Are commercial insurance providers nudging us toward clinical improvements?

September 23, 2020

If you want to encourage someone to do something, make it easy.

– Richard H. Thaler, co-author of Nudge: Improving Decisions About Health, Wealth and Happiness

The authors of the 2008 New York Times bestseller, Nudge: Improving Decisions About Health, Wealth, and Happiness, demonstrated how small changes in the way that options are presented can have significant impacts on the choices we make. Whether children in a lunch line at school, voters filling out a ballot, or seniors making use of Medicare benefits, the context in which we make our decisions will influence the end results.

In the US healthcare system, commercial insurance providers are often the organizations that structure the way in which healthcare choices can be accessed by patients and providers. Health plans can choose to incorporate vast amounts of data including clinical outcomes, cost effectiveness, ready and convenient access, and patient and provider preferences as the plans serve as “choice architects” for those who use their systems.

While challenges can exist when navigating the complexities of healthcare payers, it has been encouraging to see some commercial health plans in the US prioritize the use of coronary CTA in the evaluation of stable chest pain through “soft redirects” or “nudges.” Examples of this prioritization through education and ease of access can increasingly be found in the approaches of innovative payers across the country. Such efforts are in line with the recently published summary of a multidisciplinary summit on the need for expanded use of coronary CTA convened by the American College of Cardiology (ACC).

UnitedHealthcare is actively implementing a program to streamline workflow for providers choosing to utilize coronary CTA “as first-line testing (CCTA-First).” When seeking prior-authorization for a stress test for a qualifying patient with insurance through UnitedHealthcare, the clinician is prompted instead to consider coronary CTA. If they accept the suggestion, the authorization is immediate and automatic, and the clinician avoids the more lengthy process involved with prior-authorization for a stress test.

In communicating this change to providers, UnitedHealthcare stated that coronary CTA “is expected to replace the need for other functional stress testing in” patients with “low and intermediate risk for coronary artery disease (CAD).”

Blue Shield of California updated their policy for elective invasive coronary angiography (ICA) on 1 Aug 2020. The new policy deprioritizes elective ICA for many patients who may be better served by other pathways. In cases where clinicians are considering elective ICA, Blue Shield of California requires the provider and patient to review and sign a shared decision-making form which highlights alternatives to elective ICA, including a coronary CTA+FFRCT pathway.

Horizon Health is addressing economic factors in New Jersey which could lead to coronary CTA+FFRCT being less available in non-hospital settings. By bringing reimbursement at imaging centers and physician offices into line with those at major hospitals, clinicians are enabled to make decisions consistent with clinical factors, relieving them of the varied reimbursement concerns which may accompany varied sites of care. Beyond this, Horizon Health is supporting and educating as to the benefits of a coronary CTA-driven pathway to medical teams at centers with opportunities to increase adoption.

Highmark is creating simplified access to coronary CTA+FFRCT in hospitals within their integrated delivery network after successful pilot programs in various settings of care. Additionally, Highmark is educating PCPs who can directly order this pathway in cases of suspected CAD.

It is encouraging to see commercial insurance providers increasing access to a coronary CTA-driven pathway. These small nudges are evidence of payers seeking to encourage constructive choices that will be best for many patients, while still empowering clinicians to decide what is most appropriate for each individual.

When the balance of clinical, ethical, and financial demands can be met, as in these examples, the work of clinicians to care for patients is supported by payers who become allies in bettering our healthcare system and improving patient care. Small nudges can truly bring significant change.

— A perspective from HeartFlow Chief Medical Officer, Campbell Rogers, MD
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