Over the past 10 years, there has been a continuous rise in the utilization and cost of echocardiograms, the most widely used diagnostic imaging test for heart disease. Since 2009, utilization has doubled. As a result, concerns were raised about overutilization or misuse of this procedure, and Appropriate Use criteria were subsequently developed by leading cardiologists. Utilization of echocardiography is especially high in the Pittsburgh region, according to Highmark, and not all physicians are complying with the Appropriate Use guidelines. On Jan. 1, 2019, Highmark announced the Advanced Imaging and Cardiology Services Program, which requires prior authorization for specific outpatient, non-emergent, elective cardiology services, including transthoracic echocardiograms and nuclear imaging. Providers will be required to obtain prior authorization in order to reduce the overutilization taking place in this market. Insurers want to be certain that echocardiograms are medically necessary, and prior authorization validates this.

Healthcare providers, including members of the Pennsylvania Medical Society (PAMED) and the Pittsburgh Business Group on Health (PBGH), a coalition of regional employers that advocates for high-value healthcare for employees, have joined forces to express their mutual concern that prior authorization requirements for routine procedures will create new delays for patients to receive care, force more care into higher cost settings and create administrative burdens. Physicians and the PBGH share a commitment to low-cost, high-quality healthcare and are concerned about measures that impact that, especially the new pre-authorization policies from Highmark. Concerned Allegheny County Medical Society (ACMS) members have made inquiries about the problem, prompting ACMS to convene a meeting in January that brought together the stakeholders: PAMED; ACMS; PBGH; the Pennsylvania chapter of the American College of Cardiology; and Highmark executives.

It’s a complex problem: Patients need timely access to healthcare services, but access must be balanced with cost. What is the impact of prior authorization on this balance?

Highmark

Highmark’s Advanced Imaging and Cardiology Services Program applies to outpatient, non-emergent services. EviCore Healthcare will manage the prior authorizations for advanced imaging and cardiology services for Highmark’s fully insured Commercial, Children’s Health Insurance Program (CHIP) of Pennsylvania, Medicare Advantage and Affordable Care Act members, plus members of select self-insured (Administrative Services Only) groups. 

David S. Webster, MD, MBA, vice president and executive medical director, Highmark: “The prior authorization program is not actually new. We’ve expanded a number of things for prior authorization. When we look at the data for this market and others, we do in fact see significantly higher utilization here, and this is due to the age of the population and other factors. Utilization numbers here are trending higher compared to benchmarks in markers such as Medicare, Medicaid and other commercial plans. This is not sustainable with costs. We appreciate every perspective and having everyone come together for a discussion, for the common good.”

 

Diane Gilworth, senior vice president, Highmark: “The Appropriate Use criteria were developed by physicians; they came up with the criteria, which are designed to help clinicians with what the standard should be. We believe it should be individualized care, but within a standard framework. The Appropriate Use criteria are designed to work as an aid, or a helpful decision-making tool. With criteria, we are transparent, so the provider knows exactly what the criteria are. Dr. Webster and I are both providers ourselves; we understand caring for patients. We are very sensitive about how we approach this issue.

 

“Highmark wants to partner with all stakeholders. Our philosophy is that we truly want to work with partner organizations, to work on Appropriate Use criteria to make certain that all patients receive timely, evidence-based, appropriate care. Employers have a greater sense of the cost trajectory and play an essential role in helping all of us to manage rising costs.”

 

Pittsburgh Business Group on Health

PBGH is a growing and dynamic education and advocacy group representing a coalition of large and small regional employers that cover more than 2.2 million people and command more than $5 billion in healthcare costs through its 100 member organizations. The organization aims to fortify healthcare by developing strategies for high-value healthcare for workers, including improved insurance coverage and reduction of wasteful healthcare spending.

Jessica Brooks, MBA, chief executive officer: “The issue of prior authorization can potentially impact the patient’s access, experience and costs. If authorization is denied and the patient has heart disease, then diagnosis and treatment are delayed. Ultimately, this patient may have a worse outcome and/or higher costs. It’s better to identify heart disease earlier, when intervention may be simpler and less costly, than to delay while the condition worsens and ultimately requires major surgery or other treatment. What is the cost of doing the echocardiogram now versus not doing it now and paying more later?

“The employer perspective is that, as the purchasers of healthcare services, we make choices for the employees and we need to be well informed. This is a new program; there is no data yet. We want to see six months of utilization data. Let’s track it and answer the question – is prior authorization adding value? Employers emphasize elimination of waste, and we feel that a blanket program can delay care or ultimately create more waste. We want the right practices and policies to be in place to assure high-quality care plus elimination of waste.

“When you prioritize the needs of the patient, when everyone has that as the goal, the outcome will be beneficial for all involved. We view this as an opportunity to collaborate with providers.”

Physicians

PAMED – Recent studies of the Appropriate Use criteria for echocardiography suggest they can be practically applied and the appropriate clinical practice of echocardiography can be achieved. Physicians object to a blanket policy and feel that Highmark should have a more systematic approach, in which they identify those who are overutilizing. Overutilization is not an issue with every physician who orders echocardiograms. Physicians also have concerns about how new prior authorization requirements may affect patient care and office workflow. The administrative burden of prior authorizations has forced some practices to hire additional staff.

According to Highmark, 80 percent of approvals should occur within seconds. Practices that experience approval delays or other issues are encouraged to share their experiences with the ACMS by contacting ACMS CEO Jeremy Bonfini at (412) 321-5030 or jbonfini@acms.org. This feedback will be shared with Highmark at the summer stakeholder meeting, at which Highmark has agreed to bring back data regarding prior authorization.