Rapoport Robert J, Parker Laurence, Levin David C, Hiatt Mark D
St. Peter's Hospital, Albany, NY, USA
Thomas Jefferson University, Philadelphia, PA, USA.
Med Care Res Rev. 2016 Jun;73(3):369-80. doi: 10.1177/1077558715607749. Epub 2015 Sep 28.
A decade of rapidly rising outpatient advanced imaging utilization ended toward the end of the past decade, with slow growth since. This has been attributed to repetitive reimbursement cuts, medical radiation exposure concerns, increasing deductibles and patient copayments, and the influence of radiology benefit management companies. State Medicaid programs have been reluctant to institute radiology benefit management preauthorization programs since the time burden for obtaining test approval could cause providers to drop out. Also, these patients may lack the knowledge to appeal denials, and medically necessary tests could be denied with adverse outcomes. Little data exist demonstrating the efficacy of such programs in decreasing utilization and cost. We report a 2-year experience with an outpatient advanced imaging prior notification program for a large state Medicaid fee-for-service population. The program did not allow any denials, but nevertheless the data reveal a large, durable decrease in advanced imaging utilization and cost.
在过去十年接近尾声时，门诊高级影像检查的快速增长趋势结束，此后增长缓慢。这归因于报销费用的反复削减、对医疗辐射暴露的担忧、免赔额和患者自付费用的增加以及放射学效益管理公司的影响。自州医疗补助计划实施以来，一直不愿设立放射学效益管理预先授权计划，因为获取检查批准的时间负担可能导致医疗服务提供者退出。此外，这些患者可能缺乏申诉被拒的知识，而必要的医学检查可能会被拒绝，从而产生不良后果。几乎没有数据表明此类计划在降低使用率和成本方面的有效性。我们报告了一项针对一个大型州医疗补助按服务收费人群的门诊高级影像预先通知计划的两年经验。该计划不允许任何拒绝，但数据显示高级影像检查的使用率和成本大幅且持续下降。
