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Silver Lining for Radiology in Recent Medicare Reimbursement Policy | Diagnostic Imaging

Canadian policy to improve MRI referrals has mixed results

Canadian policy to improve MRI referrals has mixed results

By Wayne Forrest, staff writer

August 7, 2014After policy changes were implemented, including the distribution of appropriateness guidelines and the creation of an online clinical decision-support tool for referring physicians, the number of inappropriate lumbar MRI referrals dropped from 48% to 37%.

However, there was no significant difference in the number of new lumbar MRI referrals before (246 per month) and after (233 per month) the policy went into effect (JACR, August 2014, Vol. 11:8, pp. 802-807).

More studies are needed to clarify the effects of the campaign, and other interventions will most likely be required to fully improve appropriateness of the exams, according to lead author and medical student Sean A. Kennedy, from McMaster University, and colleagues.

“We hope that the results of this study specifically highlight the role radiologists can play in improving the appropriateness of imaging referrals,” they wrote. “Working as an integrated unit with referring physicians, radiologists should serve as the gatekeepers to medical imaging resources.”

History of overutilization

The overuse of MRI to diagnose back problems is not a new concern. Previous studies have linked inappropriate referrals with a lack of knowledge, as well as patient demand and the practice of defensive medicine, the authors wrote.

Kennedy and colleagues did note that Canada fares better than most developed countries in the use of MRI per capita. One study found that in 2011 and 2012, 49 MRI scans per 1,000 people were performed in Canada; by comparison, the U.S. rate was 98 MRI exams per 1,000 and Germany’s rate was 95 MRI scans per 1,000.

Still, “lumbar MRI studies for low back pain are a heavy burden on the Canadian healthcare system,” they wrote.

In May 2012, the Ontario Ministry of Health launched its campaign intended to curb overutilization of lumbar MRI, with efforts such as changing the wording of billing codes, distributing appropriateness guidelines to physicians, and developing a decision-support tool, according to the researchers. Their retrospective analysis reviewed lumbar MRI referral forms from before and after the campaign.

A total of 600 lumbar MRI referrals — 300 before and 300 after the policy changes — were randomly selected for the study. The number of new referrals during three-month periods before and after policy implementation was also counted.

The prepolicy-change group included patients referred from January 1, 2012, through March 31, 2012. This cohort contained 151 women (53%) and 133 men (47%), who had a mean age of 52.3 years (± 16.4 years).

After the policy changes went into effect, Kennedy and colleagues paused data collection for a three-month grace period, beginning May 2012. “We felt that this was appropriate given that the wait time from referral to lumbar MRI at our center is < 69 days for nine in 10 patients,” they wrote.

For the postpolicy-change period, the researchers selected three months between August 1, 2012, and September 30, 2013. This group included 163 women (55%) and 131 men (45%), who had a mean age of 53.7 years (± 18.4 years).

Exam appropriateness

To assess the referrals, the researchers used American College of Radiology (ACR) Appropriateness Criteria for low back pain imaging. The criteria include six clinical factors for lumbar MRI referrals and a rating from 1 to 9 — the higher the score, the more appropriate the referral.

Before the policy changes went into effect, 50.4% of the referrals were appropriate, compared with 62.6% after the changes, Kennedy and colleagues found. Prior to the initiative, inappropriate referrals were 47.9%, compared with 37.1% after the changes.

Appropriateness of lumbar MRI referrals
Before policy changes After policy changes
Not appropriate 47.9% 37.1%
May be appropriate 1.8% 0.3%
Appropriate 50.4% 62.6%

The mean appropriateness score increased significantly after the policy changes, shifting from 5.08 to 5.79 (p = 0.004).

There was no significant difference, however, in the number of new lumbar MRI referrals before (246 ± 20.1 per month) and after (232.7 ± 38.3 per month) the policy changes (p > 0.05).

The somewhat contradictory results of improved appropriateness but the same level of new referrals led the authors “to question whether the appropriateness increase is in fact genuine,” they wrote.

“We could speculate that referring physicians may be using certain key words (e.g., references to a ‘chronic’ timeline of pain symptoms) to artificially increase the appropriateness of their referrals,” they added.

Overall, the results are comparable to existing published data, which show that 28% to 100% of lumbar MRI studies for low back pain in the U.S. are “inappropriate or medically unnecessary,” Kennedy and colleagues noted.

Radiologists’ role

“Investing in evidence-based infrastructure such as mandated point-of-care decision-support referral forms will likely improve the appropriateness of imaging in Canada without sacrificing high-quality patient care,” they concluded. “Designing these point-of-care decision supports should involve radiologists who can use their expertise to rigidly implement best-practice guidelines.”

The authors also credited radiologists as the most likely to be informed about appropriateness criteria; therefore, radiologists are “in the best position to make decisions on whether tests should or should not be performed.”

They cited several limitations of the study, including the lack of a validated method to evaluate referrals, as well as a lack of referrals for surgical planning.

Copyright © 2014

Last Updated np 8/6/2014 5:30:40 PM

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Adventures in ‘Prior Authorization’ –


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“DEAR Doctor,” the letter from the insurance company began. “We are writing to inform you that a prior authorization is required for the medication you prescribed.”

That’s usually where I stop reading. Thousands of these letters arrive daily in doctors’ offices across the country. They are attempts by insurance companies to prod doctors away from more expensive treatments and toward less expensive alternatives. To use the pricier option, you need to provide a compelling clinical reason.

In theory, this is a reasonable way to control costs by making it harder to prescribe costlier medications. In practice, it is a wasteful administrative nightmare, a cavalcade of recurring paperwork, lengthy phone calls and bureaucratic battles.

One study estimated that on average, prior authorization requests consumed about 20 hours a week per medical practice: one hour of the doctor’s time, nearly six hours of clerical time, plus 13 hours of nurses’ time. Other studies have suggested that prior authorizations could cost individual practices tens of thousands of dollars a year.

The letter in my hand concerned one of my patients, Mr. V., who suffers from stubborn hypertension. His chart is a veritable tome, documenting the years of effort it took to find the combination of four different blood-pressure medications that controls his hypertension without upsetting his diabetes, kidney disease and valvular heart disease or making his life miserable from side effects. We’ve been on stable ground for a few years now, a state neither of us takes for granted.

But Mr. V. had changed insurance companies, and now one of his medications required a prior authorization. The last thing I wanted was for him to be turned away at his pharmacy and have his blood pressure spiral out of control, so I called right away to sort things out.

Twenty minutes of phone tree later, I discovered that the problem was that I had exceeded a pill limit for one of his medications. Mr. V. needed to take 90 of those pills each month for the high dosage that his blood pressure required. I patiently explained this to the customer-care representative.

Equally patiently, she told me that 45 pills a month was the maximum allowed for this particular medication.

Three more phone trees and three more customer-care representatives later, my patience was flagging. Apparently a request for 90 pills was flummoxing the system. Representative No. 4 asked me to list all the blood-pressure medications that Mr. V. had been on in the past, including dates of initiation and relevant lab values, a request of epic proportions in his case.

The representative went down her checklist. “Would taking 45 pills per month instead of 90 pills adversely affect Mr. V.’s health?” she asked.

At first I thought she was joking. “Well,” I replied, “it would probably make his blood pressure shoot up in the second half of the month.”

She paused, then asked her next question with the encouraging uplift of suggestion. “Has Mr. V. ever tried 45 pills per month instead of 90 pills?”

Then I realized that she was not joking. “Are you out of your mind?” I hollered into the phone. “It’s taken years — years! — to find the right combination of meds to control his blood pressure without killing his kidneys or making him dizzy or nauseated or depressed or ruining his libido or running his potassium off the charts or breaking his bank account. Do you really think I’m going to randomly jiggle the dosages just for the hell of it?”

“A simple yes or no will suffice, doctor.”

Prior authorization clearly saves money for the insurance companies, at least up front. Many physicians simply give in, because the process is just too arduous.

But prior authorization ultimately ends up costing the health care system. The time and money that medical practices devote to prior authorizations could surely be put to better use for patient care. And it’s not even clear that insurance companies save money in the long run. One study examined the records of more than 4,000 patients with Type 2 diabetes who were prescribed medications requiring prior authorizations. Those who were denied the medications had higher overall medical costs during the following year; not getting the medications probably worsened their conditions.


I bit my tongue for the remainder of my conversation with the insurance company, holding back long enough to obtain the prior authorization that would allow Mr. V. the 90 pills he needed each month. I tried not to break the phone when I finally slammed down the receiver.

I’m all for controlling medical costs and trying to apply rational rules to our use of expensive medications and procedures. But in the current system, everything seems to be in service of the corporate side of medicine, not the patient. The clinical rationale and the actual patient — not to mention the doctors and nurses involved in the care — are at best secondary concerns.

In the end, we were able to keep Mr. V.’s blood pressure under control. My blood pressure, however, was a different story.