Dunkle, Jeffrey W.

Gunderman, Richard B.

Heitkamp, Darel E.

Shea, Lindsey

English

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  This is the author's manuscript of the article published in final edited form as:  Shea, L., Heitkamp, D. E., Dunkle, J. W., & Gunderman, R. B. (2018). Educational Implications of Health Insurance Changes. Academic Radiology, 25(2), 260–261. https://doi.org/10.1016/j.acra.2017.09.003  Educational Implications of Health Insurance Changes Lindsey Shea MD, Darel E.Heitkamp MD, Jeffrey W.Dunkle MD, Richard B.Gunderman MD, PhD Department of Radiology, Indiana University, 702 North Barnhill Drive, Room 1053, Indianapolis, IN 46202  Key Words: Anthem; health insurance; education; unintended consequences  Health insurance companies naturally focus most of their attention on quality, cost, and access to care. But changes in the way they pay for health care can also exert unintended and even unforeseen effects on the education of future health professionals. Such policy changes may appear to offer cost savings in the short term, but may in the longer term limit the ability of hospital-based educational programs to prepare learners to meet the nation's future health-care needs. A case in point is Anthem's decision to restrict payments for in-hospital imaging services. Anthem is the largest for-profit company in the Blue Cross Blue Shield Association, with annual revenues of approximately $85 billion and a net income of $2.5 billion. In the summer of 2017, Anthem announced that it would require a medical necessity review for in-hospital computed tomography and magnetic resonance imaging services, and in cases without a medical necessity for hospital-based imaging, the request for authorization would be denied (1). In other words, the patient's insurance would not pay for the examination. 2  The overall impact of this change in policy would be to steer the imaging of outpatients away from hospital-based imaging and toward free-standing imaging centers. Anthem explained its decision in terms of the Institute for Healthcare Improvement's Triple Aim Initiative, which seeks to improve the patient experience of care (including quality and satisfaction), to enhance the health of populations, and to reduce the per-capita cost of health care. Anthem also indicated that clinical research documents the safety of imaging services provided in free-standing imaging centers. Within days, the American College of Radiology (ACR) registered its objections to Anthem's change in policy (2). The ACR charged that it was based on cost alone, with little concern for quality, which is often the primary consideration in physician referral patterns; that it would increase wait times and force patients to travel farther; that it would hit patients in inner cities and rural areas—for whom a local hospital's outpatient imaging may be the only immediate access point—particularly hard; and it could negatively impact patient access to standard imaging services such as radiography. Not addressed by Anthem or the ACR are the implications of such policy changes on the future of medical education, and in this case, the education of medical students, residents, and fellows. In radiology, most such education takes place in medical schools and in academic health centers, which in turn operate most of their educational programs in hospitals. Each time a patient's imaging shifts from an academic hospital to a free-standing imaging center that does not support such educational programs, a learning opportunity is lost. In the academic hospital setting, it is understood and even expected that radiologists will devote time to teaching. Likewise, ensuring that learners can participate meaningfully in patient care often entails sacrifices in terms of patient throughput and turnaround times. Looked at 3  strictly from the point of view of efficiency and cost, free-standing imaging centers may appear to perform better than academic hospitals, but this can be traced at least in large part to the fact that they focus on a narrower range of missions that does not include education. If academic hospitals had to compete with free-standing imaging centers on a strictly cost-of-care basis, they would be forced to redirect resources away from the educational mission. The threat to the bottom line may be mitigated for academic hospitals that already own and operate outpatient imaging facilities, but others—such as safety-net hospitals that provide a disproportionate amount of care to the indigent—may not have such options. Moreover, even in the cases of those that do, the outpatient imaging facilities are often less adapted for education. Some of the effects are even more subtle yet still profound. Every time a patient is imaged in a free-standing outpatient imaging center, comparison studies become less accessible should the patient later require inpatient imaging. Access to nonimaging electronic medical records may be similarly compromised. In many cases, access to the patient's records plays a crucial role in enabling learners to situate imaging in the larger context of the patient's medical situation, which favorably impacts not only education but also quality of care. It is possible that medical students, residents, and fellows could begin rotating through free-standing imaging facilities, but how many of these facilities were designed with an educational mission in mind? For example, does the physical plant provide sufficient space? Are clinical processes designed to provide time for education to occur? If such changes were made, what would be their impact on the overall financial performance of such centers, and would they lose some of their competitive advantage over hospital-based imaging? 4  It is important for everyone involved in health care—including patients, health professionals, hospitals, medical schools, and insurers—to seek ways to reduce the per-capita cost of health care. But if we adopt too narrow a focus on cost, we are likely to overlook other important missions of our health-care system, one of the most important of which is education. If we allow short-term cost reduction to trump the longer-term educational mission, we will end up eating our seed corn, with deleterious consequences for patients and communities for many years to come.   5  References 1. Anthem. Imaging program expands to include level of care reviews. Available at: https://www11.anthem.com/provider/in/f4/s0/t0/pw_g303738 .pdf?refer=ahpprovider&state=ky. Accessed September 1, 2017. 2. American College of Radiology. New Anthem imaging coverage policy will harm patient access to imaging care. Available at: https://www.acr.org/About-Us/Media-Center/Press-Releases/2017-Press-Releases/2017829-New-Anthem-Imaging-Coverage-Policy-Will-Harm-Patient-Access-to-Imaging-Care. Accessed September 1, 2017. 

Educational Implications of Health Insurance Changes

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Educational Implications of Health Insurance Changes

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