Delaware is the battleground for a fight over whether health insurers’ cardiology imaging utilization management methods are too loose, too strict or just right.
Investigators on the staff of the Senate Commerce Committee have found evidence that health carriers in Delaware have used a burdensome, confusing pre-authorization process for tests such as “nuclear stress tests” and seem to have paid independent “radiation benefits management” companies based on successful efforts to reduce utilization of the tests.
Commerce Committee staffers looked into the matter after the Delaware News-Journal reported in the spring of 2010 on a local man who believed he may have been close to dying because a radiation benefits management company had refused to authorize a nuclear stress test for him.
In Delaware, the Medicare rates are about $95 for a basic stress test and about $590 for a nuclear stress test.
Nulcear stress tests have an accuracy rate of about 90%, compared with about 70% for basic stress tests, staffers found.
But the investigators also found that about 10% of the nuclear stress tests that cardiologists ordered did not seem to be necessary according to clinical use criteria established by the American College of Cardiology, and even many doctors question whether common use of nuclear stress tests does much to improve the overall quality of care, committee staffers said.
Medicare has responded to the cost of the nuclear stress tests by reducing reimbursement rates, rather than taking active steps to reduce use of the tests, the staffers said.
“Too many Americans who need life-saving tests don’t get them,” Sen. John Rockefeller IV, D-W.Va., chairman of the Senate Commerce Committee, says in a statement about the staff study. “That’s
because health insurance companies employ third-party companies to deny tests that are costly and would hurt their bottom line. This practice is putting profits over people–and putting lives at risk. But some doctors are also part of the problem. Our investigation concluded that doctors, judged using their own standards, are clearly still ordering tests when their patients don’t need them.”
One company mentioned in the report, Blue Cross Blue Shield of Delaware, Wilmington, Del., has put out a statement saying the health and safety of its members is vitally important to the company.
“We implemented our high-tech imaging pre-authorization program to ensure our members have timely access to high-quality, safe and appropriate medical care, while minimizing the potential for duplicative and unnecessary tests,” the company says.
When Delaware Blue learned about officials’ concerns about how it was compensating an imaging services review company, it suspended denials of pre-authorization requests for imaging services and conducted an internal review, the company says.
The company says it responded to the results of the review by taking steps such as eliminating pre-authorization requirements for nuclear cardiac stress tests.
“As part of our ongoing efforts to enhance and refine our guidelines to benefit our members, we continue to consult with cardiologists concerning cardiac testing and treatment,” the company says.