Advances in imaging technology can promote earlier, safer, and more precise detection of disease. More than 80 million medical imaging tests are performed annually in the United States at a cost of more than $100 billion. About 15% of that testing is reported to be "unnecessary," including the cost

Seeking to hold down costs, many health plans are imposing preauthorization requirements for certain diagnostic imaging tests, including CT, MRI, nuclear cardiac imaging, PET, and MR angiography. Office-based physicians must contact a "radiology management program" to seek authorization before scheduling a patient for imaging; national clinical guidelines are used to evaluate medical necessity. Other measures include requirements to obtain imaging within a "network" of providers, "certificate of need" laws in states to match the supply and demand of advanced imaging technology, and physician profiling that might exclude certain physicians who have high imaging costs.

One radiology management program (MedSolutions) claims a 15%-20% reduction in "inappropriate utilization" in the first 18 months. Two-thirds of requests are authorized through an automated system in about 4 minutes; others are transferred to a nurse for further review, and about 10% of the denials are reversed at this point. A physician may ask for a "peer-to-peer" consultation, with about 10% of these requests receiving approval. The overall denial rate for CT and MRI is 12%-20%. Insurers using such a plan claim a 5%-10% reduction in imaging costs.

It is difficult to argue against such cost-saving measures. But primary care physicians order 55% of these tests, and preauthorization can lead to delay and inconvenience to patients. Also, tests may be ordered for many reasons beyond those supported by strict clinical guidelines.

To improve quality and efficiency, I would suggest additional measures. A good first step would be to measure the impact of radiology management programs in terms of cost savings, patient satisfaction, and amount of work added for the physician's office. Physicians who are "outliers" could receive counseling and education, while those with appropriate use might be exempted from preauthorization.

Also, the radiology management program should assume liability for those cases in which a delayed or missed diagnosis resulted from a denial of coverage for imaging. Steps also could be taken to compensate the work of the primary care office to implement the program.

True savings can be achieved by realigning payments for advanced medical imaging, eliminating conflicts of interest in imaging services, and matching the supply and demand for these services. Preauthorization creates another layer of administration and expense for primary care physicians, and it needs further study.

Still, preauthorization appears to have some merit as one piece of the health care quality and efficiency puzzle. The imaging issue showcases a need for realignment of health care priorities and a change in the formula for reimbursement.

DR. DAMLE, who practices in Wakefield, R.I., is governor of the Rhode Island Chapter of the American College of Physicians.

BY N.S. DAMLE, M.D.