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Anthem Blue Cross and Blue Shield drew attention and criticism earlier this summer when it announced a change in its Imaging Clinical Site of Care program. The policy states that MRIs and CT scans not deemed “medically necessary” should be done at freestanding medical imaging centers rather than at a larger hospital.
The program, which went into effect in four states on July 1 and five additional states on September 1, claims that patients will benefit from less expensive scans at outside imaging centers. Now, when physicians place an order for a scan that is not considered medically necessary, the provider portal will suggest imaging centers where a patient can go. An Anthem spokesperson also stated that the new measure should help to keep insurance premiums low, which is valuable to all patients.
Rural patients in particular face a unique set of issues when seeking medical care. There are generally not many options for those living in pastoral regions of the country, including independent medical imaging centers. However, Anthem has stated that if there is a dearth of accessible alternatives, scans may be re-categorized as medically necessary and eligible to be completed at a hospital.
In addition to patient health, some industry leaders have voiced concern that the new program will harm the financial health of some hospitals. Many hospitals rely on medical imaging revenue to make up lost revenue from other services and procedures—sometimes up to half of their overall profits.
The policy will be enacted in 13 of the 14 states where Anthem insures patients by March 2018, and will affect approximately 4.5 million customers. It will primarily affect members with high-deductible plans as the costs associated with scans done at freestanding medical imaging centers are traditionally lower than those done at hospital imaging centers, though the costs vary widely by state as well as by site of care.
Yet other industry professionals wonder whether the shift of medical imaging to freestanding centers will disrupt the patient-physician relationship. If a scan is ordered and not deemed medically necessary, this could potentially put physicians in the position of turning their patients away and directing them outside of their traditional care site and eliminating the physician’s judgement in what could be best for each individual patient. Additionally, some hospital groups have voiced concern that care coordination and delivery will be left out of the equation in favor of solely cost-cutting measures.
The policy will likely be very beneficial to independent imaging centers, as referral patterns will shift to direct a greater number of patients outside of hospitals. Many industry professionals do not see a significant difference in the quality of care patients receive at hospitals versus freestanding imaging centers, and therefore do not believe patient health would be at risk.
This trend toward independent care centers is reflective of a general shift away from hospitals, driven by consumer desire for a greater number of options when receiving care. The increasing popularity of outpatient surgery centers, or ASCs, is also indicative of this trend. In the same way that hospitals have opened associated ASCs, some could also open freestanding but separate medical imaging centers to catch patients who are directed outside of the hospital for specialty care.
Other insurers are also likely to take cost-cutting measures surrounding elective surgeries and specialty care, where the price differences are often greatest depending on the site of care. CMS seems to have anticipated this in regard to orthopedic services, as indicated by the consideration of joint replacement reimbursement for ASCs that was announced earlier this year.
Top Medical Imaging Center Corporations by Total Medicare Payments
|Corporation Name||Total Medicare Payments (M)||# Procedures|
|Diagnostic Laboratories & Radiology||$91.6||2,595,526|
|Shields Health Care Group||$9.6||169,129|
|Touchstone Medical Imaging||$6.1||606,725|
|Center for Diagnostic Imaging||$4.9||459, 472|
|Austin Radiological Association||$4.1||327, 449|
|Visiting Physicians Association||$3.9||71,579|
Fig 1 Data from Definitive Healthcare
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