RBMs shift burden to doctors: study

July 11, 2011
by Sruthi Valluri, DOTmed News
The use of radiology benefit managers (RBMs) -- third-party decision makers that authorize the use of imaging services -- could actually increase costs to the health care system, according to a recent study.

The study, which appeared in the June issue of the Journal of the American College of Radiology, found that RBMs often increase the administrative burden on providers. Nearly 28 percent of projected RBM-related savings are shifted to providers.

RBMs use proprietary algorithms to determine the appropriateness of imaging tests such as MRIs, and CT and PET scans. The algorithms are based on guidelines suggested by the American College of Radiology. Insurance companies often hire RBMs to ensure that doctors only order advanced imaging tests when absolutely necessary.

Over 88 million Americans are covered by plans that use RBMs to manage their services. These plans include insurance giants like Aetna Inc. and Cigna Corp. Under these plans, physicians need approval for a scan before insurance will cover it.

But despite their prevalence, there have been very few attempts to examine the effectiveness of RBMs.

"The way RBMs decide what is and isn't appropriate, and therefore approved, is a black box," said David Lee, lead author of the study. "They're not transparent."

To account for the lack of data, the researchers created a model of a "standard" RBM using existing literature and the experiences of one of the co-author's large academic institutions. Based on the model, roughly $160 million in costs are shifted to providers each year.

As an alternative, the researchers suggest clinical decision support tools, which are in-house computer programs that rate the appropriateness of a physician's decision on a scale of 0 to 9. Decision support tools have been successfully implemented in Minnesota. Pilot programs have shown that decision support tools reduce utilization of imaging services while improving workflow efficiency and quality of care for the patients.

Decision support, according to Lee, eliminates many of the issues such as the inherent bias that RBMs may have to deny claims, and the delay associated with requiring authorization from an RBM.

Dr. Christopher Ullrich, chair of the Utilization Management Committee at the American College of Radiology, believes that the health care system requires scrutiny to ensure its efficiency. "We have to ask, at what point does the program cost more than the savings? And the problem is, we don't know for sure," said Ullrich. "This model provides us a framework to get an idea."

The study is the first of its kind, and it comes at a time when Medicare is considering RBMs as a way to save costs. If a recent recommendation for pre-authorization for high-use referrers were adopted, it would be the first time that Medicare requires pre-authorization for a service.

But congressional proceedings are misconstrued, Lee points out. "There are very few studies that talk about an RBM's ability to actually reduce utilization of imaging," said Lee, who is also head of health economics and reimbursement at GE Healthcare. "Policy makers should understand the full implications of RBMs before they implement it."

In the current medical economy, Ullrich agrees that a macroeconomic perspective is essential. "There's a big picture here," said Ullrich. "We need to look at the macroeconomic framework -- when does it cost more, and when does it produce real tangible savings?"

According to Lee, his framework is not perfect. The researchers were unable to gather much of the necessary data, due in large part to RBMs' unwillingness to share information. The model is also based on assumptions that may not apply to all RBMs since each RBM varies in its policies and procedures.

But despite its limitations, Lee says the model is a crucial first step in understanding the full impact of third-party decision makers like RBMs in the health care system. "We live in this world of evidence-based medicine," said Lee. "But there is still interest in adopting an idea that we know so little about."