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AMIC says little evidence for prior authorization savings

by Brendon Nafziger, DOTmed News Associate Editor | October 18, 2011
From the November 2011 issue of HealthCare Business News magazine

The imaging community has come down hard on prior authorization, a program popular with some insurers that requires referring doctors to get permission from a third-party, called a radiology benefits manager, before ordering an imaging test. Still, certain groups -- such as MedPAC, which advises Congress on how to run Medicare -- have come out in support of such measures, saying they will help control inappropriate imaging and health care costs.

But a new study, run by health care policy consultant Don Moran and commissioned by a lobby of patient advocates, manufacturers and radiologists, says the evidence for savings from prior authorization is thin. And it says a budget-watching office in the federal government has probably reached the same conclusion.

"[Moran] was unable to find one single study in the peer-reviewed health economics literature to find these [methods] have merit," Tim Trysla, executive director of the Access to Medical Imaging Coalition, which paid for the study, told reporters in a press conference Tuesday.

The report, put out by the Moran Company (it has not been published in a peer-reviewed journal), trawled the literature surrounding two rival utilization-controlling strategies: prior authorization and decision-support tools. The latter, which have the backing of the American College of Radiology, an AMIC member, are computer tools that encourage doctors to use evidence-based guidelines when requesting a study.

According to the report, there's no evidence either method would generate significant savings for Medicare.

"There's nothing we can find in the literature to say that prior authorization is cost-effective," Moran said on the call.

Prior authorization programs for drugs and medical services date from the 1980s. They lost favor during a consumer backlash against managed plans in the 1990s, but then, through radiology benefits managers, have crept over to imaging over the past decade. Still, Moran said despite being in use for nearly three decades for hospital inpatients for services like surgical procedures, there were no peer-reviewed studies looking at cost-effectiveness in this area. And there was only one peer-reviewed study looking at effectiveness of prior authorization in imaging, and it used anecdotal evidence, he said.

And decision-support tools, which Moran called "promising," suffer from a similar dearth of data. Despite diffusing through the provider population and becoming increasingly relied on for appropriate imaging -- and despite some evidence suggesting they can drive down rates of inappropriate imaging -- nothing has shown the tools could produce "gigantic savings compared to where we are," Moran said.

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