There’s a debate brewing between local doctors and Rochester’s largest health insurance provider. For months, Excellus Blue Cross Blue Shield and the Monroe County Medical Society have been at odds over a proposed plan to require prior approval for imaging tests such as MRIs, MRAs, CAT and PET scans.
“We have had many different meetings with Excellus and articulated our concerns in many different ways and unfortunately they are not backing off,” says Nancy Adams, executive director of the Monroe County Medical Society.
“One of the major issues for us is trying to maintain the affordability of health care. Radiology and imaging for Excellus Blue Cross Blue Shield, we're spending more than a half billion dollars a year, across all of our regions for radiology,” says Jim Redmond, communications director for Excellus BCBS.
Under the plan, set to take effect October 8th, a physician would be required to fill out a three-page form and submit it to Excellus BCBS before scheduling a radiology imaging test for a patient. The approval could take up to two days, after which, the physician would then call the patient and schedule the test. The change does not apply to tests done in an emergency room, ultrasounds or basic, flat plate x-rays. According to the Medical Society, the combination of additional paperwork and wait time puts patients “on hold” for critical tests.
“But to ask them to go through and go back in the chart and pull every medication and every prior treatment that's already been tried, and write it down on a form and send it in. Before you can schedule a test is not practical, it interferes with patient care,” says Adams who believes the change will have its greatest effect on oncologists and primary care doctors.
“It may have a greater impact on something like oncology or urology or something like that but again, when you look at the amount of money that's being spent on these tests and the national literature says 10 to 15 percent of them are not being ordered at the right time or that it's not the right test to be given,” says Redmond who adds Excellus BCBS currently spends $560 million dollars in radiology testing per year.
Redmond contends research done for the last five years by Excellus on the topic of radiology referral shows primary care doctors would not be affected greatly by the change because they do not typically order many radiology tests.
“So you're talking one or two a week,” says Redmond, “In Rochester, from 2001 to 2006 the use of MRIs increased 50-percent, the use of CT scans increased 70 to 80 percent. What we want to do is make sure that people are getting the right tests at the right time for the right reasons.”
Adams says the changes will not only affect physicians, but the quality of care patients receive on a daily basis in Rochester. Excellus BCBS covers 70% of Monroe County for health insurance.
“While we fully agree that inappropriate tests shouldn't be ordered and there should be mechanisms in place to stop those from being done,” says Adams, “we need to step back a bit and say, where can we educate physicians instead of using this broad-brush approach. It’s like killing an ant with a sledgehammer”.
Excellus BCBS says it plans to use some of the money it hopes to save in radiology testing on doctors, giving them a better reimbursement level.
“Physicians want to be paid more, but it's not a bottomless pit,” says Redmond.
“The amount of time and the amount of staff that it's going to take to manage this program is not worth the few pennies extra that they plan on paying the doctors,” says Adams.
The Medical Society has sent letters to the New York State Health Department and is planning to meet with Attorney General Andrew Cuomo on September 26th to discuss the issue. The agency’s goal is to reach a compromise with Excellus in the near future.
“I hope that Mr Cuomo will keep his eye on this. It would be very unfortunate if there is a bad outcome because of delay of care,” says Adams.