For many years, healthcare providers and payers have sought to rein in the skyrocketing costs of medical imaging procedures through the practice of prior authorization.

But emerging new computerized clinical decision support (CDS) and predictive modeling (PM) technologies, already being leveraged successfully against many acute and chronic medical conditions, may prove to be more effective weapons in the battle to reduce costs and improve quality in medical imaging.

Healthcare in general, and medical imaging in particular, are both in the midst of dramatic economic challenges. U.S. healthcare costs, already rising at more than twice the rate of inflation, continue to climb at unsustainable rates. As of 2010, healthcare spending was nearly 18 percent of our country’s GDP—twice the average of other economically developed countries—and accelerating, according to the Organisation for Economic Co-operation and Development (OECD).

Federal legislative and regulatory efforts, such as the Affordable Care Act, Meaningful Use and ICD-10, are all being implemented in an attempt to rein in costs and improve quality. However, it’s becoming apparent that policy changes alone are not sufficient to achieve the level of cost reductions that forecasts suggest will be needed to bend the cost curve sufficiently.

As a result, new healthcare delivery and reimbursement models that put care and treatment value ahead of volume are emerging. These value-based models rely on an evidence-based approach to medicine that does exactly what its name suggests: It assesses the efficacy of any given test or treatment based on the evidence of their risks and benefits. Evidence-based medicine, in turn, relies on two major types of tools, CDS and PM.

Driven by CDS and PM, evidence-based medicine is racking up impressive gains against cardiovascular disease, diabetes, arthritis and other chronic conditions, as well as improving efficiency in such areas as the surgical suite. But evidence is also emerging that CDS and PM tools can also be effectively applied in medical imaging, where multiple studies have called attention to the patient safety risks of, and financial resources being wasted on, inappropriate and/or redundant imaging studies.

According to OECD Health Data, U.S. healthcare providers perform 265 computed tomography (CT) exams for every 1,000 persons, compared to 124 per 1,000 persons in the OECD average. U.S. physicians also order almost 98 MRI exams per 1,000 persons, compared to 46 per 1,000 in the OECD average. Despite the U.S.’ higher volumes for these exams, patient outcomes enjoy no apparent benefit, as U.S. outcomes rank well below those of the lower quartiles of the OECD data.

CDS and PM: Going Beyond Prior Authorization

Prior authorization is one of the most common ways U.S. payers and providers strive to reduce their imaging costs. However, emerging research shows that a more effective way to manage finances and outcomes tied to imaging is to employ CDS and PM tools.

In radiology, CDS and PM solutions can be leveraged at the point of care to help physicians determine what type of imaging, if any, is most appropriate for any given patient and circumstance.

One example is the Ottawa Ankle Rules, a set of guidelines that clinicians have been using since the 1990s to determine whether to take an X-ray of a patient with foot or ankle pain for bone fractures. Before the rules came about, most patients with any ankle injury were referred for X-rays; however, experience has shown that many patients do not have such fractures. As such, using the Ottawa Ankle Rules has since been able to sort those likely to have a fracture from those patients who don’t, reducing the costs and risks associated with unnecessary X-rays and radiation exposure. This use of PM is especially important for children who are more vulnerable to radiation exposure.

Evidence continues to mount that CDS and PM solutions achieve the goals of reducing costs and improving the quality of patient care in medical imaging more effectively than employing prior authorization alone. Some recent examples include:

• One study showed that following the recommendations of PM/CDS tools with respect to imaging resulted in 95 percent of cases turning up positive for the suspected diagnosis. The same study found that physicians who didn’t follow the tool’s recommendations were correct only 25 percent of the time for the suspected diagnosis.
• A second, two-year study found that a major national healthcare plan saved almost $550 million one year after beginning to leverage PM and CDS technologies to reduce inappropriate levels of CT, MRI and PET/CT examinations.
• A recent United Healthcare project in St. Louis, Mo., looking at the efficacy of CDS and PM versus prior authorization found that providers and payers who based their imaging exams on CDS tools improved the appropriateness of exam selection by 25 percent and reduced inappropriate orders by 75 percent, compared to using the prior authorization process alone.
• A study published in the Journal of the American College of Radiology found that the “targeted use of imaging clinical decision support is associated with large decreases in the inappropriate utilization of advanced imaging tests, such as MRI and CT.” 
• A review by the Agency of Healthcare Research & Quality of 31 studies done for the Centers for Medicaid and Medicare Services found that IT measures alone did not improve imaging appropriateness or outcomes, but CDS technologies did result in improvements.

The Future Lies Beyond Prior Authorization

It is quickly becoming apparent that in today’s challenging healthcare environment, policy changes alone cannot be relied upon to rein in healthcare costs and improve healthcare outcomes. Besides changing their focus from volume-based to value-based care, there’s a growing recognition among providers and payers that new technologies, such as CDS and PM tools, are required to help rein in costs and improve patient care outcomes.

By helping physicians determine at the point of care what imaging modalities are most appropriate under specific circumstances, computerized clinical decision support and predictive modeling tools can help reduce the financial costs and patient safety risks of unnecessary and redundant imaging.

Indeed, healthcare providers that rely on such technologies to guide their imaging decisions stand the best chance of succeeding in today’s highly competitive healthcare environment.