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RBMs shift burden to doctors: study

by Sruthi Valluri, DOTmed News | July 11, 2011
The use of radiology benefit managers (RBMs) -- third-party decision makers that authorize the use of imaging services -- could actually increase costs to the health care system, according to a recent study.

The study, which appeared in the June issue of the Journal of the American College of Radiology, found that RBMs often increase the administrative burden on providers. Nearly 28 percent of projected RBM-related savings are shifted to providers.

RBMs use proprietary algorithms to determine the appropriateness of imaging tests such as MRIs, and CT and PET scans. The algorithms are based on guidelines suggested by the American College of Radiology. Insurance companies often hire RBMs to ensure that doctors only order advanced imaging tests when absolutely necessary.

Over 88 million Americans are covered by plans that use RBMs to manage their services. These plans include insurance giants like Aetna Inc. and Cigna Corp. Under these plans, physicians need approval for a scan before insurance will cover it.

But despite their prevalence, there have been very few attempts to examine the effectiveness of RBMs.

"The way RBMs decide what is and isn't appropriate, and therefore approved, is a black box," said David Lee, lead author of the study. "They're not transparent."

To account for the lack of data, the researchers created a model of a "standard" RBM using existing literature and the experiences of one of the co-author's large academic institutions. Based on the model, roughly $160 million in costs are shifted to providers each year.

As an alternative, the researchers suggest clinical decision support tools, which are in-house computer programs that rate the appropriateness of a physician's decision on a scale of 0 to 9. Decision support tools have been successfully implemented in Minnesota. Pilot programs have shown that decision support tools reduce utilization of imaging services while improving workflow efficiency and quality of care for the patients.

Decision support, according to Lee, eliminates many of the issues such as the inherent bias that RBMs may have to deny claims, and the delay associated with requiring authorization from an RBM.

Dr. Christopher Ullrich, chair of the Utilization Management Committee at the American College of Radiology, believes that the health care system requires scrutiny to ensure its efficiency. "We have to ask, at what point does the program cost more than the savings? And the problem is, we don't know for sure," said Ullrich. "This model provides us a framework to get an idea."

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