Tightening the screws on pricey imaging exams, health insurerAnthem will no longer allow many patients to get MRIs or CT scansat hospital-owned, outpatient facilities, requiring them to useindependent imaging centers instead.

Anthem says the change is aimed at providing high-quality, safecare while reducing medical costs.

But critics say that imposing a blanket rule that givespreference to freestanding imaging centers is at odds with promoting quality and will lead to fragmentedcare for patients.

“To achieve true value, you have to have high-quality care at agood price,” said Leah Binder, president and CEO of the LeapfrogGroup, a nonprofit organization that advocates for improved safetyand quality at hospitals. “Anthem would be better off judging thequality of these [imaging] diagnoses” regardless of where they’reprovided and setting payment accordingly, she said.

Imaging tests are generally subject to preapproval by Anthem toconfirm that they’re medically necessary. Under the new policy, AIMSpecialty Health, an Anthem subsidiary, will also evaluate wherethey should be performed. Doctors who request non-emergencyoutpatient MRI or CT scans that can be done at an independentimaging center rather than one owned by the hospital will be givena list of centers eligible for patient referrals.

The policy doesn’t apply to mammograms or X-rays.

In rural areas that lack at least two other non-hospital imagingcenters, hospital outpatient tests will still be approved.

The new policy could save Anthem enrollees hundreds of dollars,said Lori McLaughlin, Anthem’s communications director.

“There are huge cost disparities for imaging services, dependingon where members receive their diagnostic tests,” she said.“Members can save close to $1,000 out-of-pocket for some imagingservices for those who haven’t met their deductible and up to $200for those whose plans require only a copay.”

Hospital imaging is indeed pricier than imaging at freestandingcenters. Average prices for MRI and CT scans ranged from 70 percentto 149 percent higher at hospitals, according to an analysis bythe Healthcare Financial Management Association, a membershipgroup for health care finance professionals.

But price isn’t the only important variable, and the perceptionthat all imaging studies conducted by qualified providers generallyyield comparable results is wrong, Binder said. A study published last year in The Spine Journal, for example,found that when a patient “secret shopper” with low back painreceived MRIs at 10 imaging centers, each center reporteddifferent findings. Some missed a problem they should have found,while others detected nonexistent problems.

Continued on next page >>>

Kaiser Health News, a nonprofit health newsroom whosestories appear in news outlets nationwide, is an editoriallyindependent part of the Kaiser Family Foundation.

The Anthem policy applies to 4.5 million enrollees inindividual and group plans in 13 of the 14 states in which Anthemoperates, according to McLaughlin. (Self-funded employersthat pay their employees’ claims directly are exempt but canincorporate it if they wish.) The insurer began phasing in thechanges in July and expects to finish by March. New Hampshireis the only state without an implementation date, McLaughlinsaid.

This is Anthem’s second coverage change this yearattracting attention. Earlier, the company came under fire fora new policy under which it will no longer pay for emergencydepartment visits that it determines after the fact weren’temergencies. That decision raised concerns it could discourage people who might need emergency treatmentfrom seeking care.

Patient advocates and health care providers have also expressedconcerns about the new imaging rule’s potential impact onpatients.

Cancer patients who often are being treated at cancer centerswithin hospitals would feel the effect, noted Dr. J. LeonardLichtenfeld, deputy chief medical officer for the American CancerSociety.

“They have to go to a new outpatient facility, get the film, getit read and transmitted back to the cancer center,” Lichtenfeldsaid. If, as often happens, the hospital and the imaging center’scomputer systems don’t talk to each other, the patient may have tobring the results back to the doctor on a CD. “For thatpatient who’s in a lot of stress to begin with, it adds anotherlevel of stress,” he said.

Dr. Vijay Rao, chair of the department of radiology at ThomasJefferson University in Philadelphia, said the Anthem policy willcreate extra effort for hospital radiologists on a patient’s careteam, who will need to review and possibly redo the imagingcenter’s work. Further, relying on a patient to transport the scanso that it can be put into the hospital’s electronic medicalrecord system “leaves lots of room for error,” she said.

Anthem isn’t the only insurer trying to find a way aroundhospitals’ steeper outpatient imaging costs, said Lea Halim, asenior consultant at the Advisory Board, a health care research andconsulting company. The Medicare program is taking steps as well,although its approach doesn’t directly influence patient care inthe same way.

In recent years, hospitals have been snapping up independentphysician practices, outpatient imaging and testing facilities andthen charging Medicare higher hospital outpatient fees for theirservices. In a bid to equalize payments, in January the Medicareprogram reduced by 50 percent the amount it pays some hospital-ownedoutpatient facilities, including imaging centers, that arelocated away from a hospital’s campus. A further reduction isproposed for 2018.

“So Medicare is doing something that’s in a way very similar towhat Anthem’s doing,” Halim said.

Kaiser Health News, a nonprofit health newsroom whosestories appear in news outlets nationwide, is an editoriallyindependent part of the Kaiser Family Foundation. Pleasevisit khn.org/columniststo send comments or ideas for future topics for the Insuring YourHealth column.