Unmanaged Abuses in Advanced Imaging: MR, CT, PET, Cardiac

1. Unmanaged Abuses in Advanced Imaging:MR, CT, PET, Cardiac NAMPI August 28, 2007 MedSolutions manages radiology for multiple payors, covering over 25 million people across the country, with about 3.5 million of those in Medicaid. MedSolutions manages radiology for multiple payors, covering over 25 million people across the country, with about 3.5 million of those in Medicaid.

2. 2 Why focus on Radiology The number of Imaging procedures grew 40% nationally from 2000 – 20051 Projected to grow another 26% by 20081 “Radiology costs have quietly risen to be 10 percent of the healthcare dollar and are growing at a rate of 18-20% a year,” according to the HealthLeaders-Interstudy. Cost of high tech scans is growing faster than pharmacy2

3. 3 Waste is Expensive $26 billion in imaging is contributed by duplicative studies (Health Affairs 1/05) Medicaid usage trend growing at 20-25% Overall, 30-40% of all high tech imaging is inappropriate

4. 4 Expanding Capacity There are now more MRI scanners in the Pittsburgh area than in all of Canada.

5. 5 Fraud & Abuse in Radiology Little to no oversight or regulation for the provision of imaging services on federal or state levels Improper billing practices in imaging Misrepresenting or overcharging with respect to services delivered Outpatient imaging centers and medical office settings open to abusive practices if not monitored assiduously Result = Unnecessary costs for the program Office of the Inspector General making plans to begin reviewing fraudulent practices related to imaging3 Looking to identify systemic weaknesses giving rise to fraud, waste, and abuse

6. 6 Factors Contributing to Waste Patient Demand. Many procedures are ordered because the patient requests it, not because it will contribute to their care or diagnosis.5

7. 7 Factors Contributing to Waste Physician Uncertainty. Medical liability concerns drive defensive medicine. Repetitive or Duplicative studies ordered Patients don’t share information on previous tests; MD’s don’t ask the right questions Lack of knowledge regarding appropriate study More and more, Imaging is being used in place of physical exam Tendencies toward aggressive surveillance of incurable diseases

8. 8 Factors Contributing to Waste Fraudulent Claim practices Upcoding, unbundling Recognized, rampant issue in rapidly evolving cardiovascular imaging sector where new technologies such as CT Angiography have spurred creative new billing practices Providers frequently bill the same procedure many different ways for different payors, sliding under specific coverage policies and rules. Lack of defined coverage policies by CMS on new imaging allows discrepancies to develop

9. 9 Factors Contributing to Waste Screening studies. Multiple studies and repeat studies represent high costs that can be eliminated. False positives drive additional testing MA General Hospital study: Whole-body CT scans 90.8% asymptomatic patients had at least one positive finding Only 2% actually had disease8 Large MCO studies 1,087 subjects in a cancer screening trial; 43% had at least one false-positive screening result. 83% received expensive follow-up care.9 Less precise ordering. First test fails to arrive at accurate diagnosis Repeat testing ordered

10. 10 Factors Contributing to Waste New Technologies. MD’s not trained specifically in how to order high tech imaging. Technology developed since they graduate medical school, with little to no training for most. 3D Software reconstruction as an enhancement for CT or MRI Unnecessary to provision of care in most cases

11. 11 Self-Referral Abuse No training required to purchase equipment; No mandatory certification process Non radiologists performing their own imaging at least 1.7-7.7 times as likely to order imaging than non-self referring physicians in the same specialty who see patients with the same problems.10 "Imaging increased up to 54% when a patient was sent to a facility in which a physician had a financial interest.” – ACR Study Patient Quality Issue "Deficiencies, such as image quality or patient safety are up to 10 times as common among non-radiologists as among radiologists.“11 Clear incentive for physicians to perform imaging studies when the practice will financially benefit from the study being performed. In-office imaging continues to grow as physician groups look to expand sources of practice revenue. Equipment manufacturers coach providers on how to maximize revenue potential of new scanning equipment. 2nd hand equipment is also available, along with leased purchase agreements between free-standing imaging centers and physician groups. Clear incentive for physicians to perform imaging studies when the practice will financially benefit from the study being performed. In-office imaging continues to grow as physician groups look to expand sources of practice revenue. Equipment manufacturers coach providers on how to maximize revenue potential of new scanning equipment. 2nd hand equipment is also available, along with leased purchase agreements between free-standing imaging centers and physician groups.

12. 12 Taking Advantage of Technology Areas to watch for significant waste potential: 3D Software reconstruction as an enhancement for CT or MRI Unnecessary to provision of care in most cases Color Doppler, enhanced form of Doppler echocardiography, uses colors to designate direction of blood flow. Carries its own CPT code and charge Common knowledge that this add-on is used whether or not there is any indication to observe blood flow for the patient. Submitting bill for Contrast materials, and simply neglecting to provide the service

13. 13 Seeking Solutions

14. 14 Time to Ask Questions Educate patients to become actively engaged in process Patients should ask their doctor basic questions when high tech imaging is prescribed: Why do I need this test? What are the risks and side effects? How much will it cost? Is there a less costly alternative? Where should I have the test? How soon do I need it? Why do I need this test? When a test is recommended, it is important to know what added information it will provide. How will the scan help make a diagnosis and how will results of the scan affect your treatment. MRI (Magnetic Resonance Imaging), CT (Computerized Tomography) and PET (Positron Emission Tomography) are excellent tools in diagnosing and treating illness, but they should not replace a physical exam. Physician’s training and experience are often all that are needed to take care of the majority of health problems, without the need for expensive scans. What are the risks and side effects? A. Exposure to energy source. Producing medical images involves an energy source that transmits pictures to film or computer. Radiation exposure (in CT studies), magnetic fields (in MRIs) and nuclear sources (in PET) must be considered: MRI. Done with a magnetic field and is considered safe for most patients. In general, it should not be done if someone has a pacemaker or an automatic defibrillator, has had recent surgery with metallic articles put into place, has known metal fragments in the eyes or tattoos that contain metallic dyes. CT. Done with ionizing radiation at higher levels than plain x-rays and is relatively safe if used when needed. Medical experts differ about how much radiation exposure leads to problems. This test should be avoided in pregnancy unless no other imaging would provide the needed information. PET. Done with a nuclear source and is considered safe for most patients. There is also a newer machine called a PET/CT scan that adds some radiation. B. Allergic reactions. All of these scans might call for contrast, a sterile dye-like substance usually injected into a vein. In rare cases, contrast can cause allergic reactions that require immediate medical attention. Be sure to let your doctor know prior to your test if you have ever had such a reaction, or if you have history of diabetes or kidney problems. C. Other testing. Advanced imaging techniques frequently expose abnormalities that are not necessarily a health problem. However, your physician is obligated to do further testing to ensure there is not a problem. For example, while viewing a CT for someone with stomach pain, the radiologist sees something in liver or in the gland above the kidney that would never have caused a problem, but now the doctor has to do follow up studies to make sure. This causes inconvenience and extra tests – sometimes even a biopsy – and increases the cost of health care. How much will it cost? Is there a more cost effective alternative? The price of imaging studies varies, but CT is generally less expensive than MRI, which is less expensive than PET. There are many cases where less expensive imaging studies, such as an x-ray or ultrasound study, may provide the information your physician needs. Often, waiting for the results of blood tests or other tests such as biopsies will offset the need for imaging. Ultimately, it is a decision that should be discussed completely with the doctor. Where should I have the tests? Just as quality may vary at different stores, quality at medical imaging facilities also varies. Centers may differ in the age of their equipment and quality of the images. Target points of interest/concern may include: Are the technicians and technologists certified/licensed? Are the films read by board certified radiologists? Is the equipment up to date? Are proper safety measures in place for radiation and magnetic fields? Are you treated courteously and with consideration? Is it convenient? Ask the doctor if the recommended imaging center provides quality results. 5. How soon do I need it? Most advanced imaging studies do not have to be performed immediately. Consideration should be given to how long a health problem or condition has been present and whether it is improving or not. Take MRI of the lower back for sciatica, as an example. Most orthopedists and physicians who treat this problem agree that, unless there are complications, this problem should be treated for six to eight weeks before considering an MRI. Of course, if the imaging is needed urgently, your physician will send you to the appropriate setting at the right time.Why do I need this test? When a test is recommended, it is important to know what added information it will provide. How will the scan help make a diagnosis and how will results of the scan affect your treatment. MRI (Magnetic Resonance Imaging), CT (Computerized Tomography) and PET (Positron Emission Tomography) are excellent tools in diagnosing and treating illness, but they should not replace a physical exam. Physician’s training and experience are often all that are needed to take care of the majority of health problems, without the need for expensive scans. What are the risks and side effects? A. Exposure to energy source. Producing medical images involves an energy source that transmits pictures to film or computer. Radiation exposure (in CT studies), magnetic fields (in MRIs) and nuclear sources (in PET) must be considered: MRI. Done with a magnetic field and is considered safe for most patients. In general, it should not be done if someone has a pacemaker or an automatic defibrillator, has had recent surgery with metallic articles put into place, has known metal fragments in the eyes or tattoos that contain metallic dyes. CT. Done with ionizing radiation at higher levels than plain x-rays and is relatively safe if used when needed. Medical experts differ about how much radiation exposure leads to problems. This test should be avoided in pregnancy unless no other imaging would provide the needed information. PET. Done with a nuclear source and is considered safe for most patients. There is also a newer machine called a PET/CT scan that adds some radiation. B. Allergic reactions. All of these scans might call for contrast, a sterile dye-like substance usually injected into a vein. In rare cases, contrast can cause allergic reactions that require immediate medical attention. Be sure to let your doctor know prior to your test if you have ever had such a reaction, or if you have history of diabetes or kidney problems. C. Other testing. Advanced imaging techniques frequently expose abnormalities that are not necessarily a health problem. However, your physician is obligated to do further testing to ensure there is not a problem. For example, while viewing a CT for someone with stomach pain, the radiologist sees something in liver or in the gland above the kidney that would never have caused a problem, but now the doctor has to do follow up studies to make sure. This causes inconvenience and extra tests – sometimes even a biopsy – and increases the cost of health care. How much will it cost? Is there a more cost effective alternative? The price of imaging studies varies, but CT is generally less expensive than MRI, which is less expensive than PET. There are many cases where less expensive imaging studies, such as an x-ray or ultrasound study, may provide the information your physician needs. Often, waiting for the results of blood tests or other tests such as biopsies will offset the need for imaging. Ultimately, it is a decision that should be discussed completely with the doctor. Where should I have the tests? Just as quality may vary at different stores, quality at medical imaging facilities also varies. Centers may differ in the age of their equipment and quality of the images. Target points of interest/concern may include: Are the technicians and technologists certified/licensed? Are the films read by board certified radiologists? Is the equipment up to date? Are proper safety measures in place for radiation and magnetic fields? Are you treated courteously and with consideration? Is it convenient? Ask the doctor if the recommended imaging center provides quality results. 5. How soon do I need it? Most advanced imaging studies do not have to be performed immediately. Consideration should be given to how long a health problem or condition has been present and whether it is improving or not. Take MRI of the lower back for sciatica, as an example. Most orthopedists and physicians who treat this problem agree that, unless there are complications, this problem should be treated for six to eight weeks before considering an MRI. Of course, if the imaging is needed urgently, your physician will send you to the appropriate setting at the right time.

15. 15 Management Options Utilization Management (outpatient, elective) Prior Authorization or Notification with Education Evidence-based Medicine; “Best-practices” Interactive, Educational process Reflect “diagnostic thinking”, with focus on patient outcomes Key: Ensure tests are medically necessary, contribute to patient care Most effective: approve to the CPT level; match authorizations to claims

16. 16 Management Options Managing the Network Privileging and Assessment Assess technical and service quality of imaging providers Staff training, certifications Equipment maintenance, calibration Raises quality of imaging network through education Delivers savings by concentrating patients with those facilities most qualified to perform images, potentially eliminating serious patient safety issues.

17. 17 Strong ROI from Radiology Management

18. 18 Sample Reports

19. 19 Sample Reports

20. 20 Sample Reports

21. 21 MedSolutions Program Value In 2006, our average commercial radiology management customer saved $2.00 per member per month In 2006, we implemented a large Medicaid plan for CT and MR only Saved $48.8 Million first year Per member per month cost found to be 55% less than anticipated ($3.39) Savings methodology validated by Milliman actuarial analysis

22. 22 What to look for in Radiology Manager Experience MedSolutions manages 25+ Million Members overall Program in all 50 States for Commercial 3.5+ Million total Medicaid Members Quality Certifications NCQA URAC JD Power Call Center Robust, Evidence-based Guidelines Average client impact rate 15 – 22%

23. 23 Questions?

24. 24 References Booz Allen Hamilton. Medical technology cost management strategy. Chicago: BlueCross BlueShield Association; 2003. Rundle, R. PET Scanners Become New Rx for Diagnostics. Wall Street Journal, May 2003. Department of Health and Human Services, Office of the Inspector General, Fiscal Year 2007 Work Plan Stein, Charles, “Code Red Partners Program Aims to Rein in Skyrocketing Costs of Diagnostic Imaging”; Boston Globe, June 27, 2003. Wilson IB, Dukes K, Greenfield S, Kaplan S, Hillman BJ; “The patient’s role in the use of radiological testing for common office complaints.” Arch Int Med 2001; 161:256-63 Strasser, RP, Bass MJ, Brennan M. The effect of an on-site radiology facility on radiologic utilization in family practice. J Fam Practice 1987; 24:619-23. Pennsylvania Healthcare Cost Containment Council, “The Growth in Diagnostic Imaging Utilization,”; 2005. Radiology 2005; 234: 415-422 Cancer Epidemiol Biomarkers Prev. 2004; 13: 2126-2132 Kouri BE, Parsons RG, Alpert HR. Physician self-referral for diagnostic imaging: review of the empiric literature. AJR Am J Roentgenol. 2002;179:843-850. Verrilli MS, Bloch SM, Rousseau M, Crozier MM, Yecies SB. Design of a privileging program for diagnostic imaging: costs and implications for a larger insurer in Massachusetts. Radiology. 1998;208:385-392.