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M I N A R S I N
P
E R I N A T O L O G Y
37 (2013) 292–294
Available online at www.sciencedirect.com
www.elsevier.com/locate/semperi
Obstetric ultrasound utilization in the United States: Data from various health plans Daniel F. O'Keeffe, MDa,n, and Alfred Abuhamad, MDb a
Society for Maternal-Fetal Medicine, 409 12th St., SW, Washington, DC 20024 Department of Obstetrics & Gynecology, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, VA 23507
b
A RT I C L E IN F O
A B S T R A C T There is currently a lack of published data on ultrasound utilization in obstetrics in
Keywords:
the United States. In order to get some meaningful information on this topic, we analyzed
Obstetrical ultrasound
de-identified data obtained from large insurance providers and underwriters that covered
Low risk
large segment of the United States population in various geographic areas of the country.
Data
Our results show an overall significant increase in utilization of obstetric ultrasound over
Utilization
the years, with pregnancies receiving around 4–5 ultrasounds per pregnancy. Another important aspect of the data is a higher than expected utilization of the targeted 76811 ultrasound examination, with utilization rates between 30% and 50%, beyond the original intention of the targeted code. Despite the fact that the data was not intended to shed light on indication of ultrasound or competency of ultrasound providers, in a healthcare world of shrinking reimbursement, as leaders of quality, we should ensure that ultrasound examinations that pregnant women receive are indicated and are performed by competent healthcare workers in ultrasound laboratories that meet accreditation standards. & 2013 Elsevier Inc. All rights reserved.
1.
Introduction
There is currently lack of published data on ultrasound utilization in obstetrics in the United States. This is related in part to minimal research in this area and the absence of a centralized mechanism for reporting and dissemination of this data. Undoubtedly, insurance providers with large databases have access to such data for their members and rely on this information in their decision-making process. National Medical societies that set policy and generate guidelines on indications and qualifications of ultrasound examination, do so in general, based upon the clinical evidence and without access to data regarding ultrasound utilization in the clinical practice of obstetric sonography. As several factors may drive ultrasound utilization, a process for generating and analyzing such data may be relevant. In this article, we partner with various insurance providers and underwriters to get a glimpse of obstetric ultrasound utilization in the United States. n
2.
Materials and methods
In order for us to get a wide representation of obstetric ultrasound utilization in the United States, we sent a request to a number of insurance providers and underwriters, asking for unidentified data on ultrasound utilization in obstetrics on their members for a list of specific ultrasound codes as depicted in Table 1. Source of data, derived from various insurance companies, was made anonymous and the data was presented at the fetal imaging workshop, a multi-society forum, sponsored by the NICHD and held in December 2012. The data represent a large segment of the United States population and covers various geographic areas of the country. Although this patient population is not statistically validated, based upon the data presented in this article, we believe that we have an accurate representative sample of the obstetric population in the United States.
Corresponding author. E-mail address: [email protected] (D.F. O'Keeffe).
0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2013.06.003
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E M I N A R S I N
P
Table 3 – Commercial plan 200,000 deliveries/year.
Table 1 – Ultrasound codes evaluated. First trimester o14 weeks 0 days Routine scan 414 weeks 0 days Detailed fetal anatomic scan Nuchal translucency Limited scan Follow-up scan Pregnant, transvaginal BPP—with NST BPP Fetal U.A. Doppler Fetal MCA Doppler Fetal echocardiography Fetal Doppler echocardiographs
76801–76802 76805–76810 76811–76812 76813–76814 76815 76816 76817 76818 76819 76820 76821 76825–76826 76827–76828
3.
293
37 (2013) 292–294
E R I N A T O L O G Y
Results
In this section, we are summarizing the data presented to us by insurance providers and underwriters, while maintaining anonymity of respective entities. The first set of data is presented in Table 2 and corresponds to a commercial and managed pregnant population of more than 800,000 deliveries. In Table 2, the detailed ultrasound screening code corresponds to the 76811 code, and as shown, about 36.6% of deliveries covered under a commercial plan and 34.4% of deliveries covered under the Medicaid plan received the 76811 ultrasound examination during pregnancy, with a noted progressive increase in utilization since 2009 in both the commercial and the Medicaid products. It is unclear why the commercial product has a higher utilization of the 76811 code in pregnancies. When one compares the utilization of the Doppler and biophysical profile codes (Table 2), the Medicaid product shows a higher utilization, which may imply a higher level of pregnancy risk. Data from the next plan is derived from about 200,000 deliveries/year and is presented in Table 3. Overall pregnancies in this plan are receiving on an average 6.7 ultrasounds per pregnancy with a noted steady increase since 2009. If you take out codes 76818–76828, pregnancies are receiving approximately 5 ultrasounds per pregnancy. The utilization of the basic obstetric ultrasound examination, 76805 is greater than 90% in the population and the utilization of the targeted ultrasound examination, 76811 is about 50% in this population, which is significantly higher than the expected utilization of this code in the obstetric population. The information from this plan also shows a noted increase in ultrasound utilization since 2009. Table 4 represents data derived from a low-risk pregnancy population. To ensure that this data set included low-risk
PROC_CD
Proc/delivery trend (%)
76801 76802 76805 76810 76811 76812 76813 76814 76815 76816 76817 76818 76819 76820 76821 76825 76826 76827 76828 Grand total
2010 vs 2009
2011 vs 2009
3.57 6.30 −0.71 0.77 −0.29 4.39 12.28 21.00 5.10 9.45 8.60 9.80 9.81 12.81 9.64 4.15 8.19 3.18 5.43
3.18 1.92 −1.41 −5.22 0.98 −0.21 5.73 2.12 4.75 8.14 3.76 1.32 9.46 4.05 2.30 6.66 0.27 0.26 2.44
5.98
3.78
pregnancies and deliveries only, data excluded all pregnancies and deliveries that delivered without 270 days of continued enrollment in the plan, Medicare and Medicaid deliveries, stillbirths and abortions, patients delivered by Maternal–Fetal Medicine specialists, and pregnancies with any high-risk indicators in the medical history or delivery. Ultrasound examinations added for review included those performed in the outpatient setting, and those performed 2 days prior to delivery with the following CPT codes: 76801, 76805, 76811, 76813, 76815, 76816, and 76817. Table 4 shows that in this clearly low-risk population of 61,717 deliveries from 4 regions of the United States, the mean number of obstetric ultrasound examination per pregnancy is between 4.03 and 5.15 with a median of 3–4 and a standard deviation of 3.096. The distribution by CPT code is shown in Table 5. Information that is not shown but reported by the insurance company confirms what has been displayed by other data sets in that there has been an increase in utilization of ultrasound in 2011 compared to the data from 2005 to 2007 in all parameters.
4.
Conclusion
Our review of the data generated by multiple insurance plans is consistent in highlighting very important points with
Table 2 – Commercial and managed Medicaid plans 4800,000 deliveries.
2009 2010 2011
Detailed: Screening US 76811 (%)
% Doppler
% Biophysical
Commercial
Medicaid
Commercial
Medicaid
Commercial
Medicaid
35.8 36.2 36.6
33.1 34.9 34.4
2.9 2.9 3.0
5.0 5.1 5.6
9.9 10.1 11.2
13.9 15.2 15.2
294
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37 (2013) 292–294
Table 4 – OB ultrasound utilization in singleton, low-risk deliveries, by region 2011 (N ¼ 61,717). Region
Total deliveries
Mean
Median
Standard deviation
Mean þ1SD
Mean þ2SD
Mid-America Northeast Southeast West
18,990 16,709 14,920 11,098
4.03 5.15 4.60 4.50
3 4 4 4
2.576 3.362 3.192 3.197
6.6 8.5 7.8 7.7
9.2 11.9 11.0 10.9
Total
61,717
4.55
4
3.096
7.6
10.7
Table 5 – OB ultrasound utilization in singleton, low-risk deliveries, by CPT code, by region 2011 (N ¼ 61,717).
Central NE SE WE TOTAL
76801
76805
76811
76813
76815
76816
76817
Total
0.45 0.73 0.54 0.60 0.58
1.14 0.79 0.99 1.09 1.00
0.29 0.55 0.37 0.40 0.40
0.31 0.65 0.50 0.46 0.47
0.39 0.64 0.44 0.68 0.52
0.72 1.02 0.90 0.55 0.82
0.73 0.77 0.85 0.72 0.77
4.03 5.15 4.60 4.50 4.56
regards to the utilization of obstetric ultrasound imaging in the United States. There appears to be a significant increase in utilization of obstetric ultrasound when recent data is compared to prior years. This increase in utilization is noted across the board and includes a noted increase in the low-risk pregnancies as well as in the total pregnant population. Reasons for such an increase in utilization are unclear, and whether an increase in obesity trends in the population contributes to an increase in ultrasound utilization remains to be seen. Another important aspect of the data is a higher than expected utilization of the targeted 76811 ultrasound examination, with utilization rates between 30% and 50%. This targeted or detailed ultrasound examination was intended to be indication driven and thus reserved for pregnancies of higher-risk indications.
With pregnancies receiving around 4–5 ultrasounds per pregnancy, and several getting the targeted obstetric examination, how do we determine value, quality, and competency? In a healthcare world of shrinking reimbursement, should we ensure the ultrasound examinations that pregnant women receive are indicated and are performed by competent healthcare workers in ultrasound laboratories that meet accreditation standards? Review and analysis of the data, guidelines for obstetric ultrasound examination, task force for the targeted obstetric ultrasound examination (76811) and a push for accreditation of ultrasound laboratories are required first steps. The authors wish to thank the following companies who graciously volunteered their data and staff time. Without their support, this chapter will not be possible: United Healthcare, Aetna Health Insurance, MedSolutions, and NIA/Magellan Health Services.
M I N A R S I N
P
E R I N A T O L O G Y
37 (2013) 292–294
Available online at www.sciencedirect.com
www.elsevier.com/locate/semperi
Obstetric ultrasound utilization in the United States: Data from various health plans Daniel F. O'Keeffe, MDa,n, and Alfred Abuhamad, MDb a
Society for Maternal-Fetal Medicine, 409 12th St., SW, Washington, DC 20024 Department of Obstetrics & Gynecology, Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, VA 23507
b
A RT I C L E IN F O
A B S T R A C T There is currently a lack of published data on ultrasound utilization in obstetrics in
Keywords:
the United States. In order to get some meaningful information on this topic, we analyzed
Obstetrical ultrasound
de-identified data obtained from large insurance providers and underwriters that covered
Low risk
large segment of the United States population in various geographic areas of the country.
Data
Our results show an overall significant increase in utilization of obstetric ultrasound over
Utilization
the years, with pregnancies receiving around 4–5 ultrasounds per pregnancy. Another important aspect of the data is a higher than expected utilization of the targeted 76811 ultrasound examination, with utilization rates between 30% and 50%, beyond the original intention of the targeted code. Despite the fact that the data was not intended to shed light on indication of ultrasound or competency of ultrasound providers, in a healthcare world of shrinking reimbursement, as leaders of quality, we should ensure that ultrasound examinations that pregnant women receive are indicated and are performed by competent healthcare workers in ultrasound laboratories that meet accreditation standards. & 2013 Elsevier Inc. All rights reserved.
1.
Introduction
There is currently lack of published data on ultrasound utilization in obstetrics in the United States. This is related in part to minimal research in this area and the absence of a centralized mechanism for reporting and dissemination of this data. Undoubtedly, insurance providers with large databases have access to such data for their members and rely on this information in their decision-making process. National Medical societies that set policy and generate guidelines on indications and qualifications of ultrasound examination, do so in general, based upon the clinical evidence and without access to data regarding ultrasound utilization in the clinical practice of obstetric sonography. As several factors may drive ultrasound utilization, a process for generating and analyzing such data may be relevant. In this article, we partner with various insurance providers and underwriters to get a glimpse of obstetric ultrasound utilization in the United States. n
2.
Materials and methods
In order for us to get a wide representation of obstetric ultrasound utilization in the United States, we sent a request to a number of insurance providers and underwriters, asking for unidentified data on ultrasound utilization in obstetrics on their members for a list of specific ultrasound codes as depicted in Table 1. Source of data, derived from various insurance companies, was made anonymous and the data was presented at the fetal imaging workshop, a multi-society forum, sponsored by the NICHD and held in December 2012. The data represent a large segment of the United States population and covers various geographic areas of the country. Although this patient population is not statistically validated, based upon the data presented in this article, we believe that we have an accurate representative sample of the obstetric population in the United States.
Corresponding author. E-mail address: [email protected] (D.F. O'Keeffe).
0146-0005/13/$ - see front matter & 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1053/j.semperi.2013.06.003
S
E M I N A R S I N
P
Table 3 – Commercial plan 200,000 deliveries/year.
Table 1 – Ultrasound codes evaluated. First trimester o14 weeks 0 days Routine scan 414 weeks 0 days Detailed fetal anatomic scan Nuchal translucency Limited scan Follow-up scan Pregnant, transvaginal BPP—with NST BPP Fetal U.A. Doppler Fetal MCA Doppler Fetal echocardiography Fetal Doppler echocardiographs
76801–76802 76805–76810 76811–76812 76813–76814 76815 76816 76817 76818 76819 76820 76821 76825–76826 76827–76828
3.
293
37 (2013) 292–294
E R I N A T O L O G Y
Results
In this section, we are summarizing the data presented to us by insurance providers and underwriters, while maintaining anonymity of respective entities. The first set of data is presented in Table 2 and corresponds to a commercial and managed pregnant population of more than 800,000 deliveries. In Table 2, the detailed ultrasound screening code corresponds to the 76811 code, and as shown, about 36.6% of deliveries covered under a commercial plan and 34.4% of deliveries covered under the Medicaid plan received the 76811 ultrasound examination during pregnancy, with a noted progressive increase in utilization since 2009 in both the commercial and the Medicaid products. It is unclear why the commercial product has a higher utilization of the 76811 code in pregnancies. When one compares the utilization of the Doppler and biophysical profile codes (Table 2), the Medicaid product shows a higher utilization, which may imply a higher level of pregnancy risk. Data from the next plan is derived from about 200,000 deliveries/year and is presented in Table 3. Overall pregnancies in this plan are receiving on an average 6.7 ultrasounds per pregnancy with a noted steady increase since 2009. If you take out codes 76818–76828, pregnancies are receiving approximately 5 ultrasounds per pregnancy. The utilization of the basic obstetric ultrasound examination, 76805 is greater than 90% in the population and the utilization of the targeted ultrasound examination, 76811 is about 50% in this population, which is significantly higher than the expected utilization of this code in the obstetric population. The information from this plan also shows a noted increase in ultrasound utilization since 2009. Table 4 represents data derived from a low-risk pregnancy population. To ensure that this data set included low-risk
PROC_CD
Proc/delivery trend (%)
76801 76802 76805 76810 76811 76812 76813 76814 76815 76816 76817 76818 76819 76820 76821 76825 76826 76827 76828 Grand total
2010 vs 2009
2011 vs 2009
3.57 6.30 −0.71 0.77 −0.29 4.39 12.28 21.00 5.10 9.45 8.60 9.80 9.81 12.81 9.64 4.15 8.19 3.18 5.43
3.18 1.92 −1.41 −5.22 0.98 −0.21 5.73 2.12 4.75 8.14 3.76 1.32 9.46 4.05 2.30 6.66 0.27 0.26 2.44
5.98
3.78
pregnancies and deliveries only, data excluded all pregnancies and deliveries that delivered without 270 days of continued enrollment in the plan, Medicare and Medicaid deliveries, stillbirths and abortions, patients delivered by Maternal–Fetal Medicine specialists, and pregnancies with any high-risk indicators in the medical history or delivery. Ultrasound examinations added for review included those performed in the outpatient setting, and those performed 2 days prior to delivery with the following CPT codes: 76801, 76805, 76811, 76813, 76815, 76816, and 76817. Table 4 shows that in this clearly low-risk population of 61,717 deliveries from 4 regions of the United States, the mean number of obstetric ultrasound examination per pregnancy is between 4.03 and 5.15 with a median of 3–4 and a standard deviation of 3.096. The distribution by CPT code is shown in Table 5. Information that is not shown but reported by the insurance company confirms what has been displayed by other data sets in that there has been an increase in utilization of ultrasound in 2011 compared to the data from 2005 to 2007 in all parameters.
4.
Conclusion
Our review of the data generated by multiple insurance plans is consistent in highlighting very important points with
Table 2 – Commercial and managed Medicaid plans 4800,000 deliveries.
2009 2010 2011
Detailed: Screening US 76811 (%)
% Doppler
% Biophysical
Commercial
Medicaid
Commercial
Medicaid
Commercial
Medicaid
35.8 36.2 36.6
33.1 34.9 34.4
2.9 2.9 3.0
5.0 5.1 5.6
9.9 10.1 11.2
13.9 15.2 15.2
294
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M I N A R S I N
P
E R I N A T O L O G Y
37 (2013) 292–294
Table 4 – OB ultrasound utilization in singleton, low-risk deliveries, by region 2011 (N ¼ 61,717). Region
Total deliveries
Mean
Median
Standard deviation
Mean þ1SD
Mean þ2SD
Mid-America Northeast Southeast West
18,990 16,709 14,920 11,098
4.03 5.15 4.60 4.50
3 4 4 4
2.576 3.362 3.192 3.197
6.6 8.5 7.8 7.7
9.2 11.9 11.0 10.9
Total
61,717
4.55
4
3.096
7.6
10.7
Table 5 – OB ultrasound utilization in singleton, low-risk deliveries, by CPT code, by region 2011 (N ¼ 61,717).
Central NE SE WE TOTAL
76801
76805
76811
76813
76815
76816
76817
Total
0.45 0.73 0.54 0.60 0.58
1.14 0.79 0.99 1.09 1.00
0.29 0.55 0.37 0.40 0.40
0.31 0.65 0.50 0.46 0.47
0.39 0.64 0.44 0.68 0.52
0.72 1.02 0.90 0.55 0.82
0.73 0.77 0.85 0.72 0.77
4.03 5.15 4.60 4.50 4.56
regards to the utilization of obstetric ultrasound imaging in the United States. There appears to be a significant increase in utilization of obstetric ultrasound when recent data is compared to prior years. This increase in utilization is noted across the board and includes a noted increase in the low-risk pregnancies as well as in the total pregnant population. Reasons for such an increase in utilization are unclear, and whether an increase in obesity trends in the population contributes to an increase in ultrasound utilization remains to be seen. Another important aspect of the data is a higher than expected utilization of the targeted 76811 ultrasound examination, with utilization rates between 30% and 50%. This targeted or detailed ultrasound examination was intended to be indication driven and thus reserved for pregnancies of higher-risk indications.
With pregnancies receiving around 4–5 ultrasounds per pregnancy, and several getting the targeted obstetric examination, how do we determine value, quality, and competency? In a healthcare world of shrinking reimbursement, should we ensure the ultrasound examinations that pregnant women receive are indicated and are performed by competent healthcare workers in ultrasound laboratories that meet accreditation standards? Review and analysis of the data, guidelines for obstetric ultrasound examination, task force for the targeted obstetric ultrasound examination (76811) and a push for accreditation of ultrasound laboratories are required first steps. The authors wish to thank the following companies who graciously volunteered their data and staff time. Without their support, this chapter will not be possible: United Healthcare, Aetna Health Insurance, MedSolutions, and NIA/Magellan Health Services.
