Report: Prior authorization wont cut imaging costs

Policy proposals to adopt prior authorization for advanced medical imaging as a means of controlling utilization would not provide meaningful cost savings, according to a literature review by The Moran Company. The report, released by the Access to Medical Imaging Coalition (AMIC), evaluated the cost savings of various proposed imaging policies and found that the Congressional Budget Office (CBO) is unlikely to score significant savings for these strategies.

“Our review of the literature found surprisingly little information on the impact of prior authorization, and our analysis suggests that the returns from such a program may be meaningfully smaller than its operating costs,” Don Moran, president of The Moran Company, said in a statement. “Policymakers may, instead, wish to consider the possibility of using decision support systems, which the evidence suggests can be effective means of managing imaging utilization when they are available.”

An earlier 2011 study by The Moran Company found that in 2009 the overall volume of imaging services delivered to Medicare beneficiaries declined for the first time in 11 years. In light of this trend, AMIC cautioned that prior authorization by radiology benefit managers (RBMs) will only further hinder access to life-saving diagnostic imaging services.

Andrew Spiegel, CEO of the Colon Cancer Alliance, echoed AMIC’s concerns in a press conference, saying RBMs interfere with the doctor-patient relationship.

“Frankly, what’s so bothersome about this is that somebody who does not know the patient, who does not know the patient’s history, who doesn’t know anything about this patient is going to be on the phone making a healthcare decision for this person,” said Speigel.

Speigel said the RBM process is especially burdensome for those in rural communities who have to travel long distances to receive healthcare and may not receive prior authorization for a procedure for days, forcing the patient to make multiple long trips.

Administrative difficulties exist for implementing prior authorization programs for Medicare beneficiaries, according to the report, and the potential for savings would be reduced if prior authorization denials in Medicare are successfully appealed.

The report did say decision support tools, local computing and handheld information utilities to help physicians make better decisions, can have a positive effect on utilization, but they are underused. Most physicians ordering diagnostic imaging services are not exposed to the tools or expected to use them, according to the report.

However, the report said it is doubtful the CBO would score significant savings for a program that diffused decision-support tools. The CBO expects the practice of evidence-based medicine, so the positive effects of widespread utilization of decision support tools would likely be in the baseline for scoring purposes, according to the report.

The report concluded by suggesting budget savings from utilization management in diagnostic imaging may be found with profiling programs that reduce payments for providers whose ordering patterns are aberrant.