HMSA’s new rule for imaging exams frustrates physicians

HONOLULU (AP) — The Hawaii Medical Service Association is imposing a new pre-authorization requirement that doctors say is delaying critical imaging tests and resulting in harmful consequences for patients.

The state’s largest health insurer, with 720,000 members, is now requiring physicians to go through a third party on the mainland to approve diagnostic imaging exams including MRI scans and computerized tomography, or CT, scans, and certain cardiac-related procedures in an effort to reduce unnecessary costs. The new rules started on Dec. 1.

“Now HMSA routinely denies most heart and X-ray tests,” said Dr. Christopher Marsh, a Honolulu-based internal medicine physician, in a letter to the Honolulu Star-Advertiser. “They think or assume your doctor doesn’t know what he/she is doing, and is too stupid to competently order tests on you. Or is a criminal, gaming the system, and benefiting illegally from ordering tests.”

Before Dec. 1, physicians deemed to be appropriately ordering scans received a waiver that allowed them to skip the pre-authorization step. But as medical costs escalated, HMSA changed its policy to require all of its 2,800 physicians to get approval for imaging tests. The insurer would not say how many doctors previously had waivers.

The decision on whether a test is necessary is now made by an Arizona-based company called National Imaging Associates Inc., part of Magellan Health. The company guarantees “multi-year cost savings” for its clients.

In effect, doctors say, HMSA has basically stripped local physicians of their ordering privileges for imaging exams.

HMSA defended the policy, citing research that shows trends in imaging and related services in Hawaii are higher than national benchmarks. The insurer did not say how much it is spending on excessive imaging tests or how much the program is expected to save.

“Millions of health care dollars are spent each year on unnecessary medical care that doesn’t improve the community’s health and well-being,” said Elisa Yadao, HMSA senior vice president of consumer experience, in a statement. “When we pay for unnecessary services, those costs are eventually passed on to everyone. By requiring pre-authorizations, we can reduce the number of unnecessary procedures, avoid our members being exposed to excessive radiation and lower costs.”

The majority of these imaging tests range from $600 to $700, but could be more expensive depending on the type of scan or the number of tests a patient needs, HMSA said.

Nationally, 30 percent of imaging is “non-value-added,” resulting in unnecessary exposure to radiation for members and excessive costs for the payer, said Dr. Michael Pentecost, chief medical officer of National Imaging Associates, in a statement.

“In other areas where this program has already been implemented, Magellan has found significant overuse, the management of which has driven significant improvements in patient safety and cost control,” he said, adding that HMSA uses national appropriate-use guidelines when making these determinations. “HMSA’s prior authorization program has been in place since 2006. However, this newer program will further reduce the number of unnecessary tests, therefore improving patient safety and more efficiently controlling costs.”

Still, the practice is disrupting care for patients.

Allen Chun was scheduled on Jan. 13 for a stress echocardiogram, or treadmill test, to determine how well his heart and blood vessels are working. The 60-year-old Honolulu resident had an abnormal electrocardiogram, or EKG, and “huge risk factors” for coronary heart disease, including diabetes and a family history of heart problems. The test was canceled the day before the exam when the procedure was denied.

“The experts at HMSA don’t think you need any further heart evaluation,” Marsh, Chun’s doctor for the past 30 years, told him in a Jan. 16 letter. “They think I am ordering expensive, frivolous tests and don’t know what I am doing. Better to just kick the can down the road and hope for the best. Meanwhile, please call me immediately if you develop shortness of breath or chest pain (although diabetics often don’t get any chest pain during a heart attack). Good luck!”

Marsh said he doesn’t know why the procedure was denied and is seeking to appeal the decision by HMSA.

“They routinely deny these things and require a lot more records. It is called the hassle factor, trying to limit medical care to save them money,” Marsh said. “Some idiot wasn’t satisfied with a very high-risk patient. We just don’t have 60 to 90 minutes to spend on the phone begging HMSA to pay for a semi-urgent test. These are not unusual tests. These are tests that doctors almost always order. I have no stake in ordering these tests. In most of these cases it would be malpractice not to get them. It’s been a huge stress and strain on our staff and it harms patient care.”

Appeals can take up to 30 days to get approval for a “potentially life-saving, commonly accepted heart test,” he added.

“I would want to know how my health is and overall my heart condition,” Chun said. “It’s something I wouldn’t want to take lightly. I want to make sure that I’m OK.”

HMSA’s initial review can take up to 14 days for determination, according to the Queen’s Medical Center. For urgent matters, the hospital said it does not delay the study, but continues to work on securing approval from the insurer. Pre-authorizations for outpatient imaging exams jumped to 49 percent when HMSA’s rule took effect in December, from 16 percent in the preceding months, Queen’s said.

“It is too early to determine any financial impact this new process may have,” said Kristen Bonilla, spokeswoman for Hawaii Pacific Health, parent company of Kapiolani Medical Center for Women & Children, Pali Momi Medical Center, Straub Clinic & Hospital and Wilcox Health on Kauai. “However, we have taken steps to assist our physicians to minimize any additional administrative burden and ensure our patients continue to receive the care they need when they need it. We have created a dedicated team to assist with and expedite the approval process. We are committed to reducing unnecessary diagnostic testing, from both a cost and patient care perspective, and do support having a review process.”

HMSA acknowledged that asking doctors to obtain preapproval for certain procedures may add to their administrative burden. The insurer said it has “made adjustments to streamline the authorization process while protecting the health of our members” and is offering training and webinars to help doctors through the change.

Because of the delays in getting approval, some doctors are sending patients directly to hospital emergency rooms to obtain routine imaging tests. HMSA’s pre-authorization rule is not required for orders in the emergency department or inpatient procedures.

“Physicians are throwing up their hands, frustrated with the delays and sending their patients directly to the ER. In the ER they don’t have to wait for pre-authorization,” said Dr. Scott Grosskreutz, a diagnostic radiologist in Hilo. “The more it becomes harder to order tests, to see your patients and make decisions in a timely manner, the more office patients are going to end up at the doorstep of the emergency room. That’s a lot more expensive.”

Imaging costs for insurance companies in Hawaii are much less than the mainland because utilization rates are among the lowest in the nation, and HMSA’s reimbursement rates for these services are 25 percent less than other Blue Cross Blue Shield payers, Grosskreutz said.

“It’s a problem when it comes down to a money issue,” said Dr. Chris Flanders, executive director of the Hawaii Medical Association, representing 1,100 physicians. “There’s been a big impact. The specialties that use MRI and CAT scan on a regular basis for diagnostic purposes are being impacted by this quite a bit and they’re upset about it. This is delaying patient care and with a delay in patient care comes poorer outcomes. This is damaging to our patients by having an excessive delay in the start of care.”

Dr. Linda Rasmussen, an orthopedic surgeon in Kailua, recently diagnosed a patient as having a torn meniscus, one of the most common knee injuries. The patient, a 52-year-old truck driver, had symptoms of the injury for six months, but was denied an MRI. Instead, HMSA is requiring the patient to have physical therapy for four weeks, she said.

“This is a major problem,” Rasmussen said. “The PT will cost more than the MRI or knee surgery. The insurance companies are spending more money trying to micromanage physician decisions. This leaves less money for direct patient care. It is a huge waste of money.”

It also is impacting the finances of imaging centers as fewer tests are approved, said Dr. Scott McCaffrey, an occupational medicine specialist and president-elect of the Hawaii Medical Association.

“This new measure is undermining the economic well-being of major imaging centers in our state as well as the hospitals,” he said. “For all those reasons it’s neither good medicine nor good cost control.”

HMSA’s pre-authorization rule is “causing a significant disruption in clinic work flows” for Dr. Byron Izuka, a pediatric orthopedic doctor and director of orthopedic research at the University of Hawaii Division of Orthopaedic Surgery. Izuka said it is taking his patients at least a week to get approvals for imaging tests.

“Normally patients get an MRI within two or three days,” he said. “Once approval is received, they still have to make an appointment. For most orthopedists the vast majority of MRIs confirm injury diagnoses, tumors and cancers. It’s detrimental in the sense that it changes the standard form and usual expectations. The sooner you get into rehab, the quicker you can recover.”

The biggest concern, he said, is that the new process creates another step in which patients can get forgotten and fall through the cracks.

“This is how human mistakes occur,” said Izuka, who previously had a waiver from HMSA’s approval process. “They have all the data on anyone who is an HMSA physician. They could, at any time, retroactively review my behavior. I don’t disagree with the spirit of what they’re trying to do, but we disagree with the actual approach itself. I don’t want bad apples ordering MRIs that are not medically needed. Everyone pays for wasted health care.”