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Benefits of a Utilization Management Program


Tim Casey

Los Angeles—An analysis of commercially insured, non-Medicare members of Anthem Blue Cross and Blue Shield plans found that a utilization management program helped reduce the likelihood of follow-up visits for cardiac imaging by 11.7%, a statistically significant decrease compared with a group that was not managed (P<.001). The authors noted that these findings could lead to reduced costs for health insurers, employers, and members and decrease radiation exposure from myocardial perfusion imaging and computed tomography scans.

Results were presented at the AHA meeting during a poster session. The poster was titled Utilization Management Reduces Repeated Outpatient Cardiovascular Imaging.

In this study, researchers from HealthCore, Inc. (the clinical outcomes research subsidiary of WellPoint, Inc.) examined data provided by AIM Specialty HealthSM, a specialty benefit management company for radiology, cardiology, oncology, sleep medicine, and specialty pharmacy benefits. AIM’s cardiac utilization management program examines the clinical appropriateness of cardiac imaging. The authors noted that, since 2009, the program has led to 175,000 fewer cardiac imaging studies, or 7.1% of cardiac imaging requests reviewed.

This study included Anthem health plan members from Indiana, Kentucky, Missouri, Ohio, and Georgia. The authors identified 112,308 members with continued insurance coverage who underwent cardiovascular imaging, but had no prior imaging within the previous year. They were broken into 2 groups based on whether AIM managed their utilization. The managed group included 48,455 patients and the unmanaged group included 63,853 patients.

The authors made sure the groups had similar health profiles by creating claims-derived cardiac risk scores and validating them against AIM clinical risk scores. The groups were further classified into high, moderate, and low cardiac severity sub-groups.

Mean age of patients in the unmanaged group was 50 years compared with 49 years in the managed group (P<.0001). There was also a statistically significant difference in the percentage of females in the groups: 52.7% versus 50.0% (P<.0001).

Of the patients who had a diagnostic test at the index date, 1 in 6 had a follow-up test in the 12 months following the initial test and 2 in 9 had a follow-up test within 24 months.

Of the patients in the managed group, 21.9% had a postindex cardiac imaging test compared with 24.8% of patients in the unmanaged group. After 12 months, the postimaging rate was 222 tests per 1000 patients in the managed group and 251 tests per 1000 patients in the unmanaged group.

The researchers found that the rate was 18 tests per 1000 patients lower in the managed group (P<.001) following adjustment for age, gender, Deyo-Charlston comorbidity index, medication use, history of cardiovascular events, type of indexing test, and cardiac risk group. In both the managed and unmanaged groups, patients with a history of cardiovascular events had a higher likelihood of repeated testing.

The authors wrote that, “Our study demonstrated that, in fact, repeated imaging is performed more frequently in the unmanaged group. This speaks to the need to manage not just index requests, but also subsequent requests for cardiac imaging procedures.”

This study was supported by HealthCore, Inc.

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