Prior to implementing a utilization management (UM) solution, a state fee-for-service Medicaid program experienced significant waste and misuse related to medical imaging. The results included poor-quality care for patients and higher costs for taxpayers. For example:
Overtesting Put State Medicaid Patients at Risk
- The state's growth trend for medical imaging was 9% annually.1
- In just 2 years, 170 Medicaid patients received more than 11,800 scans, at a cost to taxpayers of $2.8 million.2 That's the equivalent of 70 scans per person.
Two of the state's high-risk groups, pregnant women and young children, were particularly vulnerable to the dangers of harmful radiation exposure:
- In one case, a Medicaid patient received 22 CT scans during her pregnancy,3 exposing her unborn child to exceptional risk.
- A 2-year-old patient received 19 scans within the period of just one month, including 5 scans on a single visit.4
Claims analysis supports that some CT exams expose patients to radiation equal to the average cumulative amount delivered by approximately 300 chest x-rays
. Researchers have estimated that the risk of developing cancer increases significantly for younger patients who go on to receive multiple CT exams in a lifetime.5Delivering Results to Avoid Waste and Misuse
By implementing a UM solution, the state prevents the unnecessary exposure of two vulnerable populations to harmful radiation. Pregnant women and young children no longer receive unnecessary or duplicative tests, which can also lead to the imposition of false positives that can inhibit the accurate and timely diagnosis and treatment of such patients. Ultimately, this solution will help prevent the incidence of medically induced cancers
in the two groups of beneficiaries over their lifetimes.5
Finally, as a result of the first year's application of eviCore's UM solution and onsite expertise, the state saved more than $225 million,6 which could be used for other important taxpayer programs and priorities.
1, 2, 3, 4, 5, 6The Effects of MedSolutions' Services for the North Carolina Division of Medical Assistance. MedSolutions, October 2010.
5Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomographic examinations and associated lifetime attributable risk of cancer. Arch Internal Med 2009; 169:2078 –2086.