Criteria keep imaging costs in check
Nearly 20% of imaging referrals unnecessary
Imaging Utilization Services in Pembroke Pines, FL, used InterQual’s ISX Clinical Decision Support Criteria to screen proposed radiology services for a 100,000-member Florida managed care organization (MCO) and found that roughly 20% of all referrals were clinically inappropriate. By recommending that more conservative procedures be provided before ordering expensive imaging studies, the MCO saved $660,000 for commercial members and about $1.8 million for its Medicare members.
"Radiology services are some of the most costly to provide, and because they represent little threat of harm to patients some of the easiest for physicians to order," says Jonathan Shapir, MD, medical director of Imaging Utilization Services. "Many times, other modalities can be substituted effectively to manage a patient’s care safely and cost-effectively, and that’s what the InterQual criteria attempt to determine."
During initial screening over a 52-day period in 1996, 2,160 or 79% of imaging study requests were determined through the use of the criteria to be clinically appropriate. Clinical information supplied on the remaining 458 or 21% did not satisfy the criteria and required direct physician review. After physician review, 55 or 2.5% of the requests were considered appropriate and allowed. After consultation with referring physicians, the remaining studies 403 or 18.5% were not performed.
Shapir stresses that patients involved in the study were not inpatients or in emergency situations. "These were all outpatients. What we attempt to do is to compile the patient’s complete record and use the criteria to determine whether other more conservative modalities have been tried before authorizing expensive imaging studies," he says.
The InterQual ISX criteria are designed to screen requests for imaging studies two ways, says A. Jacqueline Mitus, MD, vice president of clinical services at InterQual, a health care software consulting firm in Marlborough, MA. "The criteria look at the ordered study and check it against a list of common indications or reasons why a physician might request those studies. Then the criteria validate that the patient has the condition the provider believes they have and ensure that all appropriate conservative therapies have been tried."
For example, before authorizing an MRI of the spine for nerve root compression, the criteria confirm specific clinical findings supporting this condition, such as radicular pain, Mitus says. Then, the criteria verify that a trial of conservative treatment such as limited activity already has been performed. The criteria also help reviewers identify unusual circumstances that require physician review.
The InterQual ISX criteria are available in book form or computer software. In addition, the criteria are available through InterQual business partners nationwide. For more information, visit InterQual’s Web site at www.interqual.com.
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