The word “steerage” has several definitions. It can mean “controlling the course of” or refer to the cheapest area on a passenger ship. Over the last few years, several large health insurance companies have launched programs that direct patients to freestanding, non-hospital affiliated imaging centers for their imaging needs. Such “steerage” programs are directing patients away from hospital-affiliated outpatient imaging due to cost-related issues. This is a subject of concern — particularly for the pediatric physician community — since many of these imaging centers may not be as well-equipped for children’s care as a dedicated pediatric facility.
Anthem was the first major insurer to institute a site-of-care imaging steerage policy. Their guidelines indicate that unless medically necessary, advanced outpatient imaging — such as CT, MRI and PET — must be done at freestanding non-hospital affiliated imaging centers or Anthem will not cover the exam. Few exceptions are listed, such as the need for anesthesia or a history of cancer. Anthem’s policy indicates that children 9 years of age and younger may be imaged at a hospital-affiliated facility, but children 10 years of age and older are essentially considered adults for imaging purposes. Thus, a 10-year-old child with seizures and requiring a brain MRI would not be approved to go to a hospital-affiliated facility, including a children’s hospital. Subsequent to Anthem’s announcement, United Healthcare (UHC) instituted a similar site-of-care policy, utilizing the same age criteria as Anthem. With UHC’s announcement, the two largest health insurance companies in the country had formalized steerage programs directing children away from hospital-affiliated imaging.
Broad-based, collaborative advocacy efforts involving representatives of the ACR, the American Academy of Pediatrics, and the Society for Pediatric Radiology were able to effectively communicate concerns to UHC, who agreed to alter their policy. Their updated criteria indicate that patients under 19 years of age are automatically permitted to have their imaging done at hospital-affiliated facilities. Despite our advocacy efforts, Anthem did not alter their criteria. Recently, Cigna, the fourth-largest health insurance provider, unveiled a similar policy — again using the 10 years of age cut-off.
Do freestanding non-hospital affiliated centers offer the same level of service to children and families as dedicated pediatric centers?
The difference in cost between hospital-based imaging and freestanding centers can be significant. In addition to a fiduciary responsibility to their investors, insurance companies are seeking ways to limit costs to their consumers. Affordability of healthcare is a major concern in the U.S. A survey showed that one in four people skipped care due to cost issues. Even those with private health insurance are not immune to financial challenges from care. Research has shown that even with insurance, patients may face significant out-of-pocket expenses from advanced medical imaging.
Although there are financial differences between sites of care, there are also potential differences in the quality of care. Specifically, do freestanding non-hospital affiliated centers offer the same level of service to children and families as dedicated pediatric centers? Beyond the value of interpretations by pediatric radiologists, there are dedicated pediatric RTs and child life specialists who ensure that the exam is performed appropriately. Radiation doses have been shown to be lower in dedicated pediatric facilities compared to general practices. Importantly, pediatric centers have personnel, procedures, and equipment to deal with adverse events in children, should they occur.
In addition to issues of quality and safety, there are concerns about choice, as well as patient- and family-centered care. For example, receiving care at one facility but imaging elsewhere inconveniences the family and may require multiple missed days of work for a parent. It can create a fractured medical record. There is also redundancy and waste, as many of the exams will require reinterpretation or even reimaging at the dedicated pediatric centers.
As physicians, our first duty is to our patients and their care. Though cliché, the phrase, “children are not little adults” is true. While not ignoring economic issues, we must recognize and vocalize that children have specialized imaging needs. We must advocate for our pediatric patients and their families, as many are not aware of the nuances of imaging subspecialization. We hope that Anthem and Cigna will follow UHC’s lead and exempt all children from their site-of-care policies.