Life or Death
UnitedHealthcare to favor imaging centers based on cost, not quality.
When you are picking a new mechanic, you probably look at some reviews to determine how well he or she figures out what is wrong with your car and how well he or she can fix it. Maybe you find one on the internet and she seems to have good reviews. Most people think she does a great job and that she can always tell what is wrong with their cars. While you’re looking though, you see website for another mechanic. He does not have many reviews and the ones he does have are so-so, but his prices are a lot less than the first mechanic’s. You now have a choice. Do you go pay more for the first mechanic who seems to do really well? Or do you try the second mechanic and maybe get a deal?
UnitedHealthcare (UHC) recently announced a new program aimed at curbing imaging costs. UHC plans on collecting survey data from physicians and imaging centers so they can evaluate their performance quality. Using this data, they will be creating different tiers for their imaging centers and placing each group into one of the tiers, the highest being “Designated Diagnostic Provider.”
What’s not to love? This seems like a great idea. You can find a doctor that has been “thoroughly reviewed” by your insurance company and, like with your mechanic, you can now see who your insurance company ranks as the best guys around.
If you are like me, though, you are probably a bit more skeptical of the motivations of a for-profit insurance company. Let’s dig a little deeper into this plan.
The quality review that UHC plans to conduct will base its findings on three things: whether the facility is accredited, how timely they provide their services, and if they submit electronic images. All of this is well and good, except that I am not aware of any imaging center that performs MRI or CT scans that is not American College of Radiology (ACR) accredited, that does to in an un-timely manner, or sends of a physical image. I would wager that ninety-nine percent of imaging centers meet the criteria UHC is setting.
So, if this bar will be cleared by almost every provider, how will UHC select who is in the top tier? UHC said in a statement, “quality and efficiency are considered equally when determining a provider’s tier level.” Let me translate from insurance-speak: “efficiency” equals “low cost.” Since everyone meets the criteria set by UHC, the tier levels will be exclusively based on cost.
Is this a bad thing? If imaging services were a commodity with no difference in quality, I would say no. For example, if imaging services were like gasoline. For gasoline, it doesn’t really matter what station you go to since the product is all generally the same, so you go to the station with the cheapest gas. That is not a bad thing.
Imaging services, though, are not like gasoline. With imaging, the difference in quality can truly mean the difference between life and death. Contrary to what UHC might think, judging quality takes much more effort than just looking at accreditation, timeliness, and electronic images.
This leads to one of the inherent problems with imaging. There are three possible outcomes when a patient goes in for an MRI scan. The first outcome is that the radiologist can make a definitive and correct interpretation of the scan and submit to the ordering provider that correct information about the patient and his or her condition.
The second possible outcome is one where the radiologist cannot make a definitive diagnosis. In this case, the ordering physician must order further testing or even surgery to get the correct diagnosis.
The final possible outcome is a misdiagnosis. The radiologist indicates that there is no cancer or tumor when there is. In this case, the ordering physician may not pursue further care because of this incorrect interpretation, and this puts the patient’s life at risk.
Despite the fact there are three possible outcomes, all three radiologists get paid the same. Furthermore, with the second and third possible outcomes costs increase, and the patient can be put in danger.
The goal for imaging should be pushing for the first outcome as much as possible and to reward those providers who achieve this goal more often than their peers. This will produce the lowest cost and the best care. Doing this takes more than just ACR accreditation. True quality includes the type of equipment, software, technicians, and often sub-specialty trained radiologists. All these things add to the cost of producing this quality and are not likely to be rewarded by the new UHC program.
We should be pushing for all advanced imaging to be read by sub-specialty trained radiologists. We should be pushing for advanced imaging to be done on the right equipment with the right software. We should be pushing for groups to conduct strong internal quality review programs. We should be pushing for the best imaging and not the cheapest imaging.
If two options are equal in quality and one is more expensive, of course the patient should be able to choose the less expensive option. The problem with UHC’s approach is that it produces the illusion of quality to push to lower cost providers, a push that will increase the profits of UHC.
Finally, do we really think that for-profit, publicly traded, insurance companies are the best arbiter of quality? I do not. If UHC, or any other payor, is really interested in quality, they why don’t they partner with someone like the ACR and fund an external, robust quality review program that includes much greater depth than just accreditation and timeliness of service? They don’t simply because it is not about quality; it is about money.
While we need to consider the cost of imaging, it should not come at the expense of a patient. Missing early detection of a tumor or a brain aneurysm can be fatal. It may not happen very often, but if it happens to you or your family you will wish UHC looked at more than just cost.