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America's Health Insurance Plans (AHIP) is a national association representing nearly 1,300 member companies proving health insurance coverage to more than 200 million Americans. Member companies offer medical insurance, long-term care insurance, disability income insurance, dental insurance, supplemental insurance, stop-loss insurance and reinsurance to consumers, employers and public purchasers.The ability to create pictures of a patient's internal anatomy and convert them to film through diagnostic imaging has revolutionized the way many diseases and injuries are detected, diagnosed and treated. Millions of Americans have avoided more invasive, and sometimes more costly, diagnostic procedures through the use of modern imaging technology.
Yet studies show that a range of 20%-50% of high-tech diagnostic imaging for a variety of conditions fail to provide information that improves patient diagnosis and treatment and may be considered redundant or unnecessary. Some studies have begun to raise questions about the added risk of radiation exposure for some imaging tests. Others suggest that a full third of imaging procedures may be inappropriate. According to a recent study by the McKinsey Global Institute, diagnostic imaging from computed tomography (CT) and magnetic resonance imaging (MRI) scans contribute $26.5 billion in unnecessary use of health services. In addition, the Center for Information Technology Leadership at Harvard University (CITL) estimates that about 20% of hospital radiology tests are duplicates that represent approximately $20 billion a year in wasted spending nationwide.
As a result, there is a growing interest in pursuing strategies that promote the appropriate use of imaging services, avoid redundancy and unnecessary exposure to radiation, reduce painful and wasteful follow-up procedures, and ensure that the patient is getting the right service the first time. These strategies have the potential to improve both the quality and affordability of health care.
Here is a look at some of the factors believed to be behind the high volume of inappropriate imaging procedures:
Deficiencies in quality. As more and more diagnostic imaging services have moved away from the hospital setting to free-standing imaging centers and physicians' offices, there is a growing concern that this may lead to incorrect diagnoses, missed pathology, and the need for additional imaging scans. Inspection of over 1,000 outpatient imaging facilities that provide diagnostic imaging services in Massachusetts found that 31% of the centers failed to meet established standards of care.
Lack of information on effectiveness and cost-effectiveness. The Food and Drug Administration (FDA) evaluates only the safety and efficacy of new drugs and medical devices. Determining the ability of new drugs and devices to improve the health of much larger and diverse populations in real-world situations and comparing their use to what is currently being used is not part of the FDA's responsibilities. As a result, there is a significant lack of reliable information about what works best. This uncertainty can result in lack of clarity about ordering a CT or a MRI. It can also result in "add on" testing in which the physician orders multiple imaging tests when one would suffice.
Consumer demand and self-referral. Increasingly, high-technology screening tests are being marketed directly to consumers through print, electronic and broadcast media. Many consumers who are willing to pay out-of-pocket for these tests can do so without a physician referral. Others are going to their physicians and requesting that they refer them for these screenings. Yet, some of the technologies being marketed are not recommended for the general population, particularly the low-risk population because of a lack of proven benefits. Additionally, screening of asymptomatic individuals carries the risk of false-positive test results that can lead to extensive or invasive follow-up examinations.
Physician ownership interest in imaging equipment. Either through in-office equipment or free-standing centers, a growing number of physicians have an ownership interest in diagnostic imaging machines. The report from the McKinsey Global Institute noted that the growth trend for use of diagnostic imaging is particularly pronounced among physicians who refer to facilities in which they have an ownership interest.
Defensive medicine. Defensive medicine -- the ordering of tests and/or procedures that are not medically necessary in order to mitigate the threat of lawsuits -- has been widely documented as a driver of rising health care costs.
A 2003 Harvard School of Public Health survey of 800 Pennsylvania physicians in six specialties considered to be at high risk of litigation found that nearly all (93%) reported practicing defensive medicine. Among the respondents, 59% said they ordered more diagnostic tests than were medically indicated.
Radiology Benefit Management
Methods used by radiology benefit management programs for new imaging technologies aim to encourage the appropriate utilization of imaging services and increase cost-effectiveness through more efficient approvals and the use of evidence-based medicine to change physician ordering patterns. Some health insurance plans use in-house resources while others have turned to radiology benefit management firms, but regardless of the application, the use of radiology management is expected to grow. In 2006, a survey of benefit managers of large U.S. corporations found that 40% of companies surveyed had some form of radiology management in place and another 20% said they will have one in place within the next two years.
An important component of many radiology benefit management programs is the development and use of standards to promote imaging quality and patient safety in "real time" by using the latest communication technology during consultations. An increasing number of health insurance plans require physicians to undergo a privileging process in order to receive reimbursement for imaging services that requires specified training and competency with respect to using imaging equipment and interpreting the diagnostic scans. Similar privileging/quality standards have been implemented for imaging centers. These standards address the quality of the imaging equipment, the quality of the images, the qualifications of the radiology technicians, and the safeguards for patient safety.
Health insurance plans can either directly require that these standards be met by participating providers or require that these providers become accredited by an accrediting organization, such as the American College of Radiology (ACR). By only reimbursing imaging services offered by qualified physicians and qualified facilities, health insurance plans are able to improve the quality of the services provided as well as diagnostic and treatment outcomes.
Health insurance plans are also disseminating nationally-recognized, evidence-based guidelines. These guidelines provide a valuable resource for referring physicians regarding the appropriate use of diagnostic imaging. In radiology benefit management programs, when a treating physician orders an imaging service, the order is compared to these nationally-recognized, evidence-based guidelines.
The physician either receives a confirmation to proceed or a recommendation to review the evidence-based literature relevant to the imaging service being prescribed in "real time". If the treating physician wishes to proceed with the use of an imaging service that is not supported by the available evidence, the treating physician is asked to consult with a radiology professional who is available to discuss alternate, more appropriate imaging services. The goal of these reviews is to ensure appropriate use of imaging. It is important to point out that making sure the patient gets the right test the first time may result in modifying the original request so that the patient receives a more expensive, but also more effective, imaging test. Radiology benefit management programs rarely result in a denial but rather provide a process through which requests for imaging services can be evaluated for their appropriateness based on the best available medical evidence.
An additional component of the benefit management process entails providing physicians with data on their imaging ordering patterns and how they compare to their peers. Profiling physicians, particularly those who have a pattern of ordering diagnostic imaging that varies greatly from their peers, and providing feedback to physicians is another way health insurance plans have been able to provide information on appropriate imaging.
This summary was drawn from a longer white paper by AHIP. To read the entire document, including descriptions of different types of technologies and greater discussion of factors driving up their use, click here.
POSTED BY: Texlaw (March 27, 2009 06:20 PM)
If there is good medical evidence and protocols in place, whether for or against a particular diagnostic, then a physician has met the standard of care. Perhaps using the science and evidence wisely in setting the standards and protocols are the key.
Reforms do gut all lawsuits, and caps gut the serious ones, where severe errors exist. In the event of serious error, the erring facility or physician gets a free pass and the patient suffers without any recourse. As designed, the limits where they are set below the litigation costs of bringing the case to trial (250K in Texas) have the effect of denying justice to those who are severely wronged.
Combining the lack of accountability of refusing to hold physicians accountable for serious errors and the historic lack of attention to license suspension or loss of privileges to the errant doctor, they suffer no consequence.
If established standards and protocols are used, based on consensus and publication in peer-reviewed journal, then a best practice system can reduce overall health care costs. I should note that many of the physicians have ownership interests in clinics that conduct the scans, so there is a financial incentive to them to order the scans, just as there are incentives to prescribe certain medications or lobby other physicians for their use.
Lest someone complain about preconceptions about attorneys, the author of this note has never practiced in med mal, but rather has represented many businesses that sometimes include physicians and medical professionals. However, the real reason for posting is that it is just good old common sense to avoid throwing the baby out with the bath water.
Effectively preventing patient recourse for serious errors by instituting a low limit on damages is wrong. It does nothing to fight the so-called "frivolous claim" which would be be a low dollar claim. However, it does excuse all physicians and facilities when serious errors are made.
POSTED BY: cdelic (April 01, 2009 02:01 PM)
Nice fairy tale texlaw. I am an internist in nyc where the head of the assembly (the most powerful man in the NYS legislature is a trial lawyer) and won't let any kind of tort reform pass. Our premiums are skyrocketing. Guidelines are great until you get in to the courtroom. I have seen many of my friends screwed despite best medical evidence.
Defensive medicine will never stop unless there is tort reform. Even our malpractice insurance company gives us seminars (required in NYS pretty much)on how to avoid lawsuits and the bottom line is better to be safe than sorry -- big time. I do agree, however, that if an MD performs an egregious maplractice -- such as cutting out the wrong kidney -- patients should have some further kind of recourse. Plus those doctors should have their license lifted.
POSTED BY: okcnhra (April 03, 2009 06:46 PM)
I'm a CPA who has seen both sides of malpractice litigation and tort reform doesn't fix the problem. I've seen cases where a life-time error has been made, the wronged party has zero funds and the attorney is risking his practice to bring the case to trial with his funds.
Across the table is the doctor, hospital and a hoard of attorney's paid by the hour by the insurance company -- which sometimes seem like unlimited funds. Whether those attorney's win/lose doesn't matter as they still get paid.
On the patient side, everything is at risk, possibly including the attorney's personal life-style and practice. So, when you win, you had better win big!
Seems to me like maybe a better forum would be to put "everyone" at risk so that "he who loses loses" including the defense counsel and doctor not just the insurance company -- that would lower a few premiums.
It's a major problem -- my daughter is an attorney and my son a physician so we had our share of how to fix the problems sitting around the dinner table.
All in all, an educated smart jury and each component of the case liable for their own costs seems to be the only solution that makes sense to try and change -- tort limits leaves too big a hole in the net trying to protect the common man.
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