High-Technology Diagnostic Imaging Initiative
Executive Summary

In recent years, providers have been ordering more high-technology diagnostic imaging (HTDI) tests. However, increased use of these tests have not shown a marked improvement in patient outcomes.

This raised concerns in the medical community. While HTDI tests like CT scans offer superior images to help providers make better diagnoses, they also expose a patient to much more radiation than a traditional x-ray. Also, the use of HTDI procedures is increasing at a rate of 15-20% annually—twice the rate of prescription drugs and far greater than the 10% annual increase in overall health care spending. This increased use of HTDI tests is raising health care costs for consumers, employers and insurance companies.

Such reasons caused several Minnesota health plans to set prior notification (PN) rules. They require the provider to contact a health plan service before ordering an MRI, CT, PET or Nuclear Cardiology test to see if it would be covered by insurance.

PN reduced the number of HTDI tests ordered in Minnesota. But it was not clear if PN resulted in more appropriate use of HTDI tests. Moreover, PN often did not let the provider order a HTDI test when their patient was present. This delayed the test and possibly delayed diagnosis or care. This burdened patients because often they had to return at a later date to receive their approved test. Also, providers claim PN added work and expense to their clinics without a known improvement in patient care.

The Institute for Clinical Systems Improvement (ICSI) was asked to address this issue because it is known for bringing diverse groups together to find solutions to health care issues that no single entity can solve on its own.

ICSI set up a pilot program to see if it could develop an alternative approach to PN so that providers could order HTDI tests while with their patients. ICSI helped define the pilot design criteria, reporting criteria, measurement of results, and what data the medical groups would send to health plans to show they were using the ICSI alternative approach.

Taking part in the pilot program were six medical groups (Allina Medical Clinic, Fairview Health Services, HealthPartners Medical Group, Mayo Clinic, Park Nicollet Health Services, and St. Mary’s/Duluth Clinic Health System), five insurance companies (Blue Cross Blue Shield of Minnesota, HealthPartners, Medica, PreferredOne and UCare Minnesota), and the Minnesota Department of Human Services.

In the pilot, the medical groups developed a model that addressed 90% of their ordered CT, MRI, PET and Nuclear Cardiology tests by using guidelines based on American College of Radiology (ACR), American College of Cardiology (ACC) and expanded ICSI imaging appropriateness criteria. This process was made part of their routine workflow so providers could order images at the point of service.

Pilot Results
Pilot medical groups met the expectation of gauging 90% of their HTDI tests against ACR/ACC/ICSI criteria, and don’t go through PN before ordering images. The combined data from the participating medical groups showed a high level of appropriate use of HTDI tests using the ICSI approach.

The health plans accepted the ICSI alternative as a more efficient and effective way to deliver patient-centered and value-driven care. Although the pilot program has ended, the pilot medical groups are continuing to use and refine their imaging appropriateness criteria. They report this approach helps providers and their patients share in the decision of whether to have a HTDI test taken.

This solution shows how medical groups and health plans can work together to accelerate improvement in patient care. Orders for HTDI tests are more appropriate under this approach and the trend of increasing usage has flattened. Clinics are more efficient and don’t have to meet PN requirements. Providers have a useful tool to educate patients on whether a HTDI test should be done.

ICSI is currently exploring whether the solution developed in the pilot program might be expanded to many other medical groups statewide. The ICSI board of directors will review this plan shortly to determine the viability of pursuing a statewide solution.