This post was authored by John Shuck, MD, FACC, governor of the Delaware Chapter of the ACC.

Over the past few years the issue of appropriate use and radiology benefit managers (RBMs) has been a “hot topic,” particularly in Delaware. Recently, the misuse of RBM's in denying cardiac stress imaging within the state came to national attention.  A Delaware patient was denied a cardiac stress test by an RBM used by a major health plan in Delaware. The patient was ultimately admitted to the hospital emergently for a catheterization and a lifesaving CABG was performed.  This patient's plight became well-publicized and sparked investigations by the U.S. Senate Commerce Committee and Delaware Insurance Commissioner as to why the test was denied.

Thanks to the efforts of many at the ACC national and state level, this past fall the Delaware Insurance Commissioner announced that the health plan will support use of the ACC’s FOCUS: Cardiovascular Imaging Strategies tool by Delaware cardiologists to make decisions about certain diagnostic imaging tests, as an alternative to RBMs. Unlike RBMs, the FOCUS tool engages providers in ongoing feedback reports and quality improvement activities. At the same time it reduces third-party costs to physicians and health plans (read more about FOCUS in a blog post here).

In January 2012 the FOCUS health plan product went live incorporating many of the same elements present in the FOCUS performance improvement module. Under the agreement, the health plan will pay for cardiologists in the state to use the online tool, which allows for consistent application of appropriate use criteria to determine when cardiovascular imaging tests are needed. Importantly, the program also provides feedback reports on the patterns of appropriate use to physician practices and health plans. FOCUS participants then use the reports to complete action plans and share best practices.

This model for managing medical costs by focusing on patient-centered decision making and quality care will hopefully be implemented by other insurers and within other states when it comes to ensuring appropriate use of medical imaging. I’m happy to see our efforts to implement this program in Delaware have not gone unnoticed as several other ACC chapters are currently in talks with health plans to implement this program at the state level.

For more information about Imaging in FOCUS, visit CardioSource.org/FOCUS. This post is from a special AUC series on the blog focusing on the “basics” of what the AUC are, how to use them now, how the AUC can/will be used in the future, as well as the various ACC resources and tools available. Click here to read more.