Case Study 2 – Immediate Reduction in Inappropriate Utilization
A large national health plan was experiencing significant inappropriate advanced medical imaging utilization in a Northeast market. Not only were utilization levels substantially higher than national averages, but they also were growing ~20% annually.
If no action was taken, this growth would require higher premiums which could negatively affect the health plan's competitiveness in the market and its ability to retain its members.
Within three months of implementing a medical necessity review program for advanced imaging, NIA was able to reduce MRI utilization rates by 30% (as shown below in Exhibit D). After this strong first-year performance, NIA also managed growth in the second year to one-half of the previous trend (as shown below in Exhibit B).
Overall, NIA's medical necessity review program resulted in savings of ~1.33 in the first year and ~2.08 in the second year (referenced in Exhibit C) for MRI/MRA, nuclear cardiology and PET alone (CT was managed under a separate program).
Exhibit A: Pre-Implementation Advanced Imaging Utilization Growth Rates by Modality Percent
Exhibit B: Advanced Imaging Utilization Trend Comparison Percent
Exhibit C:
Year One Estimated Program Savings Dollars Per Member Per
Month
Year Two Estimated Program Savings Dollars Per Member Per Month
Exhibit D: Comparison of Management Strategies Effect on
Utilization of MRI/MRA
(Annual Procedures Per 1,000 Members)
For more information about partnering with NIA to drive better patient outcomes and bottom-line results, contact us.