Quickly after Cigna Corp. waived prior authorization necessities and eased protection guidelines to make sure sufferers may obtain wanted care through the coronavirus pandemic, the well being insurer tightened restrictions in different areas.
In August, the nation’s fourth largest insurer by membership grew to become the third main payer to limit protection for many superior imaging, akin to MRIs and CT scans, when carried out in a hospital-based division or facility, besides in restricted circumstances.
The coverage applies to Cigna’s members in self-funded employer plans, totally insured industrial members, and Cigna’s personal workers and their dependents. These teams make up most of Cigna’s 17 million members. The corporate intends to roll out the coverage to particular person and household plan members in January.
Cigna’s coverage is much like these put in place by Anthem in 2017 and UnitedHealthcare final 12 months. Anthem’s controversial rule—the primary of its variety—drew ire and litigation from hospitals. Suppliers argued that the insurance policies threatened to sap a big income whereas eliminating affected person selection and interfering with the doctor-patient relationship.
Just like the insurers earlier than it, Cigna stated its new guidelines are supposed to direct sufferers away from costly hospitals towards lower-cost amenities, akin to free-standing imaging facilities or workplace settings. What makes Cigna’s coverage stand out is it was applied within the throes of a pandemic, when hospitals are coping with lower-than-normal affected person volumes and ensuing monetary losses.
“Insurance policies akin to these limit affected person entry to care with out regard to the standard or coordination of care,” stated Molly Smith, vice chairman for protection and state points discussion board on the American Hospital Affiliation. “It’s notably disturbing to see these sorts of unilateral steps to decrease affected person entry to care throughout a worldwide pandemic.”
Well being insurers have lengthy determined what to cowl based mostly on whether or not they suppose a service is medically obligatory for a affected person. Solely extra lately have they begun dictating the place that affected person ought to get that service, as they attempt to tamp down declare prices.
“The aim of the coverage is to offer protection for our prospects to get the best care on the proper place and the best time,” a Cigna spokeswoman stated in an e-mail. “Which means serving to to direct them to a freestanding radiology heart or different office-based settings when there may be not a medical motive for companies to be carried out at a extra pricey hospital setting.”
It is true that the price of an imaging service varies drastically by the place a affected person receives it. The price of an stomach MRI prices $1,751 at a hospital and $680 at a freestanding imaging heart, in line with healthcare worth transparency firm Amino. With practically 46% folks with personal insurance coverage in a high-deductible plan, sufferers may very well be on the hook for a big portion of that price. Freestanding imaging facilities are usually cheaper as a result of they supply one service and have much less overhead.
A spokeswoman for America’s Well being Insurance coverage Plans, the medical insurance sector’s lobbying group, stated in an emailed assertion that “selling lower-cost settings for companies that present the identical degree of high-quality, efficient care is likely one of the methods we work for decrease premiums and out-of-pocket prices for you.”
However critics argue that the insurer site-of-care insurance policies focus narrowly on price and disrespect the standard of an imaging heart. Analysis reveals that in healthcare, greater prices do not correlate with higher high quality.
“It is a purely cost-based coverage, which is why we’ve a problem with it,” stated Kathryn Keysor, senior director of economics and well being coverage on the American Faculty of Radiology. “If they may point out that high quality was higher at sure locations, or in the event that they not less than took high quality under consideration—however they do not.”
At present, there isn’t any knowledge out there to match the standard of imaging facilities, so it is arduous to understand how sufferers may very well be affected by the coverage, stated Leah Binder, CEO of Leapfrog Group, a not-for-profit centered on the standard and security of healthcare.
“What I feel well being plans ought to be doing is growing high quality measures on imaging. We do not have good methods to measure the standard, and till we try this, this methodology may very nicely be pennywise and pound silly—or not, we simply do not know,” she stated.
A poor-quality imaging heart may result in mistaken diagnoses, which may end in mistaken therapies and finally reparative therapies, she stated, “which is way costlier than any differential between imaging in a hospital and imaging in outpatient.”
Analysis suggests imaging facilities aren’t created equally. One 2016 examine in The Backbone Journal discovered extensive variation amongst 10 imaging facilities’ MRI examination findings of a 63-year-old lady with low again ache. The 10 exams produced 49 totally different findings, from disc bulges to disc era to stenosis. Not one of the reported findings have been unanimously reported in all 10 examinations. Researchers additionally found “an alarmingly excessive variety of interpretive errors.”
Different critics argued the coverage takes away affected person selection undercuts a doctor’s judgment.
“They need to give the would-be affected person and the doctor an opportunity to have a dialogue as a substitute of those one-way guidelines,” stated Rick Gundling, senior vice chairman of Healthcare Monetary Administration Affiliation.
Dr. Marc Succi, an emergency radiologist and director of the MESH Incubator, a know-how incubator at Massachusetts Basic Hospital, stated insurance policies that push sufferers to suppliers that are not built-in with the hospital may make it tough for a health care provider to get a full image of a affected person’s well being.
“We get CDs lacking half the pictures from all these outpatient facilities or different hospitals that aren’t a part of our system,” he stated. “The know-how is just not fairly there… Asking sufferers to go get their CDs from outpatient facilities is just not environment friendly and never good continuity of care.”
Succi additionally stated sufferers generally have issues throughout imaging, akin to a response to distinction, a dye utilized in throughout some MRIs. In these circumstances, it helps to be in a hospital setting the place assistance is 30 seconds away, he stated.
Cigna stated it will proceed to permit companies to be carried out at a hospital when a affected person’s situation warrants it. It will think about high-tech imaging in a hospital-based facility to be medical obligatory when a affected person has a identified allergy to distinction that’s going for use, or when the affected person is beneath 10 years outdated or is pregnant and requires obstetrical statement or perinatology companies.
The insurer additionally made exceptions for when imaging is said to a transplant, or when there are not any applicable different websites out there for the affected person to obtain imaging. It will cowl pre-operative imaging that’s integral to a surgical procedure or different process being carried out at a hospital, or if imaging exterior of a hospital is predicted to adversely have an effect on or delay care, as an illustration.
Past MRIs and CT scans, the coverage additionally applies to magnetic resonance angiography and computed tomography angiography. It doesn’t apply to x-rays or mammography.
The coverage may exacerbate the monetary woes of hospitals, which struggled with lower-than-normal affected person visits through the early months of the pandemic when suppliers postponed non-urgent procedures. Hospital radiology departments noticed a lower within the variety of sufferers receiving MRIs, CT scans and different imaging companies. Traditionally, radiology has been a moneymaker for hospitals.
“It is only one harder factor,” Gundling stated. “Something that places a block in entrance of the affected person’s and hospital’s relationship, it is by no means a superb factor for the affected person or the hospital.”
In line with a examine by researchers at New York-based Northwell Well being, whole imaging volumes on the well being system decreased 28% over a 7-week interval through the pandemic, in contrast with the identical interval in 2019. At its worst, volumes fell 88% within the outpatient setting, whereas the variety of MRIs delivered fell as a lot as 74%.
Researchers from Mass Basic equally discovered that common weekly imaging quantity declined 54% on the important hospital campus and 64% at affiliated imaging facilities between late March and late Might, in contrast with earlier than the pandemic. In line with Succi, one of many examine’s authors, funds have recovered, however that does not essentially imply funds have.
There isn’t any knowledge exhibiting how insurers’ imaging site-of-care insurance policies have affected hospital funds or affected person care. Keysor stated the American Faculty of Radiology hasn’t obtained calls from hospitals about their volumes dropping considerably resulting from these insurance policies.
However Brian Tabor, president of the Indiana Hospital Affiliation, stated Anthem’s coverage, which has been in impact for a couple of years within the state, has created some issues.
“Anthem’s coverage created disruptions in scheduling, usually leading to repeat or canceled visits or procedures,” he stated in an e-mail. “A canceled working room go to, for instance, not solely delays take care of that affected person however it additionally limits entry for an additional affected person who may have been scheduled. As well as, sufferers are generally despatched to low-quality imaging which presents issues for the diagnosing doctor and their sufferers.”