- The Washington Times - Tuesday, March 25, 2008

TRENTON, N.J. (AP) - Insurance companies are taking a harder look at advanced medical scans, like CT scans, citing spiraling costs and safety concerns. And some doctors agree there is emerging evidence that these scans are being prescribed too often.

“Costs are soaring in this area, quality concerns are mounting and safety concerns are mounting,” said Karen Ignagni, chief executive officer of the trade group America’s Health Insurance Plan.

Health insurers are requiring more preauthorizations before patients can receive these scans, and setting other restrictions including mandating that the imaging equipment and medical staff operating it be credentialed.

Insurers fear some patients are being exposed to dangerous radiation levels from having repeated CT and PET scans, which use many times the radiation of a regular chest X-ray. Sometimes scans are repeated because the first ones were not done properly, the equipment was outdated or the technicians were poorly trained.

Doctors, too, are concerned about patients getting excessive radiation exposure when they receive scans that aren’t needed or are ordered as “defensive medicine” to protect against possible lawsuits. There also is concern that a small number of unscrupulous doctors without adequate expertise are referring patients for tests in their own offices or imaging facilities in which they have a financial interest.

“There is a definite concern that in-office imaging could lead to scanning for dollars,” said Dr. Robert Hendel, a heart specialist who sits on American College of Cardiology panels focused on quality and appropriateness of imaging.

But doctors say the bigger problem with medical imaging tests is the insurance red tape needed to get them.

“Is this a preauthorization process or are these [insurance] companies practicing medicine?” asked Dr. Arl Van Moore, board chairman at the American College of Radiology, the specialists in medical imaging.

Dr. Moore cited another reason for increasing costs: Doctors sometimes order a diagnostic test that doesn’t need preauthorization — even if it provides less-helpful information than the one they prefer — then seek approval for a more advanced test if the first one shows it is needed.

Worse yet, sometimes patients end up getting a riskier, more invasive test than what they really need, Dr. Hendel said. For example, cardiologists wanting to assess blood flow and blockages inside a patient’s heart arteries would prefer a nuclear cardiology test. With that, a small amount of a radioactive substance is injected into the blood and tracked using a camera.

Some doctors instead will order a cardiac catheterization, which doesn’t require advance authorization, Dr. Hendel explained.

But that involves threading a catheter through a blood vessel up into the patient’s heart — and carries a 10-times higher risk of complications such as a heart attack or stroke, he said.

The two doctor specialist groups are fighting improper use of scans by supporting accreditation of the machines and doctors using them and by publicizing criteria for quality and appropriateness of various imaging tests.

Dr. Hendel said use of strategies to hold down imaging costs was fairly limited until last year, when it really was stepped up, triggering the growth of a new industry of insurance consultants called radiology benefit managers.

A recent study by the Center for Studying Health System Change, which is funded by the Robert Wood Johnson Foundation of Plainsboro, N.J., the nation’s biggest health care charity, also found that limitations on the use of MRIs, CT scans, PET scans and nuclear cardiology imaging became widespread last year. The report was based on visits and interviews in 2007 with officials of health plans, hospitals, doctors’ practices, major employers and others in 12 metropolitan areas.

The report noted that the use of CT scans in the U.S. nearly doubled between 2000 and 2005, from 12 scans per 100 people to 22 per 100. That’s partly because improved technology has made the imaging machines, which can cost $1 million to $2 million each, useful for diagnosing more problems.

Revenue from the tests, which can run $500 to $1,000 or more each, can be tempting to financially struggling hospitals and doctors squeezed by shrinking reimbursements from government health programs and commercial insurers.

The insurer restrictions seem to be working: After one health plan that was seeing 20 percent annual jumps in advanced imaging use began requiring preauthorization, its growth rate plunged. Yet the insurer said only 1.5 percent of requests were being denied, indicating doctors were ordering fewer tests.

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