Call it the COVID-19 butterfly effect or maybe it’s globalism’s revenge. On the other side of the world from Rochester, the Chinese government’s extreme response to a surge in coronavirus cases in Shanghai is hampering operations of medical imaging centers here.
The Shanghai COVID surge “is a significant problem” for local medical imaging groups, says Jennifer Harvey M.D., UR Medicine’s chief of imaging.
Harvey heads the University of Rochester Medical Center’s 23-location imaging center operation. URMC runs the region’s largest health care system, UR Medicine.
The problem Harvey refers to is a shortage of contrast dye, an iodine-based compound vital for certain scans. Supplies of contrast dye dried up without warning a few weeks ago. Medical imaging centers around the country have felt the pinch.
The shortage traces to GE Healthcare’s Shanghai plant, a facility that produces much of the world’s supply of contrast dye.
The Shanghai plant’s contrast dye output dropped suddenly when, in an effort to contain a new COVID outbreak, the Chinese government forcefully locked down the city.
Contrast dyes are not used for every medical scan. Ultrasounds don’t need them. Neither do plain old X-rays. They are needed for many CT scans, however.
CT machines produce high-resolution, computer-assisted images. Contrast dyes fed into the bloodstreams of patients undergoing scans lock on to cancer cells and vascular irregularities and show up as bright spots. Such scans are interpreted by radiologists who help oncologists detect and monitor cancers. They also help cardiologists get an accurate read of vascular damage suffered by stroke and heart attack sufferers.
In the latter case, such scans done on an emergency basis can make a life-or-death difference for patients and help limit damage like paralysis or loss of brain function.
Because of the shortage, says Harvey, radiologists have been forced to postpone scans, hoard scant supplies of contrast dye, and follow new triage protocols to make sure the most urgent imaging needs are done first and less urgent but still vital scans are done as soon as is practical.
A ripple across sites
UR Medicine’s imaging centers are not the area’s only such facilities. Rochester Regional Health also provides imaging at numerous locations around the region.
Borg and Ide Imaging, a large privately run radiology practice that is part of RadNet, a publicly traded radiology company with 350 locations in seven states, also has several Rochester-area imaging centers.
Because it is part of RadNet, which has been able to transfer contrast dye among its member imaging centers, Borg and Ide has so far been virtually unaffected by the shortage, says Borg and Ide spokesperson James McCann.
Like nearly every hospital and imaging center in the country, Rochester Regional Health is seeing the effect of the contrast dye shortage, says Rochester General Hospital chief of diagnostic imaging Adam Zinkin M.D. While the shortage persists, he says, “our team continues to collaborate with our in-house quality and safety experts to maximize our supply and ensure patients have access to the imaging services they need.”
Here and nationally, Harvey believes, every imaging center is pretty much in the same boat. Most U.S. imaging centers, especially larger ones, are supplied by GE Healthcare’s Shanghai plant.
Up to now, says Harvey, buying all their supplies from a single vendor made economic sense for imaging groups. Buying larger quantities earns discounts. GE Healthcare can supply large quantities and offers the best price.
There are smaller suppliers that could be an alternate source in theory, but in actuality none immediately have sufficient capacity to fill the hole left by the Shanghai plant’s sudden drop in production, Harvey says.
At the same time, the situation appears not to be as bad as it might.
To bring production back up to pre-lockdown levels, the GE Healthcare plant as well as other Shanghai-based manufacturing firms have created “bubbles,” housing workers at their factories to keep production humming,
Currently, says Harvey, the GE Healthcare plant’s contrast-dye production is up to 60 percent of pre-lockdown levels.
If no new stoppage intervenes, Harvey and market watchers nationally expect the contrast dye supply chain to return to normal or something close to normal by the end of June. Still, Harvey is not completely assured. So far, she says, UR Medicine, through “a great group effort,” has managed to keep its imaging operations running relatively smoothly.
Still, Harvey wonders: Could a new, currently unanticipated development—a natural disaster, a Chinese invasion of Taiwan, another pandemic or a new COVID surge—again interrupt contrast dye supplies or even some other similarly single-sourced vital component of the medical supply chain?
In the meantime, Harvey says, at UR Medicine the contrast dye shortage has highlighted another kink in the U.S. health care market’s expensive, complex and unwieldy system: prior authorization.
Under prior authorization, insurance carriers submit doctors’ requests to prescribe a particular medication or order for an imaging procedure to review by a third-party agency before approving it. Widely adopted by insurance carriers, the practice is supposed to control costs by making sure doctors don’t order unnecessary costly measures.
Since prior authorization first began to be used a decade or more ago, radiologists have complained that the practice puts a largely unneeded step between a physician’s treatment decision and the decision’s execution. The belief that such delay actually costs the system more than it saves is commonly held by many physicians.
MRI scans that use a different contrast dye that is currently not in short supply could be substituted for some CTs doctors use to screen for and pinpoint cancers, but insurers do not routinely allow MRIs—which cost more and take longer than CT scans—to be substituted for CTs, Harvey says.
UR Medicine has seen some prior-authorization delays in switching from CTs to MRIs, Harvey says. Whether those delays have caused significant problems is hard to say. An extra week in many cases might not matter, she says. But in some situations—detection of a fast-moving but previously unsuspected cancer, for example—a week could make a lot of difference.
Asked what measures this area’s largest health insurer, Excellus Blue Cross Blue Shield, is taking to ease prior-authorization delays during the contrast dye shortage, Excellus spokesperson Joy Auch supplied a statement that in part reads: “(T)hanks to feedback from local providers, we’ve temporarily modified our pre-authorization process for CTs and MRIs. These changes will continue throughout the duration of the shortage.”
The insurer, which covers well over half of area subscribers to employer-based health plans, is temporarily taking other measures as well. They include:
■ removing restrictions requiring doctors to contact the insurer to change a pre-authorization request when switching from a scan with contrast to one without it; and
■ adding an additional 90 days from the original approval date of currently approved prior authorizations.
In cases where a doctor wants to substitute an MRI for a CT scan, Excellus’ statement says, doctors “are encouraged to call or email us before or after the procedure and alert us to the change.”
Such accommodations are helpful, says Harvey. But she, like most radiologists, questions whether prior authorization for imaging scans is needed at all. Five percent or fewer of scan requests submitted to prior authorization are turned down, she believes.
For the past five years, Harvey adds, software called Care Select that essentially performs the same function as third-party prior authorization review has been available and is widely used by doctors including UR Medicine clinicians.
According to Change Healthcare Inc., the company that supplies Care Select, the software’s algorithms use “a comprehensive set of evidence-based standards (to apply) strong, data-driven governance (to) reduce the inappropriate use of imaging services and eliminate unnecessary tests.”
Harvey contrasts Care Select review to that done by third-party prior-authorization firms, which, she says, use human clerks to run through a checklist of factors. Used before tests are ordered, the software would also save time if it were to replace prior authorization, cutting two steps out of the present protocol.
As of Jan. 1, says Harvey, the federal Centers for Medicare and Medicaid Services plan to require doctors ordering scans to employ Care Select.
Excellus’ Auch could not immediately say whether Harvey’s estimate of how many scan requests prior authorization denies was accurate or supply figures comparing prior authorization’s costs to its benefits.