Date June 29 2009 To Interested Parties From Chelene Whiteaker Policy Analyst Re AIM Work Group Recommendations Background The Advance Imaging Management AIM Work Group was ta by kjt13489


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									Date: June 29, 2009

To:   Interested Parties

From: Chelene Whiteaker, Policy Analyst

Re:   AIM Work Group Recommendations

The Advance Imaging Management (AIM) Work Group was tasked with giving the
state recommendations on ways to curtail unnecessary use of high cost imaging services
in state sponsored fee-for-service programs. The group met several times in May and
June to develop its recommendations. Membership in the group included a broad
range of representatives from key groups, including a representative from WSHA.

The group was charged with developing recommendations by July 1. During the June
22 meeting, members developed a set of draft recommendations to be voted on by the
entire group on June 26. In collaboration with our work group representative, WSHA
submitted a clarification to limit the utilization management program to outpatient
imaging services. Inpatient imaging services are included in the payment for inpatient
admissions. Utilization of inpatient imaging services does not contribute to escalating
costs for the agencies‟ fee-for-service programs and establishing utilization
management controls could result in needless delays in services. While discussions
among work group members indicated the focus was on outpatient services, the
applicability of the recommendations was not explicitly clarified for the group. The
state staff for the work group declined to accept the clarification in the final vote of
work group.

The work group members voted 12 to one in favor of the recommendations produced
during the June 22 meeting. The recommendations provide parameters to be used in
contracting with a vendor to establish a utilization benefit management program that
would require prior authorization for certain imaging services. Through our work
group representative, WSHA is on record as voting “no” for the AIM Work Group
recommendations due to the lack of definition on whether the recommendations apply
to the inpatient setting. Attached below are the recommendations as approved by the
June 26 vote.

WSHA Next Steps
It is still unclear whether implementation of the utilization management program with
prior authorization requirements for certain imaging services will be applied to the
emergency department or inpatient settings by the state sponsored programs. The
work group defined applicability as “applying to all providers, to the extent possible.”
From a feasibility standpoint, we believe the state agencies will first implement a
program in outpatient settings excluding the emergency department. The agencies may
then begin researching the usage and applicability of a program for emergency
departments. The resources for the implementation of a utilization management
program are very limited and discussions have yet to take place on how it would work
in the inpatient setting.

WSHA will continue working with the work group and the state agencies as they move
forward with the implementation phase of these recommendations. We will also be
communicating our concerns about a utilization management program in the inpatient
setting. Especially given the tight time frames needed for prior authorization, we are
unclear about hospitals‟ concerns regarding a utilization management program in the
emergency department. If your hospital feels strongly about the implementation of
prior authorization for imaging in either the inpatient or emergency department setting,
please contact Chelene Whiteaker at or 206-216-2545.
                         AIM Work Group Recommendations

As adopted by the work group, the recommendations are as follows:

“Public purchasers shall implement a consistent program of mandatory utilization
management using evidence based guidelines and prospective review, where possible,
for the high cost/high variability advanced imaging studies. The program should
result in a satisfactory business case (balancing access, quality, and cost) for the State
and public purchasers. In addition, the program should stress minimizing the
administrative burden on ordering providers.

Recommendations on evidence based guidelines or protocols
    Public purchasers will use the AGREE Checklist approved by AIM workgroup to
     identify and select guidelines
    Review of guidelines will be conducted periodically
    Guidelines will not supersede the decisions of the health technology clinical
    A vendor of a public purchaser must apply the guidelines chosen by the public

Recommendations on the program, including criteria for decision tool and utilization
    Applicability
       o Target utilization management intervention to identified advanced
           imaging of high cost/high variability
       o Apply to all providers, to the extent possible

      Program Components
          o Include incentives (for example, programs such as „gold card‟)
          o Include denials (with opportunity for peer interaction)
          o Include provider education component
                 Provider performance reports
          o Minimize delays for approving requests that are consistent with evidence
             based guidelines
          o Meet State standards or URAC or NCQA criteria
          o Include a deployment and communications plan

      Evaluation component
          o Evaluate program‟s effects in 24 months initially and annually thereafter
             (cost, utilization trends, service reports, provider satisfaction)
          o Require a vendor of a public purchaser to provide quarterly data

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