With profligate use of CT and MRI scans widely blamed for increased healthcare spending, a new report shows that pairing automated prior authorization with evidence-based guidelines can ensure such tests are only used when necessary, improving patient safety while reducing medical costs by perhaps 40 percent.
The recent study, published in September's Journal of Managed Care Medicine, suggests that automated prior authorization can help put a damper on overuse of such advanced imaging services.
ADVANTAGE Health Solutions, an Indianapolis-based health plan, performed the research as part of a larger study that evaluated the impact of physician engagement on accountable care. It deployed an automated authorization solution developed by Seattle-based MCG (formerly Milliman Care Guidelines), which develops clinical guidelines for the healthcare industry.
"There's good evidence that advanced imaging services such as CT, MRI, and PET scans are over utilized," said Anthony N. Akosa, MD, vice president of medical affairs and informatics at AHS, in a press statement.
"This is not just a cost issue," he added. "It's also a patient safety and care quality issue, particularly for scans emitting ionizing radiation."
The AHS study "strongly suggests that pairing automated authorization with evidence-based clinical guidelines" can make for safer and more efficient care, while "also reducing medical costs by 39 percent or more," he said.
The focus on automated prior authorization is part of larger AHS study aimed at reducing overutilization of emergency room services and expanding use of comparable generics, all within a framework of increased provider and patient engagement. Overall, the report shows such interventions bringing return on investment of eight to one.
"Physician engagement is critical to the success of any program where physicians are accountable for the quality, cost and overall care of an assigned population of patients like an accountable care organization," wrote Akosa.
"It is well known that physicians control the majority of healthcare cost," he wrote. "However, as overall healthcare cost is a factor of unit cost and utilization rate of services, physicians could impact utilization of services but still not be able to control overall healthcare cost due to lack of control of cost of hospital-based services and outpatient procedures."
Other takeaways from the AHS study:
- The level of physician engagement could directly affect the level of achievement of the triple aim.
- Physicians make decisions that control 87 percent of health care costs.
- Alignment of incentives will increase physician engagement.
- Overall cost is determined by both utilization of services and unit cost of services.
- Physicians, especially primary care docs, have very little control over the cost of hospital-based services and most outpatient procedures.
- To improve overall cost, providers should partner with hospitals to reduce both utilization and unit cost of services. Although ACOs sponsored by physician groups have seen more growth recently, the majority of ACOs are still sponsored by hospitals.
- To remain competitive in the post health care reform environment, these hospital-sponsored ACOs have to reduce overutilization of services and lower their pricing. The lost revenue from reducing unit cost and decreasing over utilization of services could be recouped from the shared savings agreements with payers.
"The AHS research indicates that, equipped with accurate information, physicians are better able to champion effective care," said Jon Shreve, chief executive officer of MCG, in a press statement. "We're pleased to work with partners such as AHS to explore new, evidence-base avenues that support accountable care."
Read the full report here (PDF).
[See also: Imaging to play bigger role in health IT]
