What Anthem’s Imaging Policy Means for Hospitals
Hospital-based imaging centers are not going away, but they are going to become less of a destination for outpatient imaging in many markets.
Anthem, the nation’s second largest health plan, is implementing a new policy in which it will deny most claims for computed tomography (CT) and magnetic resonance imaging (MRI) studies performed in hospital outpatient radiology departments. Instead, its members will be pointed toward freestanding imaging centers or outpatient clinics, where the imaging is less expensive.
The imaging site-of-care policy was launched in several states last year and will be rolled out to all but one of the states Anthem serves by Spring 2018.
That policy serves as a red flag to all hospitals that offer outpatient imaging, even if they are not affected by Anthem’s policy. The Advisory Board cites a 2017 Medicare analysis showing that, on average, freestanding imaging facilities are paid at about 35 percent of the hospital rate.
Payers and patients are increasingly unwilling to pay such differentials, says Lea Halim, senior consultant at the Advisory Board’s Research Division. “Hospital-based imaging centers are not going to go away, but they are going to become less of a destination for outpatient imaging in many markets,” she says. “Anthem’s policy is not the only thing that is pushing that trend.”
Anthem’s Site-of-Care Policy
Anthem’s new policy for MRIs, CT scans, and certain other imaging tests is administered by AIM Specialty Health.
Citing the continued growth of diagnostic imaging volumes, Anthem says it can save money for employers by limiting the number of outpatient images performed in the outpatient hospital setting and directing patients to lower-cost freestanding centers or physician offices. The health plan says 80 percent of its high-tech imaging expenditures are for MRI and CT scans, which have high cost variability by site of service.
The policy went into effect in Indiana, Kentucky, Missouri, and Wisconsin in July 2017 and in Ohio, Colorado, Nevada, Georgia, and New York in September 2017. It will extend to California, Connecticut, Maine, and Virginia by March 1, 2018, with only one state in Anthem’s service territory—New Hampshire—not included. The policy applies to Anthem members covered by individual or employer-sponsored fully insured commercial plans; self-funded employers can adopt the policy if they choose.
Mammograms and X-rays are not affected by the policy change.
Web Extra: Access a formula to determine the financial impact of Anthem’s imaging policy at hfma.org/rcs/AnthemImagingPolicy
Will Others Follow Suit?
While Anthem’s imaging site-of-service policy is the toughest hospitals have seen, it is certainly not the first attempt to steer patients to lower-cost imaging providers. Halim points out that health plans have been encouraging their members to choose freestanding or physician-owned imaging centers for years, offering incentives such as gift cards and coaching them on the lower out-of-pocket costs they will incur.
Whether other health plans follow Anthem’s decision remains to be seen. Richard L. Gundling, HFMA’s senior vice president for healthcare financial practices, encourages hospital leaders to recognize that this situation reflects the value movement in healthcare. “Other health insurance plans will carefully look at Anthem’s experience and make their decisions accordingly,” he says.
To succeed in this environment, hospitals must be able to demonstrate that the quality and patient experiences they offer justify the higher costs of their imaging services.
“If health systems’ imaging services aren’t differentiated from the standalone imaging centers, then price may be the differentiator,” he says.
How Will Patients Be Affected?
In a written statement, Anthem cites two benefits to its members:
- More affordable premiums as a result of Anthem’s lower expenditures for high-tech images
- Lower out-of-pocket responsibility, as Anthem estimates that members who have not met their deductibles and must pay the entire cost of high-tech scans may save close to $1,000 by avoiding hospital-owned imaging centers, while those who are responsible only for copayments may save up to $200
The American College of Radiology (ACR) sees a different side to the policy. It issued a statement saying it is “gravely concerned” about the effect it will have on patient care. It cited two big worries:
- Timely access to advanced imaging services, particularly for patients in rural areas who do not have easy access to freestanding imaging centers.
- Interruption of pre-existing relationships between referring physicians and radiologists, which should be based on the skills of radiologists who perform and interpret imaging studies.
James Rawson, MD, chair of ACR’s Commission on Patient- and Family-Centered Care, is also worried about continuity of care for two groups of patients: those who are discharged with orders for post-discharge imaging and those with chronic diseases that are monitored over time.
For recently discharged patients, the information in hospitals’ electronic health records and the images obtained during hospital stays might be valuable in interpreting subsequent images performed on an outpatient basis. “If [the radiologist at a freestanding center] is looking for any type of interval comparison, the prior studies that are here would not be available, so from a continuity-of-care standpoint on a post-hospital discharge patient, that’s a concern,” he says.
Similarly, patients with chronic diseases like cancer or multiple sclerosis may have serial imaging studies over several years. “If you fragment the care, you end up with a radiologist who is able to read the current study but can’t give you an assessment of interval change, which is often needed to make treatment or management decisions,” Rawson says.
What To Do Now
Gundling encourages health plans to consider the price and quality of imaging services in total, rather than basing coverage policy only on the setting of the services. “It may be beneficial to consider the clinical integration and transformation that is going on in the healthcare delivery system and the costs that may be saved from care coordination and reducing unnecessary variations in care,” he says.
Meanwhile, hospitals and health systems must recognize they can no longer rely so heavily on cross-subsidization—charging higher prices for certain services, such as imaging, to cover the costs for low-profit services, such as burn centers—to balance the books.
He points to recommendations from HFMA’s Value Project report for creating meaningful improvements for care purchasers. For most health systems, this means optimizing the efficiencies of existing services and investing in new technologies and infrastructure to improve value in the future.
Perhaps the most important recommendation: Face reality and take action. “Embrace the likelihood of disruption in health care by investing in innovation,” the report reads. “An organization is better off disrupting its own business model than having it disrupted by others.”
This article originally appeared in HFMA’s Payment & Reimbursement Forum, November 2017.
Interviewed for this article:
Richard L. Gundling, FHFMA CMA, is senior vice president-healthcare financial practices, HFMA, Washington, D.C.
Lea Halim is senior consultant, Research Division, Advisory Board, Washington, D.C.
James V. Rawson, MD, is chairperson, American College of Radiology Commission on Patient- and Family-Centered Care, Augusta, Ga.