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 reimbursement.

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 existing workflow.

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 even more.

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 considered.

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 members.

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 report-writing.

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 medication."

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

References

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.