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New Reports on RBMs Provide Opportunity for Education on Appropriate Use Criteria

Updated May 2, 2011

The Senate Commerce Committee and the Delaware Insurance Commission recently released their respective reports of their investigations into consumer access to diagnostic imaging tests in Delaware. Both  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, a radiology benefit manager (RBM) for health plans.  The man ultimately was admitted to the ER, where a life saving CABG was performed. 

The reports affirm what the American College of Cardiology (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 to ensure the appropriate use of tests for patients. The Delaware Insurance Commission report specifically found that the MedSolutions  volume-based contingency contract 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 appropriate use criteria (AUC) developed by the ACC and other specialty societies and resulted in unnecessary confusion and testing limits.  At the same time, the report recognized that inappropriate testing is taking place and the failure to date of clinicians to avoid such testing. 

The Delaware Insurance Commission recommends that the criteria used going forward are not more restrictive than AUC established by the ACC or other recognized professional medical specialty organizations. In addition, once the information provided in the physicians’ request meets AUC recommendations, the insurance company should promptly approve the request for nuclear cardiac imaging testing.

Next Steps: Both reports 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.

It also offers an opportunity to clarify the AUC development process, which has been erroneously cited as rife with conflict of interest by MedSolutions. The ACC takes relationships with industry and their potential impact on clinical guidelines and appropriate use criteria very seriously.  In fact, the Institute of Medicine recently cited the College as a best practice example for its processes to mitigate issues of possible industry bias in guideline development. All AUC developed to date – SPECT MPI, RNI, CCT, CMR, echocardiography and coronary revascularization – were determined by panels comprised of a wide variety of physician perspectives.  All relationships are posted for the  panels making recommendations.  In the particular case of AUC for RNI, the chair of the panel (a general cardiologist) did not have any relationships with industry, nor sees any financial benefit as a result of the AUC, contrary to assertions by Gregg Allen, MD, MedSolutions’ chief medical officer.

To date, the ACC and the ACC Delaware Chapter have sent a follow-up letter to Senate Commerce Committee Chair John Rockefeller to provide an update on their work with health plans to implement FOCUS: Cardiovascular Imaging Strategies, an ACC product that allows for transparent, AUC-based and robust point-of-care decision support developed by the College and powered by Medicalis. Unlike RBMs, FOCUS does not engage in hard denials, engages providers in ongoing feedback reports and encourages quality improvement activities. At the same time it reduces third-party costs to physicians and health plans.

The College has documented  significant improvements in appropriate use (as high as 50% reduction in inappropriate use) over the past year by more than 300 imaging labs across the country that are taking part in the ACC’s voluntary Imaging in FOCUS community. This progress directly addresses one of the shortcomings of AUC cited in the Senate report: the limited ability of the College’s initial 2007 pilot sites to improve.   The FOCUS voluntary community has collected numerous practical approaches to improving the appropriate use of testing.  The dedication of these practices to improve demonstrates what is possible when the profession is allowed the opportunity to act based on patient clinical needs rather than on utilization determinations made by for-profit, third party radiology benefit managers.

More Information: For more information on how to engage health plans or other stakeholders around these issues as well as more about ACC's Imaging in FOCUS initiative, please contact focus@acc.org or visit www.cardiosource.org/focus. You can also learn get the full reports using the following links: