Insurer-Driven Steering of Imaging Site-of-Care: Implications for Major Stakeholders

Insurer-Driven Steering of
   Imaging Site-of-Care:
  Implications for Major
      Stakeholders

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       Authors and Disclosures
• Mohsin Mukhtar, BS, BA
  – The author has nothing to disclose
• Kalen Riley, MD
  – The author has nothing to disclose

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                   Purpose
• Insurers are driving a movement to reduce
  healthcare costs by steering patients to access
  care at locations less expensive than hospitals
• In particular, Anthem’s new imaging site-of-
  care policy has ramifications that extend
  beyond patients and their providers
• Who are the major stakeholders and how will
  they be affected by such policies?

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        Materials and Methods
• A review of all relevant literature, policy
  language and press releases was performed
  to:
  – Identify the major stakeholders
  – Assess the implications of insurer-driven imaging
    site-of-care on identified major stakeholders

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                     Results
• Five major stakeholders are identified:
  – Hospital systems
  – Standalone imaging facilities
  – Patients
  – Academic community
  – Field of radiology

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                     Results
• Hospital systems
  – Lost revenue from a traditionally profitable service
  – Disrupted patient care requiring reorganization of
    patient referral system
  – Increased risk of erroneous clinical decision-
    making as access to comparison studies and non-
    imaging electronic medical records is potentially
    compromised
  – Risk to maintenance of standard imaging services

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                     Results
• Standalone imaging facilities
  – Increased patient load
  – Uncertain capability to immediately handle influx
    of patients and potential complications during
    advanced imaging
  – Increased revenue, profitability and leverage
    power in the marketplace

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                      Results
• Patients
  – Increased wait times and delayed access to care
  – More fragmented and insurer-driven care
    straining the patient-physician relationship
  – Inner city and rural residents hit particularly hard
    given limited options
  – Enrollees in low-deductible health plans forced to
    fulfill imaging needs at sites other than hospitals

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                     Results
• Academic community
  – Lost teaching opportunities for academic
    radiologists
  – Lost learning opportunities for fellows, residents
    and medical students
  – Lost opportunity to train the next generation of
    radiologic professionals

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                       Results
• Field of radiology
  – Pitting of hospital-based and standalone
    radiologists against each other
  – Fueling of a hostile culture within the profession
  – Distracting from the larger mission of being in
    service to patients
  – Setting of a dangerous precedent

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                  Discussion
• Cost disparities for imaging services exist
  – Per 2017 analysis published by Healthcare
    Financial Management Association, average prices
    for MRI and CT scans are 70-149% higher at
    hospitals vs standalone imaging facilities
• But cost alone does not capture the diversity
  of missions of these two sites of care
  – Mission-blind approach to cutting costs is myopic

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                 Discussion
• Insurers have fiduciary responsibility to
  minimize costs and maximize profits
• This responsibility to cut healthcare costs is
  shared by everyone else – hospitals, patients,
  academic community, etc.
• These parties should be equally involved in
  the discussion to seek creative and mission-
  minded approaches to cost-cutting

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                  Conclusion
• Insurer-driven steering of imaging site-of-care
  has obvious deleterious consequences for four
  of five major stakeholders
  – Standalone imaging facilities alone face a clear
    and optimistic future while hospital systems,
    patients, the academic community and the field of
    radiology all face less certain futures
• All stakeholders have a critical role to play in
  shaping future policy decisions

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                                           References
•   American College of Radiology. New Anthem imaging coverage policy will harm patient access to imaging care. Available at:
    https://www.acr.org/Media-Center/ACR-News-Releases/2017/New-Anthem-Imaging-Coverage-Policy. Accessed January 27,
    2018.
•   American Medical Association. Letter to Anthem on Imaging Policy. Available at: https://www.acr.org/-
    /media/ACR/NOINDEX/Advocacy/Anthem/AMA-Letter-to-Anthem-on-Imaging-Policy.pdf. Accessed January 27, 2018.
•   Andrews, Michelle. Need An MRI? Anthem directs most outpatients to independent centers. Kaiser Health News. Available
    at: https://khn.org/news/need-an-mri-anthem-directs-most-outpatients-to-independent-centers/. Accessed January 27,
    2018.
•   Anthem. Imaging program expands to include level of care reviews. Available at:
    https://www11.anthem.com/provider/in/f4/s0/t0/pw_g303738.pdf. Accessed January 27, 2018.
•   Anthem. Level of Care: Advanced Radiologic Imaging. Available at:
    https://www.anthem.com/medicalpolicies/guidelines/gl_pw_c191757.htm. Accessed January 27, 2018.
•   Cleverley, Jamie. Identifying the Gap Between Hospital and Free-Standing Prices. Healthcare Financial Management
    Association. Available at: http://www.hfma.org/Content.aspx?id=52656&pagesid=1. Accessed January 27, 2018.
•   Joint Medical and Patient Groups. Letter to Anthem on Imaging Policy. Available at: https://www.acr.org/-
    /media/ACR/Files/Advocacy/Managed-Care/Group-Letter-to-Anthem-FINAL-11618.pdf. Accessed January 27, 2018.
•   Livingston, Shelby. Anthem's new outpatient imaging policy likely to hit hospitals' bottom line. Modern Healthcare. Available
    at: http://www.modernhealthcare.com/article/20170826/NEWS/170829906. Accessed January 27, 2018.
•   Society of Pediatric Radiology. Letter to Anthem on Imaging Policy. Available at: https://www.acr.org/-
    /media/ACR/Files/Advocacy/Managed-Care/SPR-Letter-to-Anthem-Nov-17-2017.pdf. Accessed January 27, 2018.

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           Thanks for Reading!!
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                @momukhtar   @KRileyMD
• Email:
  – mohsmukh@iupui.edu
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