One-Adam-12, One-Adam-12, see the doctor…

I  recently  ordered  an   MRI  on  a patient who had had several months of severe knee pain.  I suspected some kind of tear in the joint.  Despite having tried more conservative treatment first, which included an inconclusive knee radiograph, the MRI was rejected by the patient’s insurance.

I phoned the so-called “radiology benefit manager” and spoke with a rather surly physician.  Based on her 15 second familiarity with my patient, derived entirely on what the computer screen in front of her told her, the RBM doc advised physical therapy.  I responded that physical therapy would involve moving the knee joint around quite a bit.  This caused my patient considerable pain which is why I was ordering the MRI.  In medicine the technical term for this sort of reasoning is common damned sense!  The exasperated RBM physician at last deigned to authorize my patient’s MRI which would reveal a tear in her medial meniscus.

According to Anna Wilde Mathews, writing in the Wall Street Journal, this sort of “radiology policing” is becoming increasingly common:

Big insurers including Aetna Inc., WellPoint Inc. and Cigna Corp. have hired so-called radiology benefits managers, or RBMs. Health plans say they want to ensure that doctors use high-tech scans only when it is clear that patients will benefit. The RBMs say their guidelines are based on scientific evidence and medical groups’ recommendations. Often, the firms require doctors to get permission to do a scan before the insurer will agree to pay for it.

This is not a good idea.  Here’s why:

Edward Agura, an oncologist at Baylor University Medical Center, wanted to monitor a patient, Dallas resident S. Blaine Porter, with PET scans every three months for two years after Mr. Porter, 47, was treated for aggressive lymphoma in 2006. Dr. Agura and Mr. Porter say RBM American Imaging Management and Mr. Porter’s insurer, Blue Cross and Blue Shield of Texas, a unit of Health Care Service Corp., required pre-approval for each scan, which delayed the tests. As a result, they say, Mr. Porter waited around four months or more between PETs. In July 2007, Mr. Porter had a seizure that turned out to be caused by a new tumor, this one between the two lobes of his brain.

Dr. Agura says he believes that the new brain tumor might have been detected earlier if the scans had taken place promptly every three months. “Every time we scanned him, we had to go through a lengthy approval process,” he says. “Delays in approval lead to cancers coming back and not being detected.”

Admittedly, doctors probably do order too many diagnostic imaging studies.  Two obvious reasons for this are fear of lawsuits by physicians and the fact that third party payors, rather than the patient, usually end up picking up most or all of the bill.  It would be better if we reformed our legal system to prevent frivolous lawsuits.  Additionally, if patients rather than third party payors dealt directly with imaging facilities with respect to payment, the cost of these imaging studies would actually come down.

Increasingly, the once authoritative “doctor’s orders” is being subverted into “Mother, may I?” as third party payors — in fairness, themselves fellow victims of rising health care costs — try to do what is best for the bottom line, but not necessarily for the patient.