One eye on the image and the other on the wallet

There is no question in anyone's mind that the increased use of high-tech diagnostic imaging has significantly improved the diagnosis and treatment of patients during the past decade.

"These tools can reduce unnecessary or risky procedures," says Bruce Niebylski, MD, senior associate medical director for the Health Alliance Plan (HAP) in Detroit. "That's a wonderful thing."

Many physicians, especially those trained prior to 1990, lack the necessary skill sets to know when to order (and not to order) a high-tech diagnostic imaging service. As a result, physicians order these services when they are not appropriate, driving up the cost of healthcare.

"There are various estimates out there that say as many as one-third of the high-tech imaging services ordered are fairly discretionary, meaning they are nice to have, but they don't affect clinical management," says Keith Folkert, MD, medical director of health management for Minneapolis-based Blue Cross Blue Shield (BCBS) Minnesota.

Gregg P. Allen, MD, executive vice president and chief medical officer for MedSolutions, a Franklin, Tenn.-based company that provides radiology management products to health plans, says there is a "knowledge gap" among physicians about when to order what test at what point in a patient's workup. More training, he maintains, is needed.

FASTEST GROWING SEGMENT

This knowledge gap has produced an explosion in the amount that health plans pay for these services. For example, HAP, which has more than 500,000 members in Michigan and has 25 different networks of physicians, was paying $4 per-member per-month (2% of the healthcare premium) for radiology in 1999. Today, it is paying $15 per-member per-month (6% of the healthcare premium).

These cost increases are directly attributable to the growing utilization of high-tech imaging services.

"Earlier in [the] decade, pharmaceuticals was the leading area in which we were seeing tremendous cost growth," Weinstein says. "Imaging doesn't represent the highest proportion of every dollar of healthcare, but it is an area that represents one of the fastest-growing segments, especially in the outpatient side."

Recognizing that the costs of high-tech imaging services have to be brought under control, health plans have taken the lead by establishing clinical guidelines for their use-and making sure their providers know what those guidelines are. Some are teaming with radiology management companies to implement educational and prior authorization programs.

These programs are not being implemented solely to cut costs. Health plan executives say they are willing to spend the money on high-tech imaging, they just want to make sure that the money is being spent appropriately.

"We want to be sure that the right studies are being done for the right patients," Dr. Niebylski says. "We don't want redundant care or wrong care."