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Blue Cross to require preapproval for scans

MRI, other imaging costs up 20% in year

Blue Cross and Blue Shield of Massachusetts, the state's largest health insurer, said it will seek to control runaway radiology costs by requiring many doctors to receive authorization before scheduling advanced imaging procedures.

Under a plan scheduled to take effect Dec. 1, doctors in practices that have a record of ordering an above average number of imaging procedures such as MRIs and PET scans will face the stiffest scheduling requirements.

But in a recent letter to doctors, Blue Cross said it will not deny payment for any imaging procedure that meets its medical policies. Nor will the review process apply to hospitalized patients or those seeking emergency room care.

Dr. Peter Goldbach, a medical director at Blue Cross, said costs for high-tech imaging are increasing at an annual rate of about 20 percent.

''We're facing a pretty ugly trend where high-cost imaging is outpacing the increase in general medical expenses by two to one," Goldbach said. ''Many people have called this unsustainable."

Blue Cross will be the state's last major health insurer to adopt measures to curb rising radiology expenses. Harvard Pilgrim Health Care instituted a review program last year, and Tufts Health Plan recently announced a cost-savings plan that is scheduled to take effect Oct. 1.

Under the Tufts plan, some procedures requested by doctors may ultimately be rejected, leaving the doctor or patient responsible for the cost if they decide to proceed.

Goldbach said that won't happen with the Blue Cross program. ''We will never refuse a study. We only advise," he said.

Advanced diagnostic imaging is considered one of the biggest contributors to rising healthcare expenses. The number of imaging procedures, including traditional X-rays, is rising by 20 percent a year, according to National Imaging Associates, a New Jersey firm that provides imaging services for many health plans, including Harvard Pilgrim and Tufts. But costs for advanced imaging techniques are increasing by as much as 35 percent annually, according to the company. Even though they account for a small percentage of the number of overall imaging procedures, they account for most of the spending increase.

If current trends continue, imaging will ''eclipse pharmacy costs as a percentage of overall medical dollars," said John J. Donohue, chief executive of National Imaging. In 2003, $90 billion was spent on diagnostic imaging, compared to $180 billion for prescription drugs, he said.

Donohue said there are many reasons for the rapid growth of advanced imaging, including the development of new technologies, demand from consumers who want the latest test regardless of its suitability, and increasing use of advanced imaging by doctors to minimize the possibility of malpractice lawsuits.

Under the Blue Cross program, to be run by American Imaging Management of Chicago, requirements for scheduling an imaging procedure will depend on a patient's primary care physician. A primary physician who works in a medical group with a below-average number of imaging requests will have to register online or by telephone to perform some imaging procedures. For other types of imaging procedures, the physicians will be required to fill out a form describing the patient's condition. They also might also have to speak to a ''physician reviewer" at American Imaging.

Primary care physicians who work in medical groups where imaging requests are above-average will have to provide patient information for every advanced imaging procedure they request.

Doctors whose practices already have a procedure for reviewing imaging requests may be exempt from the plan.

Some doctors say the Blue Cross plan will be burdensome. Dr. Eric J. Sax, president of the Massachusetts Radiological Society and a radiologist at Newton-Wellesley Hospital, said that is the point of the review process.

''The hassle factor is what the payers are counting on to minimize utilization," Sax said. ''They're making it so hard to get a study the referring doctors will stop asking."

Goldbach acknowledged the plan creates more administrative work.

''We're making a sincere effort to lower the administrative bar and make this as easy as possible," he said.

Rather than eliminate medically valid tests, Goldbach said, the program will prevent unnecessary imaging procedures or those that aren't optimal for diagnosing a patient's condition.

He said he couldn't predict how much money Blue Cross would save.

Dr. Jeff Levin-Scherz, chief medical officer of Partners Community Healthcare Inc., a large doctors group, said the Blue Cross system could create confusion. For instance, the program measures the use of radiology procedures by a patient's primary care physician, but many referrals for imaging are made by specialists.

''We certainly hope they'll be implementing this program in a way that will have no impact on patients who need procedures urgently," Levin-Scherz said.

Blue Cross and Blue Shield of Massachusetts is a not-for-profit health insurance company covering 2.8 million members, making it larger than all of the other health insurers in Massachusetts put together.

Jeffrey Krasner can be reached at krasner@globe.com.

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