization growth, and this is one way of doing it. Otherwise, the federal government and payors will keep cutting imaging reimbursements until radiology becomes unsustainable."
