Highmark Expanding Program To Help Ensure High-Quality Cardiac Imaging Services

In an effort to address growing patient safety concerns about radiation exposure from cardiac imaging procedures, Highmark Inc., beginning in September, is expanding its existing program designed to improve the quality and appropriateness of diagnostic imaging services.

General practitioners, cardiologists and other providers will be required to request an authorization before performing a commonly used diagnostic cardiac imaging test, myocardial perfusion imaging (MPI). Since April 2006, Highmark has required providers to obtain pre-authorization when ordering selected advanced diagnostic imaging procedures, such as magnetic resonance imaging (MRI), computerized axial tomography (CAT) and positron emission tomography (PET).

Highmark is expanding its current program amid increasing public awareness and scrutiny of the risks of over-exposure to medical radiation. A July 2010 article in the Journal of the American College of Cardiology, by Dr. Jersey Chen of the Yale University School of Medicine, noted that with the growing use of cardiac imaging tests with radiation exposure, “clinicians and patients must consider tradeoffs between the benefits of cardiac imaging procedures and their potential long-term risks due to radiation, mainly those of malignancy.”

Virginia Calega, M.D., Highmark’s vice president of medical management and policy, said the radiation dose from an individual MPI study is greater than the radiation dose from many other common diagnostic imaging tests. “Highmark members are undergoing more cardiac imaging tests, especially MPI studies, compared with members of other health plans, increasing the risk of radiation exposure. Some Highmark members are undergoing repeat MPI studies over a three-year period.”

Highmark is also expanding the program in response to growing concerns from many of its employer group customers about the appropriateness and the cost of advanced imaging services, in particular cardiac imaging testing. A 2009 study reported in the Journal of the American College of Cardiology found that more than 14% of MPI studies were inappropriate and another 15% had an uncertain level of appropriateness.

To help ensure the delivery of high-quality cardiac imaging services, Highmark is using the cardiac-specific guidelines developed and validated with cardiologists based on American College of Cardiology and American Heart Association guidelines.

“We are trying to reduce the overutilization of cardiac imaging procedures that don’t meet the appropriate use criteria of the American College of Cardiology,” Dr. Calega said. “Because of the wide variation in the use of MPI studies across communities in Pennsylvania, some low-risk patients are receiving inappropriate tests.”

The Highmark program encourages physician-to-physician communications. Physicians ordering a cardiac imaging test that does not meet the clinical guidelines will have the opportunity to discuss the case with a reviewing cardiologist.

Beginning also in September, providers ordering another commonly used cardiac imaging test, stress echocardiography, will need to provide notification when they perform this study. This policy is intended to help Highmark evaluate data to identify both appropriate and inappropriate patterns of ordering alternative cardiac imaging procedures and to work with physicians to better evaluate cardiac testing options that are less risky for patients.

The radiology program applies to most Highmark health plans in western Pennsylvania and central Pennsylvania. For five years, Highmark has implemented its radiology program working with National Imaging Associates (NIA), Inc., a national radiology management company that currently works with 13 Blue Cross and Blue Shield organizations across the country. NIA provides radiology management services for a number of health plans in Pennsylvania, all of which require prior authorization for nuclear cardiology studies such as MPI.