In Washington, the debate continues over the government's role in health care. But doctors say there's already someone playing a role in your care, you probably don't know about. You won't ever meet them, but they could have the final say in your health care decisions.
At Iowa Health Cardiology, you'd expect doctors like Saima Zafar to know what's best for her patients. She's an expert in her field, yet inside her exam room someone else is calling the shots.
"I thought it was ridiculous. Particularly where there are people hired to say 'no' to a test that I'm ordering," said Dr. Zafar. Those people are known as Radiology Benefit Managers. They never actually see any of Zafar's patients, but they have the power to over-rule her recommendations.
"We want to make sure that when these tests are done, when they're ordered, that they're being done for the right reasons," said Dr. Paul Karazija, the Chief Medical Officer for Wellmark. To enforce those 'right reasons,' Wellmark and many other insurance companies now turn to Radiology Benefit Management Company. The company must approve certain tests for Wellmark members before the insurance company will pay for them. These include CT scans, MRI scans, Nuclear Cardiology exams and PET scans.
"Because of the increasing volume of high-tech imaging studies both in Iowa and South Dakota, this raised a concern whether all these high-tech imaging studies were appropriate," said Dr. Karazija. A recent study by UnitedHealth Care and the American College of Cardiology shows 4%- 22% of high tech imaging studies may not be appropriate. Insurance companies say radiology benefit managers are weeding out these unnecessary tests.
So here's how the process works: When a patient visits the doctor, and the doctor decides they needs a test, a request for the test must first be made to a radiology benefit manger through an online system. "The organization then assesses the information that they get, and based on criteria developed by national experts, will then feed back to the physician that the test is appropriate, or whether there are some questions about the nature of the tests," said Karazija.
Dr. Craig Clark is the Governor of the Iowa Chapter of the American College of Cardiology. He says the process meant to curb unnecessary testing is also cutting necessary testing. "We have to tell patients, this is the test we think they need. This is why we think they need it. But their insurance company may choose to deny it," said Clark.
About 75% of the tests are initially approved, but some are not. That's when Dr. Zafar says things can get ugly. "The last thing you want to say to somebody who you suspect is having heart problems is that your insurance company is declining your test," she said.
When tests are denied, doctors may try to make their case over the phone. "You have to literally prepare yourself for a duel! Its like a wrestling match," said Zafar. We received accounts of these matches with radiology benefit managers from cardiologists around the state. Dr. Jihad Khalil of Dubuque writes in an email, "I spend 45 minutes arguing with them about the validity of the test to no avail." Dr. Chad Williams in Iowa City is also concerned about patient care writing that the pre-authorization process is causing "big delays."
Then there's the added expense. Iowa Health Cardiology had to hire additional staff to help manage the test requests.
"We recognize that this program does add some administrative burden" said Karazija. "But we also recognize that this isn't the ideal solution to the issue." Wellmark says it looks forward to the day it can end the pre-approval process-- when doctors show they're consistently making the right calls.
In the meantime, doctors who say they already are, are left to battle for what they believe is best for their patients. "My decisions and my judgment, if its going to be questioned like that, I don't know what role we are expected to have as physicians," said Zafar.
Clark says the ACC is encouraging insurance providers to consider alternatives to RBMs. He says some insurance providers have developed a way for physicians who consistently order appropriate tests to be exempt from the benefit management process. Wellmark said it is not considering that option at this time. The ACC is also looking at new types of technology through the company Medicalis to ensure patients are receiving appropriate tests.
At Iowa Health Cardiology, you'd expect doctors like Saima Zafar to know what's best for her patients. She's an expert in her field, yet inside her exam room someone else is calling the shots.
"I thought it was ridiculous. Particularly where there are people hired to say 'no' to a test that I'm ordering," said Dr. Zafar. Those people are known as Radiology Benefit Managers. They never actually see any of Zafar's patients, but they have the power to over-rule her recommendations.
"We want to make sure that when these tests are done, when they're ordered, that they're being done for the right reasons," said Dr. Paul Karazija, the Chief Medical Officer for Wellmark. To enforce those 'right reasons,' Wellmark and many other insurance companies now turn to Radiology Benefit Management Company. The company must approve certain tests for Wellmark members before the insurance company will pay for them. These include CT scans, MRI scans, Nuclear Cardiology exams and PET scans.
"Because of the increasing volume of high-tech imaging studies both in Iowa and South Dakota, this raised a concern whether all these high-tech imaging studies were appropriate," said Dr. Karazija. A recent study by UnitedHealth Care and the American College of Cardiology shows 4%- 22% of high tech imaging studies may not be appropriate. Insurance companies say radiology benefit managers are weeding out these unnecessary tests.
So here's how the process works: When a patient visits the doctor, and the doctor decides they needs a test, a request for the test must first be made to a radiology benefit manger through an online system. "The organization then assesses the information that they get, and based on criteria developed by national experts, will then feed back to the physician that the test is appropriate, or whether there are some questions about the nature of the tests," said Karazija.
Dr. Craig Clark is the Governor of the Iowa Chapter of the American College of Cardiology. He says the process meant to curb unnecessary testing is also cutting necessary testing. "We have to tell patients, this is the test we think they need. This is why we think they need it. But their insurance company may choose to deny it," said Clark.
About 75% of the tests are initially approved, but some are not. That's when Dr. Zafar says things can get ugly. "The last thing you want to say to somebody who you suspect is having heart problems is that your insurance company is declining your test," she said.
When tests are denied, doctors may try to make their case over the phone. "You have to literally prepare yourself for a duel! Its like a wrestling match," said Zafar. We received accounts of these matches with radiology benefit managers from cardiologists around the state. Dr. Jihad Khalil of Dubuque writes in an email, "I spend 45 minutes arguing with them about the validity of the test to no avail." Dr. Chad Williams in Iowa City is also concerned about patient care writing that the pre-authorization process is causing "big delays."
Then there's the added expense. Iowa Health Cardiology had to hire additional staff to help manage the test requests.
"We recognize that this program does add some administrative burden" said Karazija. "But we also recognize that this isn't the ideal solution to the issue." Wellmark says it looks forward to the day it can end the pre-approval process-- when doctors show they're consistently making the right calls.
In the meantime, doctors who say they already are, are left to battle for what they believe is best for their patients. "My decisions and my judgment, if its going to be questioned like that, I don't know what role we are expected to have as physicians," said Zafar.
Clark says the ACC is encouraging insurance providers to consider alternatives to RBMs. He says some insurance providers have developed a way for physicians who consistently order appropriate tests to be exempt from the benefit management process. Wellmark said it is not considering that option at this time. The ACC is also looking at new types of technology through the company Medicalis to ensure patients are receiving appropriate tests.
