Understanding
Steerage
WAKE RADIOLOGY UNC REX HEALTH
Given the increased prevalence of steerage and the confusion it’s causing patients and referring providers, Wake Radiology has summarized the 2013 American College of Radiology (ACR) white paper on Imaging Services Steerage Programs to help answer some common questions.
For questions related to steerage, Wake Radiology encourages patients and referring providers to contact our Billing team at 919-787-8221 or askbilling@nullwakerad.com.
Payors often have programs to control the utilization and cost of high tech imaging modalities (e.g., MRI, CT and nuclear medicine studies). Payor utilization management programs, whether administered internally or by a third party radiology benefit management company (RBM), typically use a combination of medical need determination and pre-authorization or pre-notification strategies. Once the imaging study is authorized, imaging services steerage programs (ISSP) attempt to re-direct the patient to “preferred imaging providers.”
Two Types of Steerage Programs
There are two types of payor steerage programs—active and passive:
- Active steerage occurs when the patient or physician is contacted to direct approved service requests to a payor preferred provider. A few programs provide immediate incentive rewards such as gift cards or cash for choosing certain providers.
- Passive steerage typically consists of payor provided information on facility costs and other data. The patient or treating physician can consult this database and voluntarily choose a provider as they see fit. Variable co-payment levels are designed to incentivize these choices.
Focus is on Price While Quality is Ignored
As long as basic quality standards are met, many ISSP treat imaging as an undifferentiated commodity and use pricing alone as the provider discrimination criterion. Other important quality-related information that is frequently ignored includes:
- Individual patient needs
- Radiologist expertise and subspecialty training
- Continuity of care
- The age and performance level of the imaging equipment
- Examination protocols
- Practical access to pertinent patient clinical information (e.g., prior imaging studies and longitudinal imaging record)
- Quality assurance programs
- Patient safety and convenience
- Physician communication and consultation
- Patient satisfaction
According to the ACR, any credible determination of “value” must take the above factors into consideration. Furthermore, in deciding the value of healthcare, the best care and the lowest cost may not be the same choice.
When payors try to directly influence the patient’s or treating physician’s choice of imaging provider, this strategy is typically referred to as “steerage.” Imaging steerage programs have a simple goal of lowering service costs. While quality equivalence may be claimed, quality improvement is not a goal. In fact, the college has discovered that ISSPs do not actively redirect patients from lower quality to higher quality facilities except due to price. And no quality outcomes data are collected to ensure that patients are not harmed.
Lack of Transparency
Importantly, many ISSP redirect imaging provider appointments after the patient leaves the referring physician’s office:
- This is done without the knowledge or input of that responsible physician.
- In many cases, the economic interests or motivation of the benefit management company are not transparently disclosed to the patient who is being contacted. Additionally, health plan or RBM employees are sometimes directly compensated based on patient steerage success.
- Referring physicians are often not provided with an opportunity to review the information given to the patient to ensure accuracy, and the caller scripts used by the companies to call patients are also undisclosed.
- All ISSP arrangements are not ethically acceptable. Direct cash, gift card or equivalent payments to a patient or a physician from a payor for choosing a particular imaging provider may be inappropriate incentives in healthcare. Payments from a provider to the payor or their agent for an increased volume of referrals may be unethical and potentially illegal.
- Caller scripts are frequently misleading, and they intentionally present inaccurate information designed to steer a patient to a particular provider. When organizations fail to promptly correct inaccurate information after appropriate notification, this is arguably a breach of ethical business practices.
- Many patients have difficulty making fully informed decisions in these situations.
Costly Negative Impact
Patients trust their treating physician’s choice of imaging provider. ISSP for some patients causes confusion and anxiety. Patients assume the alternate facility has equivalent capabilities, access to their records, that their treating physician and healthcare system have access to their imaging findings, and that the provided steerage information is accurate. However, the radiologist and imaging facility where the patient is redirected frequently do not have easy access to prior imaging studies and a complete patient medical history. Obtaining this information may be difficult, increases their costs, and may not be accomplished. Additionally, steerage can lead to:
- Sub-optimal interpretation, inappropriate follow-up recommendations, etc.
- In some cases, the referring physician needs to have a second interpretation done because of incomplete clinical information, lack of comparison studies, and other legitimate concerns.
The bottom line for the ACR is that all these steerage situations create the risk that patients make vital medical decisions on the basis of non-medical information and incentives rather that what may be medically best for that patient.