Editor's Note: This is part one of a two-part series.
As new treatment modalities become available, it has become more difficult to know the right test. Diagnostic imaging tests are ordered for more than 830 different clinical conditions. The latest developments in imaging technology have created a plethora of complexity. These advanced tests (MRs, CTs and PET-CTs) are also the hardest to match appropriately to each patient's diagnostic needs.
Imaging has expanded its role and is no longer used only for the identification or confirmation of a patient's condition. Imaging is intertwined with therapy for oncology patients and used at every stage of care: screening, diagnosis and staging, treatment, and monitoring. It is a tool for lifelong follow-up. In fact, according to an article by Christopher Farr of Sg2, the expanded utility of these applications will increase utilization by 189% by 2016.
Imaging also continues to be one of the fastest growing areas of spending for health plans, with costs expected to double over the next four years to $200 billion by 2011. As a response to this increase, many payers have contracted with radiology benefit managers (RBMs), who utilize various utilization management techniques.
The challenge for health plans, radiologists, and referring physicians is how to reduce the use of unnecessary or inappropriate imaging while ensuring access to clinically valuable imaging, especially in a period of rapid technological advancement and increased use.
History Repeats Itself
Prior to the introduction of RBMs several years ago, pharmacy benefit managers (PBM) arrived on the scene for much the same reason: help in controlling escalating costs.
In 2007, PBM spending was reduced to 6-8% of premium from a 18.2% increase in 1999. Comparatively, the radiology expenditure was 2% of benefit in 1999 and is currently 18-20% of premium today. This increase is driven by advances in imaging technology, advertising directed at patients, physician self-referrals, a wide disparity in appropriateness, and an aging population. This growing complexity has led to wide variation in the appropriateness, pricing, and quality of imaging services.
Imaging Sharpens Disease Identification and Management
Successful care management strategies offer payers many opportunities for reducing costs and improving patient outcomes. Care management tools help payers integrate data from various sources into a patient's medical record with financial and clinical data. Combining that information with laboratory, radiology, and pharmacy data provides an optimal longitudinal view of the patient's care history.
These eight dimensions of radiology management identify shifts leading managed care organizations have made as they've adapted to industry changes and consumer expectations:
1. Wellness and prevention. includes screening and programs targeted at keeping the member population at the healthy end of the care continuum. Programs are designed to address issues before they become problematic, so patients stay well and employers and payers spend less money on treatments. One of the best-of-breed options is screenings. Screenings use a test to check people who have no symptoms of disease, to identify people who might have that disease, and allow it to be treated at an early stage when a cure is more likely.