Soon after Cigna Corp. waived prior authorization requirements and eased coverage rules to ensure patients could receive needed care during the coronavirus pandemic, the health insurer tightened restrictions in other areas.
In August, the nation's fourth largest insurer by membership became the third major payer to restrict coverage for most advanced imaging, such as MRIs and CT scans, when performed in a hospital-based department or facility, except in limited circumstances.
The policy currently applies to Cigna's fully insured commercial members and Cigna's own employees and their dependents. The company intends to roll out the policy to individual and family plan members in January and self-funded employer plans later next year. That means it would apply to most of Cigna's 17 million members.
Cigna's policy is similar to those put in place by Anthem in 2017 and UnitedHealthcare last year. Anthem's controversial rule—the first of its kind—drew ire and litigation from hospitals. Providers argued that the policies threatened to sap a large source of revenue while eliminating patient choice and interfering with the doctor-patient relationship.
Like the insurers before it, Cigna said its new rules are meant to direct patients away from expensive hospitals toward lower-cost facilities, such as free-standing imaging centers or office settings. What makes Cigna's policy stand out is it was implemented in the throes of a pandemic, when hospitals are dealing with lower-than-normal patient volumes and resulting financial losses.
"Policies such as these restrict patient access to care without regard to the quality or coordination of care," said Molly Smith, vice president for coverage and state issues forum at the American Hospital Association. "It is particularly disturbing to see these kinds of unilateral steps to diminish patient access to care during a global pandemic."
Health insurers have long decided what to cover based on whether they think a service is medically necessary for a patient. Only more recently have they begun dictating where that patient should get that service, as they try to tamp down claim costs.
"The goal of the policy is to provide coverage for our customers to get the right care at the right place and the right time," a Cigna spokeswoman said in an email. "That means helping to direct them to a freestanding radiology center or other office-based settings when there is not a clinical reason for services to be performed at a more costly hospital setting."
It's true that the cost of an imaging service varies drastically by where a patient receives it. The cost of an abdominal MRI costs $1,751 at a hospital and $680 at a freestanding imaging center, according to healthcare price transparency company Amino. With nearly 46% people with private insurance in a high-deductible plan, patients could be on the hook for a large portion of that cost. Freestanding imaging centers are generally cheaper because they provide one service and have less overhead.
A spokeswoman for America's Health Insurance Plans, the health insurance sector's lobbying group, said in an emailed statement that "promoting lower-cost settings for services that provide the same level of high-quality, effective care is one of the ways we work for lower premiums and out-of-pocket costs for you."
But critics argue that the insurer site-of-care policies focus narrowly on cost and disregard the quality of an imaging center. Research shows that in healthcare, higher costs don't correlate with better quality.
"It's a purely cost-based policy, which is why we have an issue with it," said Kathryn Keysor, senior director of economics and health policy at the American College of Radiology. "If they could indicate that quality was better at certain places, or if they at least took quality into account, the policy would be better—but they don't."
Currently, there is no data available to compare the quality of imaging centers, so it's hard to know how patients could be affected by the policy, said Leah Binder, CEO of Leapfrog Group, a not-for-profit focused on the quality and safety of healthcare.
"What I think health plans should be doing is developing quality measures on imaging. We don't have good ways to measure the quality, and until we do that, this method could very well be penny-wise and pound-foolish—or not. We just don't know," she said.
A poor-quality imaging center could lead to mistaken diagnoses, which could result in mistaken treatments and eventually reparative treatments, she said, "which is far more expensive than any differential between imaging in a hospital and imaging in outpatient."
Research suggests imaging centers aren't equal. One 2016 study in The Spine Journal found wide variation among 10 imaging centers' MRI exam findings of a 63-year-old woman with low back pain. The 10 exams produced 49 different findings, from disc bulges to disc generation to stenosis. None of the reported findings were unanimously reported in all 10 examinations. Researchers also discovered "an alarmingly high number of interpretive errors."
Other critics argued the policy takes away patient choice undercuts a physician's judgment.
"They should give the would-be patient and the physician a chance to have a dialogue instead of these one-way rules," said Rick Gundling, senior vice president of the Healthcare Financial Management Association.
Dr. Marc Succi, an emergency radiologist and director of the MESH Incubator, a technology incubator at Massachusetts General Hospital, said policies that push patients to providers that aren't integrated with the hospital could make it difficult for a doctor to get a full picture of a patient's health.
"We get CDs missing half the images from all these outpatient centers or other hospitals that are not part of our system," he said. "The technology is not quite there... Asking patients to go get their CDs from outpatient centers is not efficient and not good continuity of care."
Succi also said patients sometimes have complications during imaging, such as a reaction to contrast, a dye used in during some MRIs. In those cases, it helps to be in a hospital setting where help is 30 seconds away, he said.
Cigna said it would continue to allow services to be performed at a hospital when a patient's condition warrants it. It would consider high-tech imaging in a hospital-based facility to be medical necessary when a patient has a known allergy to contrast that is going to be used, or when the patient is under 10 years old or is pregnant and requires obstetrical observation or perinatology services.
The insurer also made exceptions for when imaging is related to a transplant, or when there are no appropriate alternative sites available for the patient to receive imaging. It would cover pre-operative imaging that is integral to a surgery or other procedure being performed at a hospital, or if imaging outside of a hospital is expected to adversely affect or delay care, for instance.
Beyond MRIs and CT scans, the policy also applies to magnetic resonance angiography and computed tomography angiography. It does not apply to x-rays or mammography.
The policy could exacerbate the financial woes of hospitals, which struggled with lower-than-normal patient visits during the early months of the pandemic when providers postponed non-urgent procedures. Hospital radiology departments saw a decrease in the number of patients receiving MRIs, CT scans and other imaging services. Historically, radiology has been a moneymaker for hospitals.
"It's just one more difficult thing," Gundling said. "Anything that puts a block in front of the patient's and hospital's relationship, it's never a good thing for the patient or the hospital."
According to a study by researchers at New York-based Northwell Health, total imaging volumes at the health system decreased 28% over a 7-week period during the pandemic, compared with the same period in 2019. At its worst, volumes fell 88% in the outpatient setting, while the number of MRIs delivered fell as much as 74%.
Researchers from Mass General similarly found that average weekly imaging volume declined 54% at the main hospital campus and 64% at affiliated imaging centers between late March and late May, compared with before the pandemic. According to Succi, one of the study's authors, volumes have recovered, but that doesn't necessarily mean finances have.
There is no data showing how insurers' imaging site-of-care policies have affected hospital finances or patient care. Keysor said the American College of Radiology hasn't received calls from hospitals about their volumes dropping significantly due to these policies.
But Brian Tabor, president of the Indiana Hospital Association, said Anthem's policy, which has been in effect for a few years in the state, has created some problems.
"Anthem's policy created disruptions in scheduling, often resulting in repeat or canceled visits or procedures," he said in an email. "A canceled operating room visit, for example, not only delays care for that patient but it also limits access for another patient who could have been scheduled. In addition, patients are sometimes sent to low-quality imaging which presents problems for the diagnosing physician and their patients."
This story was updated after Cigna clarified when it is rolling out the policy to certain members.