Anthem intercepting and redirecting imaging referrals

Need an MRI? Anthem might have a deal for you

By Shari Rudavsky
January 30, 2011

... an Anthem Blue Cross and Blue Shield pilot program made its debut in December. Under the program, an Anthem employee calls policyholders who have been approved for scans and lets them know whether a cheaper, high-quality option exists close to them. If the policyholder agrees, Anthem sets up the appointment.

Anthem officials say they designed the program to steer their patients toward higher-quality facilities that charge less. But some say more emphasis is being placed on costs and not on quality of care and consequences for the patient.

The program is currently limited to Central Indiana policyholders scheduled for imaging such as MRI and CT scans. Still, it could usher in a major change in health care in which insurers work directly with policyholders to keep costs low for a variety of medical services.

"This puts a lot more control in the hands of the individual consumer and allows the consumer to make a decision that is a good one," said Susan Pisano, a spokeswoman for the Association of Health Insurance Plans. "I think you're going to see this kind of program more and more in the short term."

If the program proves successful, the company might explore the idea of similar programs for lab tests or colonoscopies.


By Don McCanne, MD

WellPoint's Anthem Blue Cross and Blue Shield subsidiaries have led the health insurance industry in innovation, but these innovations have been designed to improve their business model and profits, not to improve health care. Even though regulatory oversight of the insurers should increase as a result of enactment of the Patient Protection and Affordable Care Act, this new innovation of intercepting and redirecting patient referrals reveals that the private, for-profit insurance industry has every intention expanding the range of self-serving innovations that increase profits as long as the innovations fall below the threshold that would induce a patient backlash.

There are a great many reasons why a physician may select one imaging center over another for the patient's procedure. The decision may be based on the quality of the equipment or the skills of the radiologist's team. It may be based on prior positive or negative experiences with the centers. It may be based on integrated eHealth systems. It may be based on specific procedures not utilized in all centers. Regardless, these are clinical decisions that should be made by physicians who have their patients' health care needs first and foremost in their minds.

(Physicians also may selectively refer to their own imaging centers - a conflict of interest that is another problem, though not covered in today's message.)

When the insurer intercepts and redirects a referral, it is done to reduce the insurer's costs. The insurer may claim that the intervention is to direct the patient to higher quality services, but the referring physician should be in a much better position to make that judgement. No, the decision is made on the basis of, "It's the prices, stupid."

The problem that the insurers are addressing is very real. Prices do vary tremendously, especially between facilities that are contracted with the insurer and those that are not. This raises the extremely important point that a health care financing system based on multiple private insurers acting independently cannot possibly bring us appropriate, reasonable pricing throughout the entire health care delivery system.

Of course, this is one of the more important advantages of a single payer system. Prices are not based on secret contracts and dysfunctional markets; instead they are based on negotiation with a public administrator, taking into consideration legitimate costs and fair profits. The interests of patients are served by preventing excessively high prices that waste taxpayer funds while providing adequate payment to ensure that the health care professions will remain attractive to well qualified individuals. The private insurance industry will never get this right.