Health insurance companies naturally focus most of their attention on quality, cost, and access to care. But changes in the way they pay for health care can also exert unintended and even unforeseen effects on the education of future health professionals. Such policy changes may appear to offer cost savings in the short term, but may in the longer term limit the ability of hospital-based educational programs to prepare learners to meet the nation’s future health-care needs. A case in point is Anthem’s decision to restrict payments for in-hospital imaging services.
Anthem is the largest for-profit company in the Blue Cross Blue Shield Association, with annual revenues of approximately $85 billion and a net income of $2.5 billion. In the summer of 2017, Anthem announced that it would require a medical necessity review for in-hospital computed tomography and magnetic resonance imaging services, and in cases without a medical necessity for hospital-based imaging, the request for authorization would be denied . In other words, the patient’s insurance would not pay for the examination.
The overall impact of this change in policy would be to steer the imaging of outpatients away from hospital-based imaging and toward free-standing imaging centers. Anthem explained its decision in terms of the Institute for Healthcare Improvement’s Triple Aim Initiative, which seeks to improve the patient experience of care (including quality and satisfaction), to enhance the health of populations, and to reduce the per-capita cost of health care. Anthem also indicated that clinical research documents the safety of imaging services provided in free-standing imaging centers.
Within days, the American College of Radiology (ACR) registered its objections to Anthem’s change in policy . The ACR charged that it was based on cost alone, with little concern for quality, which is often the primary consideration in physician referral patterns; that it would increase wait times and force patients to travel farther; that it would hit patients in inner cities and rural areas—for whom a local hospital’s outpatient imaging may be the only immediate access point—particularly hard; and it could negatively impact patient access to standard imaging services such as radiography.
Not addressed by Anthem or the ACR are the implications of such policy changes on the future of medical education, and in this case, the education of medical students, residents, and fellows. In radiology, most such education takes place in medical schools and in academic health centers, which in turn operate most of their educational programs in hospitals. Each time a patient’s imaging shifts from an academic hospital to a free-standing imaging center that does not support such educational programs, a learning opportunity is lost.
In the academic hospital setting, it is understood and even expected that radiologists will devote time to teaching. Likewise, ensuring that learners can participate meaningfully in patient care often entails sacrifices in terms of patient throughput and turnaround times. Looked at strictly from the point of view of efficiency and cost, free-standing imaging centers may appear to perform better than academic hospitals, but this can be traced at least in large part to the fact that they focus on a narrower range of missions that does not include education.
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References
1. Anthem : Imaging program expands to include level of care reviews. Available at https://www11.anthem.com/provider/in/f4/s0/t0/pw_g303738.pdf?refer=ahpprovider&state=ky Accessed September 1, 2017
2. American College of Radiology : New Anthem imaging coverage policy will harm patient access to imaging care. Available at https://www.acr.org/About-Us/Media-Center/Press-Releases/2017-Press-Releases/2017829-New-Anthem-Imaging-Coverage-Policy-Will-Harm-Patient-Access-to-Imaging-Care Accessed September 1, 2017