Washington State offers glimpse of evidence-based future

Radiology, like all of healthcare, is changing in the face of reform, and one noticeable shift is the growing emphasis on evidence-based medicine. As U.S. organizations look to turn best practices into evidence-based policy for their regions—and committees like the Independent Payment Advisory Board aim to make a similar impact nationally—those working in medical imaging can look toward efforts like the Washington State Health Technology Assessment Program as a preview of what’s to come.

The program was the focus of an article written by C. Craig Blackmore, MD, MPH, of Virginia Mason Medical Center in Seattle, and published in the September issue of Academic Radiology.

Blackmore explained HTAP was founded in 2007 and tasked with making decisions on which medical procedures and technologies would receive coverage under Washington’s four publicly funded medical plans—Medicaid; the Basic Health Plan, which provides coverage for low-income individuals who are not eligible for Medicaid; the Uniform Medical Plan, which covers state employees; and the Worker’s Compensation program. Decisions are based on formal assessments of published evidence with regard to procedure effectiveness, safety and cost.

At the heart of HTAP is the Health Technology Clinical Committee (HTCC), a group of 11 providers which makes final decisions about coverage or noncoverage, according to Blackmore. The committee must have a majority of physicians, but providers from nursing, chiropractic or other medical fields can also be included.

“Because of rapidly increasing utilization, extensive variability, and high cost, imaging has been of interest to the program since its inception,” wrote Blackmore. “In addition, there is increased awareness of the potential risk of ionizing radiation, contributing to safety concerns, particularly for computed tomography.”

The HTCC has rendered decisions on 26 technologies to date. Nine of these are relevant for radiology, and Blackmore explained the committee’s track record of approving or not approving imaging studies has been mixed. Some HTCC decisions outlined in the article included:

• Upright MRI for lower back pain: The HTCC found insufficient evidence of effectiveness and rendered a no coverage decision.
• CT colonography: CT colonography was found to be of equivalent accuracy to optical colonoscopy, but coverage was withheld due the higher cost of CT colonography.
• CT angiography: Evidence demonstrated benefit was limited only to patients at low or intermediate risk evaluated in the emergency department for chest pain. HTCC approved CT angiography for limited coverage.
• CT calcium scoring: HTCC rendered a no coverage decision for CT calcium scoring due to lack of rigorous evidence.
• PET imaging in lymphoma: Covered for treatment planning and restaging, but not routine surveillance.

Blackmore wrote that the biggest barrier for radiology technology coverage is a lack of evidence, and suggested this points to a great need for comparative effectiveness research.

Although it’s hard to quantify the results of the program’s efforts, Blackmore reported that savings estimates have surpassed $20 million per year. “Evidence-based policy decisions from groups such as the HTAP are a potential method for improving the quality of care and lowering cost through noncoverage of ineffective interventions.”