By March 1, 2008, otolaryngologists offering point-of-care CT scanning-and who are UnitedHealthcare providers-must initiate accreditation of their diagnostic facilities. One of the nation’s largest insurers, UnitedHealthcare has instituted a quality initiative for all medical imaging facilities providing MR, CT, PET, nuclear medicine, and echocardiography exams to adopt accreditation programs as a requirement for reimbursement. Industry observers believe it is likely that other major carriers will soon follow suit and also establish accreditation as a reimbursement requirement.
Explore This IssueFebruary 2008
But even if otolaryngologists are not currently UnitedHealthcare providers, obtaining accreditation for the operation of their diagnostic equipment makes good sense. Accreditation, said Gavin Setzen, MD, of Albany ENT and Allergy Services in Albany, NY, is one additional checkpoint that allows the practice to ensure appropriate and quality testing. He considers the accreditation process absolutely critical for otolaryngologists who are considering point-of-service CT. One has to determine if this is a viable business model for implementation in one’s own practice, based on economic factors and clinical patient and payer mix, he said. Obtaining accreditation allows one the opportunity to reevaluate how CT imaging is provided within one’s office. The goal, at the end of the day, is to ensure that one can preserve point-of-service care and provide an optimal patient experience that is safe, effective, and of the highest quality.
Tamara A. Sloper, Director of Marketing with the Intersocietal Accreditation Commission (IAC), which offers a new program for accrediting in-office CT scans of the sinus and temporal bone, believes that despite requirements for accreditation by third-party payers such as UnitedHealthcare, accreditation stands alone as a worthy endeavor. Any provider of the imaging services that we accredit is very much encouraged to go through the accreditation process voluntarily, as a mechanism for demonstrating their quality, to undergo peer review, and for a multitude of reasons way beyond just the reimbursement issue, she said.
For Part 2 of this series on point-of-care diagnostics, we will focus on accreditation issues, whereas Part 3 will address legal and regulatory issues of offering in-office diagnostics.
Otolaryngologists whom we interviewed for both parts 1 and 2 of this series have found that point-of-care CT scanning improves patient care and is also cost-effective (see part 1 in the January issue of ENT Today). But with the growth of the new, compact volume/cone beam scanners, insurers are understandably concerned about rising utilization rates. Manufacturers’ marketing efforts, especially those that tout otolaryngology-specific CT scanners as a route to increase practice revenues, may serve to increase those concerns, some believe. In the current economic and regulatory climate, it is imperative for otolaryngologists (and all physicians) to adhere to appropriate utilization standards for CT and other diagnostic modalities, asserted Dr. Setzen. A recent survey in the Annals of Internal Medicine indicated that physicians do not always follow professional guidelines for ordering diagnostics. For example, one-third of surveyed physicians reported they would accommodate patient requests for a test (such as an MRI) that they knew was unnecessary.1
At Albany ENT and Allergy Services, a full-body CT scanner has been an important addition to the diagnostic armamentarium since 2001. After careful financial analysis to make sure the expense of installing a scanner was warranted, Dr. Setzen and his colleagues also proactively addressed possible utilization concerns. They met with their major carriers to suggest a two-year period to monitor appropriateness of utilization. At the end of the first year, the practice was no longer required to monitor utilization rates, because they were able to demonstrate that they were continuing to utilize the technology appropriately.
Pathways to Accreditation
At present, UnitedHealthcare recognizes both the American College of Radiology (ACR) and the IAC’s Intersocietal Commission for the Accreditation of Computed Tomography Laboratories (ICACTL) programs for accrediting CT scanners. Since 1963, ACR has provided accreditation for diagnostic imaging and radiation oncology. The IAC, established in 1989, uses an intersocietal approach, drawing from a range of medical specialties in addition to radiology, to develop its program standards for a variety of testing modalities, such as echocardiography, magnetic resonance imaging, and others, in addition to CT. (Each of these commissions has a separate designation and set of accreditation standards for each modality-for example, the Intersocietal Commission for the Accreditation of Echocardiography Laboratories, or ICAEL.)
Both organizations’ programs for accrediting CT are three-year programs, are peer-review processes, and are comparably priced. However, ACR’s approach is to accredit the unit (that is, the CT machine itself), whereas IAC accredits the diagnostic laboratory. Both programs offer several pathways for oversight of the CT scanning process. For example, the supervising physician for the ACR accreditation program can be a board-certified radiologist or diagnostic radiologist, or another physician who has completed continuing medical education units and has interpreted 500 cases within the last 36 months. Accordingly, the ICACTL standards also require the diagnostic laboratory’s medical director to have completed training in CT scanning in organ systems in his or her specialty, continuing medical education in radiation safety, and independent interpretation of at least 50 CT examinations. Both programs also have stringent qualifications for technical staff (radiologic technologists, medical physicists, and the like).
For a summary of the ACR’s CT accreditation program requirements, go to www.acr.org/accreditation/computed/ct_reqs.aspx . To view and download ICACTL’s CT Standards, go to www.icactl.org/icactl/apply/standards.htm .
Although the ACR and the IAC are now technically competing organizations, Ms. Sloper and Pamela A. Wilcox, RN, MBA, Assistant Executive Director for Quality and Safety for the ACR, report that their organizations share a healthy respect for their different approaches to accreditation. The ACR, as stated above, accredits the CT unit itself, and as part of the quality review process, requires phantom images to be furnished for review. In this process, a lucite simulation of human tissue is scanned by the machine, which allows assessment of the technical capabilities of the scanner to assure appropriate calibration. According to Ms. Wilcox, the ACR is currently evaluating data from manufacturers of the compact otolaryngology-specific CT scanners to see whether they can meet ACR criteria. However, if a practice installs a full-body CT scanner, the option to apply for ACR accreditation is open. (Dr. Setzen stated that some two-slice full-body scanners are comparable in price to the compact otolaryngology-specific scanners.)
If the otolaryngologist is using a CT scanner that is the compact, limited-use volume/cone beam type highlighted in part 1 of this series, accreditation for the near term is available only through ICACTL. The latter is a recent development; standards were formalized and published in September 2007 and are supported by 10 sponsoring organizations, including the American Academy of Otolaryngology-Head and Neck Surgery. Dr. Setzen sits on the ICACTL board of directors and serves as its secretary. He also participated in the pilot accreditation program developed by ICACTL. He found the process a valuable one: Who better than an ENT to give input about ENT standards, ENT utilization and the appropriateness of ENT scans? The ICACTL program allows our academy to be part of an institutional effort to ensure that ENTs are well served in the process and that quality patient care is ensured.
Mary T. Lally, RT(R), Technical Manager for ICACTL, concurred. In the otolaryngology community, we find that due to the use of the mini-CT scanners, the ENT physicians typically only scan sinus and temporal bones, she said. The ICACTL accreditation program offers a pathway for the ENT physician to both perform and interpret their scans, providing they meet the criteria outlined in the standards. All CT scanners, whether they are full-body or volume/cone beam units, must meet the same quality assurance [QA] criteria. Also, all laboratories that apply for ICACTL accreditation must have a comprehensive QA program that includes both technical and interpretive quality assessment.
Reimbursement Reasons Only?
Whatever the path to in-office CT scanning-full body or mini-CT-accreditation is now becoming de rigueur for UnitedHealthcare providers and other practices.
Ms. Wilcox noted, I think that accreditation, whether it’s through the ACR or through the IAC, is an important assessment. They are both peer-review programs, but the whole self-assessment process that goes on in preparing for accreditation can be very enlightening about areas where quality is less than optimal. [Accreditation] is all about quality patient care. It’s a way for ENTs to demonstrate that they’re committed to providing good quality imaging, not just the direct patient care that they are already obviously dedicated to delivering.
- 1. Campbell, EG, Regan, S, Gruen, RL, et al. Professionalism in medicine: results of a national survey of physicians. Ann Int Med 2007;147(11):795-802.
©2008 The Triological Society