Updates to the MRI Protocol and Clinical Guidelines for MS: CMSC Working Group - Episode 9
David Li, MD, FRCPC: One of the things I was going to remind ourselves to talk about was one of the aspects we discussed about an issue that is not as familiar to me or Fred. It is the situation about payers and insurance companies, and where patients end up having the scans. This is because that makes it even more difficult since we talked earlier about how within the Canadian system people are on scanners that you’re familiar with, and yet we have difficulty implementing them. You have the additional difficulty that patients may not necessarily end up on the scanner that they want or where you would want them to go. I’d love to hear from Scott, what are some of the ways that we can help resolve that?
Scott D. Newsome, DO, MSCS, FAAN: That’s a big hurdle. I would say that the one thing that comes to mind is someone’s insurance could change year to year. Depending on the payer, obviously they have sites of care, including radiology, so you could have someone on 1 scanner consistently for a couple of years, and then they have to go somewhere else because of that change in insurance. It’s similar to the vendor situation where we have to bring in potentially the major players, at least within the United States, and educate them why this is important. Actually, down the road, this could be financially good for them. This is because if we’re providing better care for our patients across the board, then that may be more cost saving for them because we’re not escalating to more costly medications or maybe patients aren’t having adverse events.
Frederik Barkhof, MD, PhD: That’s why I think education and public outreach is really important to make sure everybody is using it, not just in the so-called expert centers.
June Halper, MSN, APC-C, MSCN, FAAN: Exactly.
Frederik Barkhof, MD, PhD: But really across the nation.
Scott D. Newsome, DO, MSCS, FAAN: Yes, it has to be.
Frederik Barkhof, MD, PhD: This is so that if patients move, they will still get a scanner that is comparable. That doesn’t prevent issues with interpretation, if I may, as a radiologist. Getting an outside scan is not very helpful because, first of all, you have to get it onto your system. Then the image looks slightly different than you’re used to, even if they try to follow the protocol. You have to realize that there’s an outside report, so if you report on it, you have to check that it’s not deviating from the outside report or be able to explain it. It brings a level of complexity that is unavoidable, so I’m still not a big fan of it. But if it has to happen for payer reasons, then it has to happen, so we need to make sure that at least we get a minimum quality. The core sequences that you mentioned are really important to get them straightened out and implemented globally.
June Halper, MSN, APC-C, MSCN, FAAN: Our next job is to meet with the payers to make them understand that when a prescription is written, it should go to a unit that has adopted our protocol, because otherwise they’re just wasting their money.
David Li, MD, FRCPC: That’s a very critical point that you do the scans, and if the scans cannot be used in the right way, and if it has to be repeated, that’s additional cost. But even worse is if it leads to the wrong management decision. That’s even more costly because the cost of a scan is miniscule compared to the cost of the medication over that period.
Scott D. Newsome, DO, MSCS, FAAN: I’ll tell you how I deal with it clinically, and I’d like to hear your viewpoint on this as well. If we have someone who establishes care with us and they have a bunch of outside scans that are subpar quality, we’ll usually try to update the MRI [magnetic resonance imaging] at that point. This is even if the radiologist mentions, “OK, there may be a new lesion present,” I will usually take the approach of repeating the MRI 6 months down the road, which adds cost to it, right? This is because now you’re talking 3 MRIs in the calendar year, but we’ll do that. At least, I’ll try to get those approved because of the patient, to make sure that there’s not new disease activity happening in a short period.
But if we go back to how the core sequences are adopted by all radiology centers, at least more than not, then you may not have to worry about that. This is because the quality will be there. Even if it’s on a 1.5 tesla strength, 3T, I still think that if you have core sequences, that’s going to give you the information that you need clinically and to be mindful, obviously, of the clinical phenotype and how they’re doing examination wise. But I would love for that to happen. It’s less tube time for the patients, which I can tell you, you probably hear it from the patients, “I hate being in the MRI tube,” because they may be claustrophobic. If we’re doing spine imaging, that’s an extra 30 minutes to an hour, so it adds that as well.