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Reports Find RBMs Aren't So Appropriate

ACC responds with letter to Sen. Rockefeller

The Senate Commerce Committee and the Delaware Insurance Committee launched investigations following news reports last spring about a Delaware man who was denied a cardiac stress test by MedSolutions, the radiology benefit management companies (RBM) used at the time by BlueCross BlueShield (BCBS) of Delaware. The man ultimately was admitted to the ER, where a life saving CABG was performed. As a result of subsequent discussions with the ACC DE Chapter, BCBS of DE has removed MedSolutions as a vendor for review of cardiac imaging tests. ACC National, the DE Chapter, and BCBS of DE are now working together on addressing many of the findings in the report by working toward the launch of FOCUS: Cardiovascular Imaging Strategies, an ACC RBM alternative.

Findings: The reports affirm what your ACC has been saying all along: RBMs, while providing cost-savings to payers, are burdensome, confusing, and potentially dangerous for both consumers and health care providers. Their ultimate goal is to reduce the use of advanced imaging services, not necessarily to ensure the appropriateness of tests for patients. The Delaware Insurance Commission report specifically found that the MedSolutions and BCBS of Delaware contracts volume-based contingency clause violated state insurance regulations. In addition, it found that MedSolutions denied a significant number of appropriate tests as well as engaged in substantial numbers of administrative denials based on technical not clinical omissions. The Senate report also found that MedSolutions cardiac testing guidelines conflicted with ACCs and resulted in unnecessary confusion and testing limits.

Recommendations: The Delaware Insurance Commission report recommends that the criteria used by BCBS of DE going forward are not more restrictive than appropriate use criteria (AUC) established by your ACC or other recognized professional medical specialty organizations. In addition, once the information provided in the physicians request meets AUC recommendations, the Company should promptly approve the request for nuclear cardiac imaging testing. Both these recommendations will be implemented when BCBS of DE begins using our FOCUS: Cardiovascular Imaging Strategies program in a few months.

Next Steps: Your ACC and the ACC Delaware Chapter are working to sent a follow-up letter to Senate Commerce Committee Chair John Rockefeller to provide an update on our work with BCBS to implement the new FOCUS: Cardiovascular Imaging Strategies, a product of the ACCs Imaging in FOCUS initiative. This product allows for transparent, AUC based and robust point-of-care decision support developed by ACC and powered by Medicalis. Unlike RBMs, it engages providers in ongoing feedback reports and quality improvement activities. At the same time it reduces third-party costs to physicians and health plans. Through the hard work on 300+ imaging labs across the country, ACC has been documenting significant improvements in appropriate use over the past year in ACCs voluntary FOCUS community. This significant progress will address one of the shortcomings of AUC cited in the Senate report: the limited ability of our initial 2007 pilot sites to improve. Both reports issued last week provide an opportunity for the ACC and cardiovascular professionals that provide imaging services to educate health plans and members of Congress about the benefits of AUC, as well as what the College is doing to put AUC directly in the hands of providers and ensure appropriate testing. If you are interested in finding out how to engage health plans or other stakeholders in your state around these issues as well as find out more about ACC's Imaging in FOCUS initiative, please contact focus@acc.org or visit www.cardiosource.org/focus.

More Information:

  • Senate Report
  • DE Insurance Commission Report
  • NBC Nightly News
  • Delaware News Journal
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