Radiology Utilization Management: More than Cost Savings

Every couple of years the public is reminded that radiation is potentially harmful. Most of us yawn as this is not exactly a eureka moment, while some of us panic, but what is being done about it? In the past week the media brought this issue to our attention through an article published in the Archives of Internal Medicine which projected that radiation used in computed tomography (CT) scans performed in 2007 would ultimately induce 29,000 cancers and kill 15,000 people. The American College of Radiology responded that there were some legitimate concerns about the accuracy of these projections, but there is little argument about the crux of the issue: x-ray exposure carries the risk of induced malignancies.

For many decades improving technology had allowed steady reductions in the amount of radiation needed to produce diagnostic x-ray examinations, thus lessening our attention to radiation dosage. This changed radically when CT became available. A CT procedure requires much more radiation than plain film x-ray. Nonetheless it has been the belief of most physicians that the benefit of improved diagnostic accuracy more than compensated for the risk. This is only true, however, if the CT examination is appropriate to the clinical question for which it is ordered. If, on the other hand, the CT procedure is not appropriate, or can only provide information already at hand, or worst of all was ordered for “defensive” or commercial reasons, the risk far exceeds the benefit. (See for an excellent brief discussion of the roots of overutilization.) The problem, then, is what to do about this?

Radiology Benefits Management (RBM), including prior authorization of medical imaging requests, is perhaps the single most effective tool in addressing this problem. RBM has proven to significantly reduce inappropriate utilization of medical imaging in general, and is especially effective in high-tech procedures such as CT, MRI, PET, and Nuclear Cardiology. Since its beginning, Care to Care, the youngest of the RBM companies, has seen its role as one of promoting patient welfare by reducing both wasteful radiation exposure and expense.

The most effective approach to consumer radiation safety is to be as sure as possible that only tests that will aid in diagnosis and treatment are performed, and that they are done by high-quality facilities and physicians who meet stringent quality guidelines.

The utilization management component, traditionally through a medical necessity review or prior authorization, uses evidence-based criteria to screen out procedures that are inappropriate by virtue of being redundant, not medically indicated, or mistakenly substituted for a better test. Our criteria are designed to allow rapid assessment of requests, and a staff of radiologists is available to discuss clinical and imaging issues with requesting physicians whenever requested and always before any negative determination is made. We are always open to suggestions from the referring physicians, and believe that they are better informed as a result of our efforts. In essence, by promoting the choice of the proper test at the earliest opportunity, we reduce imaging cost, prevent unnecessary radiation exposure, and improve the quality of care.