Improving Patient Care and Saving Taxpayer Dollars – A State Medicaid Showcase

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:

• 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.

Overtesting Puts State Medicaid Patients at Risk 

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.⁵

Delivering 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