Achieving a balance between managing care and managing costs is the bane of many providers' existence because it often forces them to spend precious time wrangling with payers instead of caring for patients. However, by integrating clinical appropriateness guidelines with pre-certification and utilization management, radiology practices can have at their disposal an efficient and patient-specific management solution.
Whether they are operating under discounted fee-for-service
contracts or fully capitated agreements, radiologists simply cannot
afford the economic consequences of overutilization that result
when medical resources are used inefficiently or inappropriately.
At the same time, every patient who needs an imaging study must be
assured of getting one.
Achieving this balance between managing care and managing costs
is the bane of many providers' existence these days because it
often forces them and their staff to spend precious time wrangling
with payers instead of caring for patients. However, by integrating
clinical appropriateness guidelines with software for
pre-certification and utilization management (UM), radiology
practices can have at their fingertips an efficient management
solution that spells out the patient-specific thresholds at which
resources are used appropriately. This solution also provides the
rationale for decisions to withhold resources when clinical
indications are absent-removing debate about appropriateness and
Such a clinical decision support system can yield measurable
benefits when it comes to controlling healthcare costs without
compromising quality which, in a managed care environment, is of
paramount importance to both providers and payers. To successfully
implement such a system, however, two conditions must be met.
First, the clinical decision support criteria that are used must be
patient-specific, objective, and fair. Second, the system
architecture must be able to operationalize the criteria so that
they are easy to use and fit seamlessly into an organization's
Utilization management and the bottom line
The road to efficient physician-driven utilization management is
still largely unpaved, but that's beginning to change, especially
in practice areas such as radiology.1 For most radiologists,
managed care takes the form of discounted fee-for-service
contracts. Under such contracts, however, there is little to no
incentive for radiologists to assist in managing care.2
Unfortunately, in the face of healthcare cost-containment
pressures and the explosive growth of managed care and capitation,
few providers-including radiologists-can bear the financial brunt
of inefficient or inappropriate use of medical resources.
Overutilization costs money. At the same time,
underutilization-whether from oversight or financial
disincentive-jeopardizes patient outcomes and may ultimately cost
Pre-certification can control radiology costs by avoiding
inappropriate studies. Clinical decision support criteria not only
can verify that conservative measures such as limited activity,
physical therapy, and analgesics have failed before ordering spine
imaging studies for radiculopathy, for example, but also can
determine the appropriateness of each specific imaging study being
For example, it is well documented that MRI may reveal
pathologic disk abnormalities in asymptomatic patients. Criteria
that address the clinical necessity of performing MRI should
specify that certain findings, such as radicular pain, are present
before such a study is ordered. Requiring a period of conservative
therapy before an MRI is ordered for these patients will help
decrease the number of medically unnecessary imaging studies and is
consistent with sound clinical practice.3
Consider this case in point. A radiology utilization management
group under contract to a managed care organization (MCO) in
Florida found that nearly 20% of imaging studies ordered by
referring physicians were clinically unnecessary. Using criteria
from InterQual-the Marlborough, Massachusetts-based vendor of ISXTM
(Indications for Imaging Studies and X-rays) to precertify
outpatient MRI, CT, angiography, and nuclear medicine studies, the
MCO realized projected annual savings of approximately 10 percent
of its total radiology budget. This MCO has a base rate of
approximately 2,000 of all types of radiology exams per 1,000
Medicare members per year and 670 exams per 1,000 commercial
Out of 2,160 advanced modality imaging studies requested in a
52-day period, 458 (21%) were questionable under the criteria. The
MCO physician advisor found 55 of those studies justifiable, for a
final non-approved rate of 18.5%. This rate translates into 6.6
studies per day (or 1,650 per year) for every 100,000 commercial
members, and 18.15 per day (or 4,537 per year) for every 100,000
Medicare members. The breakdown by modality of studies avoided was:
MRI, 49%; CT, 40%; nuclear medicine, 10%; and angiography, 1%.
Assuming an average cost per exam of $400, annualized savings
were projected as follows in table 1.
According to Jonathan Shapir, MD, medical director of Imaging
Utilization Services in Ft. Lauderdale, FL, which uses InterQual's
criteria to perform precertification for outpatient imaging and
reported these results, this MCO's overall radiology utilization is
now down by 20%, which translates into projected annualized savings
of $2.5 million; its non-approval rate is now down to about 10%. A
radiology practice could easily achieve similar benefits by
employing clinical decision support criteria.
Automating clinical decision support criteria
A growing number of software vendors, such as IMA Technologies
(Sacramento, CA) and the Lauren Company (Denver, CO), are embedding
clinical content into their utilization and quality management
systems, making it easier for providers (and payers) to codify
their clinical decision making. The key to optimizing the
effectiveness of decision support criteria, however, lies in the
system's capability to automate and integrate the criteria into an
organization's existing workflow. This means that the system must
support the way an organization functions, automating the process
of utilization management, not simply automating data capture or
With the right set of explicit, externally developed guidelines
embedded in the right software, radiologists have at their
fingertips a way to deflect inappropriate demand, conform to
quality-of-care parameters, and justify healthcare decisions
without appearing self-serving.
For example, a treating physician may have a patient who's
demanding an MRI because, in the patient's words, "My
brother-in-law was given an MRI when he had the same symptoms.
I think I should have one too to get to the heart of my
problem." The dilemma is that patients want technology and, indeed,
technology is often faster and easier for the physician than
conservative, cognitive services. But overuse of technology skims
money out of the capitation pool. By acceding to the whims of
uninformed patients, the problem becomes one of overutilization at
the physician's expense.
However, in applying clinical decision support criteria, a
radiologist has the tools to assess the appropriateness of imaging
resource use. Decisions about patient care can be made and applied
consistently. Should it appear appropriate to withhold a certain
study, it can be done in a rational framework, with appropriate
reasons and citations to support the decision. The radiologist can
help the treating physician to explain to his patient, "Yes, I know
your brother-in-law was given an MRI, but in your case, with your
set of symptoms, our medical knowledge says an MRI isn't warranted.
You will be better off with a week of bed rest and over-the-counter
Why clinical decision support criteria are used
Clinical guidelines define the sequence of interventions for
diagnosing and treating a clinical problem. The criteria for
performing specific interventions, such as imaging studies, can be
defined based on these guidelines. The criteria outline specific
clinical steps that should be performed before the threshold for a
particular intervention is reached.
Physicians and/or medical reviewers refer to software-based or
hard-copy criteria to determine the appropriateness of a given
intervention. When these clinical decision support criteria are
operationalized by software, the patient-specific clinical
knowledge necessary for appropriate utilization management is
readily and consistently available, leading to faster approvals,
improved data aggregation, clinically meaningful profiling of
provider practice patterns, and more effective cost management.
Patient-specific clinical knowledge is necessary for appropriate
utilization management, clarifying the appropriate threshold at
which to perform imaging studies based on the individual patient's
clinical needs. For example, while they both present with back
pain, the threshold for performing an imaging study on a frail
65-year-old woman at risk for osteoporosis is likely to be quite
different than that for an active woman of the same age who played
golf for the first time last weekend.
As they seek to balance demand for services with managing the
financial risk they've assumed from managed care plans,
radiologists need a way to bring the clinical knowledge applied in
utilization management to their desktops in the form of decision
support. They can do this by taking advantage of the "marriage" of
clinical appropriateness guidelines with automated solutions for
pre-certification and utilization management. In today's managed
care environment, it is a marriage of necessity-and one which
radiologists should embrace. AR
1. Hayes, Emily. "Studies assess home-grown utilization
management." Diagnostic Imaging, April 1997.
2. Fortner, Thomas. "Managing Managed Care," Imaging Economics,
January/February 1997: 27-29.
3. Karcz, Anita, MD. "Critical Pathways to Utilization Review."
Administrative Radiology Journal, August 1995: 23-25.
4. Hongsermeier, Tonya, MD. "Need Another Opinion? Just Ask Your
Computer." Managed Healthcare, April 1996: 86-90.