Increased Diagnostic Imaging Complexity Leads to New Challenges for Payers

September 18, 2017

The field of radiology has expanded dramatically. Today, radiology covers diseases from the fetus through to the multimorbid aging population, from prostate to pituitary gland and from pancreatic neoplasia to bone dysplasia.

New knowledge in imaging is developing at a rapid pace. The use of imaging for functional evaluation and cellular activity has created a wealth of knowledge and needed expertise unseen in the recent past. Improved image clarity and tissue differentiation has dramatically increased the range of diagnostic information and, in many cases, the demonstration of pathology without the need for invasive tissue sampling.1

To ensure quality diagnoses, this growth in information gathered from the radiology specialty requires careful interpretation without preconception from highly trained specialists. Further, the ever-growing number of modalities adds increasingly complex requirements for imaging equipment and the facilities that house them, meaning that ensuring patients receive examinations at quality facilities is more important than ever before when it comes to ensuring quality care and the wise use of health care resources.

Complexity Leads to Complexity—and Misuse

This increased complexity has led to confusion in the referring physician community, often resulting in inappropriate ordering practices.

The Medicare Payment Advisory Commission has estimated that 1 in 3 imaging studies may be unnecessary. This would equal about $55 billion of the more than $170 billion spent on imaging annually, according to Jeff Goldsmith, Ph.D., the president of Health Futures and coauthor of a book about medical imaging.2

Further, the issue with self-referral continues. A June 2015 Government Accountability Office report found the growth rate of self-referred services outpaced non-self-referred services by a 7-to-1 margin for MRI scans and by a 3.5-to-1 margin for CT scans.3

“This is a huge problem,” Jean Mitchell, Ph.D., a Georgetown Public Policy Institute economist who has studied self-referral, told Managed Care magazine.2

To help referring physicians choose appropriate, indicated diagnostic procedures and to address self-referral behavior carefully and diligently, payers must develop partnerships with trusted programs that manage diagnostic imaging services, particularly programs that use the most recent ordering best practices to guide physicians; identify the most highly trained, truly independent specialists for image interpretation; and highlight the highest quality facilities that follow up-to-date, leading-edge protocols.

HealthHelp Focuses on the Best Diagnostic Options—and the Best Diagnoses

HealthHelp, a leader in the field of health care utilization management, helps ensure the best imaging test is ordered, that it is performed at a quality facility, and that a qualified specialist interprets it. HealthHelp manages diagnostic imaging requests from referring physicians, helping plan members receive the best diagnostic options for their presenting issues across multiple modalities.

HealthHelp’s model is based on nondenial of services, meaning that it does not deny treatment requests from a member’s physician, instead consulting with him or her to collaboratively determine the best form of diagnosis or treatment. Network physicians prefer this nondenial, collaboration-focused approach, and this approach helps payers ensure members receive the appropriate treatments at the right times. Overall, HealthHelp’s program improves patient outcomes while lowering the cost of care.

HealthHelp’s program results in lasting provider education and ordering optimization; management of self-referral behavior to ensure specialized and trained physicians perform consults; and patient education on safety, quality, and costs to simplify facility and physician choices. In addition, HealthHelp offers optional radiology-facility certification.

Standards, Evaluation, and Certification Promote Facility Best Practices

Further, HealthHelp offers quality-based, cost-saving site assessment and site-certification programs that promote best practices in imaging and other specialty services to help imaging facilities achieve a high level of quality that benefits all members of the health care continuum.5

HealthHelp’s DiagnosticSite Assessment Program promotes the creation of an imaging network that promotes quality and patient safety through facility ranking.6

National standards and benchmarking are established through ongoing partnerships with providers, public policymakers, regulators, academic institutions, and other key stakeholders and through guidance and peer-review from DiagnosticSite’s volunteer advisory board and standards committee.

DiagnosticSite has the largest database of diagnostic imaging equipment in the United States, offering quality and safety to over 6.5 million Americans. Standards include the full spectrum of imaging modalities and all clinical settings.

More than 29,000 facilities have participated in the program, with over 89,000 quality-assessed imaging devices.6

A Comprehensive, Collaborative Radiology Solution

Trained specialists in diagnostic imaging bring targeted knowledge and quality facilities bring optimal equipment and best practices to the patient-care equation.

To promote quality care for plan members and cost efficiency for payers, HealthHelp manages diagnostic imaging requests to make sure the appropriate imaging is done at the appropriate time by qualified, trained specialists.

Let’s discover how we can help you. Contact HealthHelp at 800-405-4817 or visit www.healthhelp.com/radiology for more information.

 

Sources:

1 “The future role of radiology in healthcare,” European Society of Radiology 2009, January 16, 2010. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259353/

2 “The enduring temptation of physician self-referral,” Managed Care magazine, October 2011. https://www.managedcaremag.com/archives/2011/10/enduring-temptation-physician-self-referral

3 “What can patients do in the face of physician conflict of interest,” Health Affairs Blog, April 10, 2015. http://healthaffairs.org/blog/2015/04/10/what-can-patients-do-in-the-face-of-physician-conflict-of-interest/

4 “Radiology Benefits Management: Appropriate imaging and reducing radiation exposure,” HealthHelp. http://www.healthhelp.com/radiology/

5 “Site: Quality-based, cost-saving site assessment and certification programs,” HealthHelp. http://www.healthhelp.com/site/

6 “DiagnosticSite,” HealthHelp. http://www.healthhelp.com/diagnosticsite/

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