Sunday, August 21, 2005

The Imaging Test Pre-Certification Blues

The Philadelphia Inquirer reported on the movement towards more restrictions on imaging tests by managed care organizations. Independence Blue Cross (of Pennsylvania) has noted that their payments for "diagnostic radiology" grew by 57% from 2001 to 2003. So on October 1, the company will begin to require that physicians obtain authorization before ordering (apparently all) outpatient diagnostic imaging tests. Aetna Inc. has required pre-certification for "high-technology diagnostic imaging" in the Philadelphia area for two years. Horizon Blue Cross Blue Shield of New Jersey started requiring pre-certification on January 1.
The Inquirer noted some down-sides of pre-certification, including adding to the bureaucratic burden on physicians, and the possibility that pre-certification will lead physicians to forego tests that would actually benefit patients. One physician noted that the pre-certification requirements are overly broad, not particularly targeted on specific kinds of over-use, and appear to be meant to discourage testing across the board, "pre-certification is meant as something of a roadblock to ordering imaging."
I was particularly fascinated by an aside in the article about the amounts Blue Cross is paying for imaging tests: $500 - $700 for CT scans, $700-$900 for MRIs, and $2000 for PET scans.
We had posted here about how generously insurers and managed care organizations reimburse for diagnostic imaging tests,. This article suggests that the cost to a hospital or radiology center of doing a CT scan is now only about $102 per procedure. So at least 80% of Blue Cross reimbursement for CT scans is pure profit for the owners of CT scanners. The reimbursement rates of CT scans in Philadelphia seem to be yet another example of "Wooden-Headed Health Care Reimbursement."
If health insurers and managed care companies are so concerned about health care costs, inquiring minds want to know why they keep paying so lavishly for imaging servicies? And why oh why don't managed care organizations and insurers bargain down reimbursement rates for these procedures to something more reasonable?
This cost-cutting approach would make a lot more sense than their continuing heavy-handed efforts to heap bureaucracy on doctors to discourage them from ordering radiology procedures.

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