Imaging groups not onboard with BCBS prior authorization proposal

By Molly Merrill
11:05 AM

The Medical Imaging & Technology Alliance (MITA)  and The Access to Medical Imaging Coalition (AMIC) have called on Congress to reject the Blue Cross Blue Shield ssociation’s (BCBSA) proposal for Medicare to use prior authorization for advanced imaging services. 

The proposal was included in a plan that BCBSA submitted to Health and Human Services and Congress, called Building Tomorrow's Healthcare System: The Pathway to High-Quality, Affordable Care in America, that aims at moving the healthcare system away from a fee-for-service model to a patient-centered model.

If adopted, the recommendations would save $319 billion over the next decade, according to an economic analysis by Ken Thorpe, Robert W. Woodruff professor and chair department of Health Policy & Management at Emory University's Rollins School of Public Health.

What MITA and AMIC are taking issue with is that the proposal calls for Medicare to “actively manage potentially harmful and costly technologies with a high risk of overuse or misuse, such as advanced imaging services. Prior authorization and beneficiary education relating to safety concerns and alternative diagnostic options should be considered. Private Radiology Benefit Managers have demonstrated success in the private sector and could make a substantial impact in public healthcare programs as well.”
The report points to Wellmark Blue Cross and Blue Shield partnership with a radiology benefit management company to ensure appropriate outpatient diagnostic imaging utilization, the use of evidence-based clinical criteria and appropriate exchange of member information, which it says has “consistently demonstrated an annual return of at least 3-to-1 and realized a gross return on investment of over 10-to-1 in its first two years.”

“A proposal by an association of the health insurance industry to put medical decisions in the hands of the health insurance industry is simply a means to reduce access to medical imaging,” said David Fisher, executive director of MITA. “Medical decisions should remain in the hands of physicians and their patients, rather than the insurance industry.”

There is no peer-reviewed health economic research that shows prior authorization actually produces savings for the Medicare program. Instead, a recent American Medical Association physician survey found that 63 percent of the 2,400 respondents said that prior authorization delays needed medical procedures.   Additionally, the Department of Health and Human Services (HHS) has already stated that a prior authorization program would be “inconsistent with the public nature of the Medicare program,” due to the lack of transparency and reliance on private companies using proprietary systems to deny physician-prescribed care. HHS also noted that the Medicare appeals process could overturn a “high proportion” of denials, rendering such a policy ineffective and highly burdensome.

“We know that these programs are highly burdensome and reduce access to care," said Fisher. "Policymakers should not place additional hurdles between patients and necessary diagnostic and screening services. Instead, healthcare providers should use evidence-based, physician-developed appropriateness criteria to ensure patients have access to the right scan at the right time.”

AMIC also cautioned that prior authorization is an ineffective and unproven mechanism for encouraging appropriate imaging utilization and likely will result in denying seniors’ access to life-saving diagnostic and therapeutic services.

The coalition notes that the BCBSA proposal comes on the heels of Blue Cross Blue Shield of Delaware’s (BCBSD) failed attempt to impose prior authorization requirements on patients. Following intense scrutiny of the quality of BCBSD’s delivery of care under its prior authorization program for cardiac nuclear imaging, BCBSD was ordered by the Delaware Insurance Commissioner to scrap prior authorization and instead use the American College of Cardiology’s (ACC) FOCUS program.

“It’s ironic that Blue Cross Blue Shield of Delaware was taken to task by the state insurance commissioner for denying patient care as a result of using prior authorization for imaging services, yet their national association chooses to advocate that Medicare adopt a similar scheme,” said Tim Trysla, executive director of AMIC. "The Delaware Insurance Commissioner’s decision underscores the ineffectiveness and negative consequences of prior authorization and it would be irresponsible to enact these tools more broadly.”

“There is not a single peer-reviewed, evidence-based study that shows prior authorization programs for medical imaging achieve any real cost savings," said Trysla. "However, multiple studies have shown that alternatives to prior authorization like physician-developed appropriateness criteria and decision support tools effectively drive appropriate imaging use without compromising patient access. No matter how loudly private payers advocate for prior authorization, Congress and CMS cannot ignore the data: prior authorization for advanced imaging doesn’t work and will actually cost taxpayers more.”

Click here to read Building Tomorrow's Healthcare System: The Pathway to High-Quality, Affordable Care in America.