PITTSBURGH (August 11, 2004) - Highmark Inc. is launching
a new program designed to improve the quality and appropriateness
of diagnostic imaging services delivered to its members.
Dr. Paul M. Kiproff, MD, chairman of Allegheny General Hospital's
radiology department, said that with steady advances in medical
technology, "it is important that radiologists, other physicians
and health plans work cooperatively to ensure quality and proper
use of diagnostic imaging consistent with clinical guidelines."
Highmark pays more than $500 million a year for outpatient imaging services
for its members, including advanced imaging services, such as
magnetic resonance imaging (MRI), computerized axial tomography
(CAT) and positron emission tomography (PET). The company's
payments for advanced imaging services have increased more than
20 percent annually in each of the last three years.
Highmark has signed an agreement with National Imaging Associates, Inc.,
a national radiology management company, to help implement the
program. NIA is the country's leading provider of radiology
management services, covering more than 14 million lives in
30 states. NIA currently works with many Blue Cross and Blue
Shield organizations across the country.
Initially, the program will focus on reprivileging radiologists and other
physicians that perform imaging services who currently participate
in Highmark's managed care network in Western Pennsylvania (and
privileging providers who want to join the network), using more
stringent quality and patient safety guidelines.
To receive Highmark reimbursement, all network providers who perform
imaging services outside of the hospital setting must become
privileged, which means they must meet certain objective, professional
guidelines to deliver high-quality imaging services. A committee
of independent physicians and health care professionals, who
provide, perform or order imaging services, reviewed the guidelines.
The privileging process began in July.
In the second phase of the program, beginning later this year,
providers ordering outpatient, non-emergency advanced imaging
tests will be asked to provide notification when they order
certain MRI, CAT and PET studies. The focus will be on selected
services that are high-cost, or at high risk for inappropriate
use. This policy is intended to help Highmark evaluate data
to identify both appropriate and inappropriate patterns of ordering
advanced imaging tests and for physician consultation purposes.
In 2005, Highmark plans to require providers to request pre-authorization
when ordering selected advanced diagnostic imaging procedures.
All phases of the program apply to most Highmark health plans
in Western Pennsylvania. Highmark plans to implement a radiology
management program in Central Pennsylvania at a later date.
The quality and appropriateness of advanced imaging services has
recently emerged as an important issue, both in Pennsylvania
and nationally. As an example, some patients are asked to undergo
repeat MRI or CAT scans as a result of inappropriate testing,
substandard equipment and insufficient supervision at the facility
where the service is performed.
Diagnostic imaging has also recently gained attention because more non-radiology
specialty physicians are installing equipment in their offices.
Studies have shown that the appropriate use of advanced imaging
services will vary depending upon the specialty of the ordering
physician. With the exception of mammography, there is limited
state or federal regulation of diagnostic imaging.
Thomas Dehn, MD, chief medical officer at NIA, noted that Maryland
has a law that prevents physicians other than radiologists from
putting MRI or CAT units in their offices. "In most states,
any licensed physician may purchase this equipment and provide
services to patients," Dr. Dehn said. "Nationally,
more health plans are developing programs that focus on the
quality and safety of their imaging network."
Highmark is an independent licensee of the Blue Cross and Blue Shield
Association, an association of independent Blue Cross and Blue
Shield Plans. For more information on Highmark, visit www.highmark.com.
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