News | February 26, 2009

MITA Warns of RBMs' Negative Impact on Diagnostic, Therapeutic Imaging Access

February 26, 2009 - The Medical Imaging & Technology Alliance (MITA) said it supports the health policy goals presented in the President's federal budget, however, the association said that the budget's proposed reliance on radiology benefit managers (RBMs) will deny imaging services, and is an ineffective model that undermines the doctor-patient relationship in making healthcare decisions.

If the Medicare program depends on RBMs, it will lead to further reducing seniors' access to life-saving medical services. MITA said it agreed with the Department of Health and Human Services’ (HHS) critique of RBMs.

In the June 2008 Government Accountability Office (GAO) report “HHS raised several concerns about the administrative burden, as well as the advisability of prior authorization for the Medicare program. First, the agency said there was no independent data—other than self-reported—on the success of RBMs in managing imaging services. Second, it stated that RBMs’ use of potentially proprietary information, including clinical guidelines and protocols for approval of services, may be inconsistent with the public nature of Medicare. Third, the effectiveness of a prior authorization program could be diminished if a high proportion of denied services were overturned through Medicare’s statutory and regulatory appeals process. HHS also raised a question about how prior authorization would fit within its current post-payment review program.”

"We must ensure that patients have access to the right scan at the right time. The RBM model is the wrong approach and the Administration and Congress should instead build on appropriateness criteria – a successful approach that was established in last year's Medicare law, and which is used by and proven effective in many of the nation's leading health systems," said Ilyse Schuman, managing director of MITA. "Not only is medical imaging integral to best practices and medical guidelines for disease prevention, early detection, diagnosis and treatment, but research has also demonstrated that imaging technologies both improve health outcomes and reduce healthcare costs when used appropriately.

"As the Obama administration and the Congress take on the important work of healthcare reform, it is critical that they remember the tremendous amount of value that medical imaging brings to the table," Schuman added.

RBMs, which are currently not regulated, are for-profit managed care companies that some in health insurance industry use to deny imaging services to patients. Physicians who have operated under an onerous RBM model say that RBMs typically employ insurance actuaries who do not even have medical degrees to evaluate doctors' requests for images. As a result, RBMs undercut the doctor-patient decisions, lead to inefficiencies and hamper patient care.

As outlined in its healthcare reform principles, MITA is a staunch advocate for policies that make health care more accessible, enhance the quality of patient care, reduce inefficiencies and remove barriers to appropriate screenings and treatments. Most recently, MITA proposed and supported the appropriateness criteria and accreditation provisions that were included in last year's Medicare improvement law. These provisions focus on the use of evidence-based guidelines to ensure that medical imaging is utilized appropriately and effectively, without compromising patients' ability to access the right scan at the right time.

"MITA continues to identify and propose policy solutions that will reduce duplicative or unnecessary medical imaging without resorting to blunt policy instruments such as arbitrary, across-the-board cuts to Medicare reimbursements,” Schuman said. “Unfortunately, we have already seen the negative effects of ill-informed cuts on patient access in rural areas, making it all the more important to identify sustainable, win-win policies. At this juncture, making further, arbitrary cuts, before existing cuts and reforms such as appropriateness criteria and accreditation are given a chance to work, would be akin to cutting off the nose to spite the face."

According to the Government Accountability Office (GAO), the Deficit Reduction Act of 2005 (DRA) resulted in $1.64 billion in Medicare cuts for imaging services in 2007 alone, the first year cuts were implemented, which was three times larger than what Congress intended. The GAO also found that utilization of advanced imaging services has slowed significantly, which suggests that further cuts could endanger the availability of these services.

For more information: www.medicalimaging.org

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