A success story in advocating for better radiology insurance coverage

December 06, 2021
by John W. Mitchell, Senior Correspondent
When Anthem Insurance issued a new policy in 2017 determining where its members could get radiology services, a consortium of medical groups took exception to the fine print. Anthem instructed that all of its adult members would need to seek services at lower-cost outpatient centers — the only problem was that the company defined adults as any patient ten years or older.

Other insurers soon followed suit. The redirection of patients to lower charging outpatient providers is a common action by insurance companies known as steerage. The policy set up a four-year advocacy fight that ended in August when the last of three insurers reversed the policy, moving the adult age to 18.

For Dr. Richard Elliott Heller III, pediatric radiologist associated with the University of Chicago Medical Center’s Comer Children’s Hospital, the work to reverse the policy came down to two strategies: persistence and forming a coalition of medical organizations too big to be ignored and too big to fail. He presented his experience as part of an RSNA 2021 session titled “Health Policy Agenda: Are Radiologists at the Table?”

"They would have sent (my ten-year-old) to (an outpatient center) regardless of if the imaging center has pediatric neuroradiologists," said Heller.

In making the decision, Anthem cited research that demonstrated the safety of providing services in free-standing centers. Anthem, Heller said, cited access to quality while reducing costs when a member's health was not put at risk. But Heller suspected the primary motivation was financial and not about quality — and he said he had good reason to think that.

“This [was] economically motivated patient steerage, sending patients to imaging centers without reason,” he said. “There’s a consistent theme — it's a lot cheaper … to go to the imaging centers than to get your imaging done at a hospital outpatient department.”

The research Anthem cited in justifying the change included a 2016 study titled "Guidelines for Diagnostic Imaging During Pregnancy and Lactation." Heller said that the study obviously had no association with pediatric standards of care. To get organized and confront the policy, he and colleagues took the following steps:

– Defined the issue: The Anthem policy broke the first rule of pediatric care — children are not little adults. Heller said the group worked to convey the value of pediatric radiologists, noting that it’s not that other radiologists are not competent. But pediatric radiologists (and technologists) are trained in children’s pathology and have insight into what’s normal and abnormal and what variance is acceptable. Also, pediatric imaging deploys protocols to minimize dose exposure.

– Found friends: They got other medical groups on board with their push-back. In addition to the Society for Pediatric Radiology, the consortium also included The American Academy of Pediatrics, The American Hospital Association, The American Medical Association, the American College of Emergency Physicians, and the American College of Radiology.

– Built a campaign: These groups began a four-year campaign of letter writing, media appearances, and generally trying to raise awareness about how misguided the policy was. Two other insurance companies — United Healthcare and Cigna — also adopted the Anthem policy during their advocacy campaign. But eventually, Cigna (2020) and United Healthcare (2021) rescinded their decision and returned the adult age to 18.

Anthem resisted until August of this year, when it posted a new policy on its website, excluding pediatrics through 18 years of age. Heller said in making the announcement, Anthem listed back the talking points the consortium has been making. Among Anthem’s new reasoning:

– Children can require specialized pediatric equipment.
– Children are more radiosensitive than adults.
– Average doses are lower in pediatric facilities compared to general care facilities.

Aetna, another large insurance company, had been silent on the issue. But this year, they also announced a policy of steerage to outpatient providers, but excluded children and teens under the age of 18.

“(Aetna) was a battle that we won that we never had to fight. If you’re passionate about an issue, speak up. Be the squeaky wheel. This issue was taken care of because physicians stood up,” Heller concluded.