David Soffa, MD
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President Barack Obama's healthcare goals establish an ambitious road ahead for healthcare reform. While the ideas will be
subject to extensive debate, certain aspects offer immediate opportunities to improve healthcare and control costs. Introducing
radiology benefit management (RBM) into Medicare—estimated by the President's plan to save $260 million over 10 years—is one
such opportunity.
Diagnostic imaging is one of the fastest growing costs in healthcare. According to a June 2008 GAO report, Medicare spending
for imaging services doubled between 2000 and 2006 to $14 billion. During this period, spending on the most expensive imaging
services such as CT and MRI increased by an average rate of 17% a year.
UNNECESSARY TESTING
It is widely accepted that a significant number of diagnostic imaging studies—perhaps as many as one-third of all studies
performed—are clinically unnecessary. Aside from the cost implications, unnecessary imaging can create detrimental health
effects such as excessive radiation exposure and sub-optimal clinical outcomes because of false positives or insignificant
incidental findings. Radiology benefit management is a solution with 20 years of experience in the private health insurance market. RBM companies
review requests for advanced imaging to ensure that the clinical rationale for the order is consistent with clinical guidelines
that are based on criteria developed by organizations such as the American College of Radiology and the American College of
Cardiology. Clinical algorithms allow most requests to be approved at first pass. When additional review is needed, it is
performed by nurses and physicians, and denials usually are not issued until ordering physicians have been given the opportunity
to speak with another physician.
PROVEN TRACK RECORD
Do these programs work? The track record of the RBM industry, which provides services for more than 100 million health plan
members, suggests that they do. These programs have been shown to decrease utilization by 15% to 20% and reduce long-term
growth trends by up to 50%—and can do so with a denial rate of less than 3%. NCQA mandated surveys have shown provider satisfaction
ratings above 90% across the last five years. In short, if properly constructed and executed, these programs can deliver value
and service.
As with any new initiative, entities with a vested interest in the current system are opposing change. In this case, medical
imaging manufacturers and the American College of Radiology have denounced potential RBM participation in Medicare. While
both groups claim to support reform and better cost management, neither is offering a solution that has demonstrated any tangible
results, much less results comparable to what RBM companies have delivered.
Given the immediate need to improve healthcare and reduce costs, it is clear that proven solutions are required. Radiology
benefit management offers more than 20 years of demonstrated success and is immediately available for the Medicare program.
David Soffa, MD, currently serves as senior vice president, medical affairs, for American Imaging Management. Dr. Soffa is
a board-certified radiologist and is a fellow of the American College of Radiology.
