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A success story in advocating for better radiology insurance coverage

por John W. Mitchell, Senior Correspondent | December 06, 2021
Pediatrics X-Ray
From the March 2022 issue of HealthCare Business News magazine

When Anthem Insurance issued a new policy in 2017 determining where its members could get radiology services, a consortium of medical groups took exception to the fine print. Anthem instructed that all of its adult members would need to seek services at lower-cost outpatient centers — the only problem was that the company defined adults as any patient ten years or older.

Other insurers soon followed suit. The redirection of patients to lower charging outpatient providers is a common action by insurance companies known as steerage. The policy set up a four-year advocacy fight that ended in August when the last of three insurers reversed the policy, moving the adult age to 18.

For Dr. Richard Elliott Heller III, pediatric radiologist associated with the University of Chicago Medical Center’s Comer Children’s Hospital, the work to reverse the policy came down to two strategies: persistence and forming a coalition of medical organizations too big to be ignored and too big to fail. He presented his experience as part of an RSNA 2021 session titled “Health Policy Agenda: Are Radiologists at the Table?”

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"They would have sent (my ten-year-old) to (an outpatient center) regardless of if the imaging center has pediatric neuroradiologists," said Heller.

In making the decision, Anthem cited research that demonstrated the safety of providing services in free-standing centers. Anthem, Heller said, cited access to quality while reducing costs when a member's health was not put at risk. But Heller suspected the primary motivation was financial and not about quality — and he said he had good reason to think that.

“This [was] economically motivated patient steerage, sending patients to imaging centers without reason,” he said. “There’s a consistent theme — it's a lot cheaper … to go to the imaging centers than to get your imaging done at a hospital outpatient department.”

The research Anthem cited in justifying the change included a 2016 study titled "Guidelines for Diagnostic Imaging During Pregnancy and Lactation." Heller said that the study obviously had no association with pediatric standards of care. To get organized and confront the policy, he and colleagues took the following steps:

– Defined the issue: The Anthem policy broke the first rule of pediatric care — children are not little adults. Heller said the group worked to convey the value of pediatric radiologists, noting that it’s not that other radiologists are not competent. But pediatric radiologists (and technologists) are trained in children’s pathology and have insight into what’s normal and abnormal and what variance is acceptable. Also, pediatric imaging deploys protocols to minimize dose exposure.

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