Radiology in the era of value-based healthcare: A multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR and RSNA.

BACKGROUND: The value-based healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Radiology in the Era of Value-Based Healthcare: A Multi-Society Expert Statement From the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

BACKGROUND: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Radiology in the Era of Value-based Healthcare: A Multi-Society Expert Statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

Background The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. Methods, findings and interpretation This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined. Published under a CC BY 4.0 license.

Radiology in the Era of Value-Based Healthcare: A Multi Society Expert Statement From the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

BACKGROUND: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Radiology in the era of value-based healthcare: a multi-society expert statement from the ACR, CAR, ESR, IS3R, RANZCR, and RSNA.

BACKGROUND: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation. METHODS, FINDINGS AND INTERPRETATION: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the healthcare value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined.

Vascular imaging of the spine in the US Medicare population: Catheter and MR angiography volumes from 2004 to 2016.

AIMS: The purpose of our study was to analyze utilization trends and physician specialty distribution in spinal catheter angiography and magnetic resonance angiography in the Medicare fee-for-service population. METHODS: Data from the CMS Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were used for this study. The Current Procedural Terminology version 4 codes for spinal magnetic resonance angiography (72159) and spinal catheter angiography (75705) were used to analyze the volumes of these procedures. Using Medicare's 108 specialty code, we compared procedure volumes among physician specialties. Data analysis was performed using SAS version 9.3 for Windows. RESULTS: The volume of spinal catheter angiography performed was 4758 in 2004, peaked at 6869 in 2012, and dropped to 6656 in 2016. Overall, the volume of spinal catheter angiography increased by 40% from 2004 to 2016. Radiologists performed the majority of these procedures (3736 or 56.1%) in 2016, followed by neurosurgeons (2456 or 36.9%), and neurologists (346 or 5.2%). The spinal magnetic resonance angiography volume fluctuated between 0 and 1 from 2004 to 2009, then precipitously increased to 40 in 2010, peaked at 133 in 2011, and declined to 81 in 2016. The volume of spinal magnetic resonance angiography procedures increased by 8000% from 2004 to 2016, with radiologists performing the majority of them. CONCLUSION: Our results show that spinal catheter angiography volumes continue to rise in the Medicare fee-for-service population, and are largely performed by radiologists, neurosurgeons, and neurologists. Although spinal magnetic resonance angiography volumes have started to increase, they comprise only a small fraction of studies performed for vascular evaluation of the spine.

Trends in Percutaneous Embolization Procedures by Radiologists and Other Specialists.

PURPOSE: To evaluate utilization trends in percutaneous embolization among radiologists and nonradiologist providers. MATERIALS AND METHODS: The nationwide Medicare Part B fee-for-service databases for 2005-2016 were used to evaluate percutaneous embolization codes. Six codes describing embolization procedures were reviewed. Physician providers were grouped as radiologists, vascular surgeons, cardiologists, nephrologists, other surgeons, and all others. RESULTS: The total volume of Medicare percutaneous embolization procedures increased from 20,262 in 2005 to 45,478 in 2016 (+125%). Radiologists performed 13,872 procedures in 2005 (68% of total volume) and 33,254 in 2016 (73% of total volume), a 140% increase in volume. While other specialists also increased the number of cases performed from 2005 to 2016, radiologists strongly predominated, performing 87% of arterial and 30% of venous procedures in 2016, more than any other single specialty. In 2014 and 2015, a sharp increase in venous embolization cases performed by nonradiologists preceded a sharp decrease in 2016, likely the result of complicated billing codes for venous procedures. Radiologists maintained a steady upward trend in the number of cases they performed during those years. CONCLUSIONS: The volume of percutaneous embolization procedures performed in the Medicare population increased from 2005 to 2016, reflecting a trend toward minimally invasive intervention. In 2016, radiologists performed nearly 10 times more arterial embolization procedures than the second highest specialty and more venous embolization procedures than any other single specialty.

Utilization Trends in Abdominal Imaging, 2004-2016.

OBJECTIVE. The purpose of this study was to analyze recent trends in abdominal imaging utilization in the Medicare population. MATERIALS AND METHODS. Medicare Part B databases for 2004-2016 were reviewed, and all Current Procedural Terminology codes pertaining to noninvasive imaging of the abdomen and pelvis were identified. Codes were grouped into six categories: CT and CT angiography (CTA), MRI and MR angiography (MRA), ultrasound, radionuclide imaging, radiography, and gastrointestinal fluoroscopy. Annual utilization rates per 1000 Medicare beneficiaries were calculated. Medicare physician specialty codes were used to identify studies performed by radiologists versus nonradiologist physicians. Reimbursements were determined. RESULTS. Total abdominal imaging utilization decreased from 558.0 examinations per 1000 Medicare beneficiaries in 2004 to 441.9 in 2016 (-20.8%). CT and CTA examinations increased by 22.5% from 2004 to 2010, followed by a sharp drop in 2011 caused by code bundling. From 2011 to 2016, CT and CTA use increased by only 7.2%. Radiography utilization decreased from 129.6 examinations per 1000 Medicare beneficiaries in 2004 to 91.5 in 2016 (-29.4%). Radionuclide studies decreased from 14.0 to 9.5 (-32.1%), and gastrointestinal fluoroscopy decreased from 37.8 examinations to 22.5 (-40.5%). Utilization of ultrasound increased slightly (1.5%), whereas MRI and MRA utilization sharply increased on a percentage basis (81.2%). Reimbursements peaked in 2009 at $1.704 billion, dropped substantially in 2011 because of code bundling, and remained relatively stable thereafter. The radiologists' market share of abdominal imaging was approximately 87% in both 2004 and 2016. CONCLUSION. Abdominal imaging utilization rates have declined in recent years, in part due to code bundling, but also largely because of a decrease in the use of abdominal radiography, gastrointestinal fluoroscopy, and nuclear imaging. Reimbursements have also declined. This study also showed that most of the abdominal imaging was performed by radiologists.

Trends in the Use of Percutaneous Versus Open Surgical Breast Biopsy: An Update.

PURPOSE: Despite the emergence of core-needle (percutaneous) biopsy as the standard of breast care, open surgical breast biopsies continue to be performed with variable frequency. The aim of this study was to compare trends in the use of percutaneous and open surgical breast biopsies and the relative roles of radiologists and surgeons in performing them. METHODS: The nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were reviewed, and trends were studied in the total volume of breast biopsies performed in the Medicare fee-for-service population and in volumes of imaging-guided percutaneous biopsies (IGPBs) and open surgical biopsies. Using Medicare's physician specialty codes, the numbers of procedures performed by different specialties were determined. Trends in the type of imaging used for IGPBs were analyzed using the relevant Current Procedural Terminology codes, introduced in 2014. RESULTS: Between 2004 and 2016, utilization of IGPBs increased from 124,423 to 187,914 (+51%), whereas the use of open surgical breast biopsies declined from to 6,605 to 2,373 (-64%). IGPBs performed by radiologists increased from 89,493 to 160,485 (+79%), and IGPBs by surgeons declined from 30,264 to 24,703 (-18%). Among IGPBs from 2014 to 2016, ultrasound-guided and MRI-guided percutaneous biopsies increased, whereas stereotactic biopsies declined. CONCLUSIONS: There is a steady upward trend in the utilization of imaging-guided breast biopsies, and a majority are performed by radiologists. Ultrasound is the primary guidance technique used in percutaneous breast biopsies.

Recent Trends in Endovascular and Surgical Treatment of Peripheral Arterial Disease in the Medicare Population.

OBJECTIVE. Although radiologists developed endovascular treatment of peripheral arterial disease (PAD) in the 1960s, vascular surgeons and cardiologists have become increasingly involved in its application. The purpose of this study was to examine utilization trends in endovascular and surgical treatment of PAD in recent years in the Medicare population. CONCLUSION. Surgical treatment of PAD has decreased each year from 2011 to 2016, whereas endovascular treatment has increased each year. By 2016, Medicare patients who needed revascularization for PAD were more than four times as likely to undergo endovascular as they were to undergo surgical treatment. Between 2011 and 2016, radiologists, vascular surgeons, and cardiologists all increased their endovascular volume, but by 2016, vascular surgeons and cardiologists performed three of every four endovascular procedures for the Medicare population. While only 12% of the total endovascular procedures for PAD were performed in 2016, radiology has grown its procedural volume each year from 2011 through 2016.

Recent Trends in Medicare Reimbursements to Nonradiologist Physicians for In-Office MRI and CT.

PURPOSE: Previous studies demonstrated rapid growth in payments to nonradiologist providers (NRPs) for MRI and CT in their private offices. In this study, we re-examine the trends in these payments. METHODS: The nationwide Medicare Part B master files from 2004 to 2016 were accessed. They provide payment data for all Current Procedural Terminology codes. Codes for MRI and CT were selected. Global and technical component claims were counted. Medicare specialty codes identified payments made to NRPs and radiologists, and place-of-service codes identified payments directed to their private offices. RESULTS: Medicare MRI payments to NRPs peaked in 2006 at $247.7 million. As a result of the Deficit Reduction Act, there was a sharp drop to $189.5 million in 2007, eventually declining to $101.6 million by 2016 (-59% from peak in 2006). The NRP specialty groups with the highest payments for MRI ownership include orthopedists, neurologists, primary care physicians, and hospital-based specialists (pathology, physiatry, and hospitalists). Medicare CT payments to NRPs peaked in 2008 at $284.1 million and declined to $94.7 million in 2016 (-67% from peak). Cardiologists, primary care physicians, internal medicine specialists, urologists, and medical oncologists accounted for the most payments made to NRPs. Dollars paid to radiologists for private office MRI and CT dropped substantially since they peaked in 2006. CONCLUSIONS: NRP private offices (and radiology offices also) experienced massive decreases in Medicare payments for MRI and CT since peaking in 2006 and 2008, respectively. These trends suggest the financial viability of private office practice may be in jeopardy. However, certain recent policy changes could promote a resurgence.

Advanced Imaging Interpretation by Radiologists and Nonradiologist Physicians: A Training Issue.

OBJECTIVE. The purpose of this study was to examine the degree to which nonradiologist physicians provide formal interpretations for advanced imaging and to consider whether adequate training can be achieved for those physicians. This investigation assumed that hospitals are the only places where formal imaging training occurs. MATERIALS AND METHODS. The CMS Physician/Supplier Procedure Summary Master Files (PSPSMFs) of the Medicare Part B datasets for 2015 were reviewed. We selected the Current Procedural Terminology (CPT) codes for four categories of noninvasive diagnostic imaging: CT, MRI, PET, and general nuclear imaging. Medicare place-of-service codes allowed us to determine the location of each study interpretation. We narrowed our analysis to data from the three major hospital places of service: inpatient facilities, hospital outpatient departments, and emergency departments. Provider specialties were determined using Medicare's 108 specialty codes. Procedure volumes among nonradiologist physicians were compared with those among radiologists. RESULTS. Of the 17,824,297 hospital-based CT examinations performed in the Medicare fee-for-service population, radiologists interpreted 17,698,360 (99.29%) and nonradiologists interpreted 125,937 (0.71%). Of the 4,512,627 MRI examinations performed, radiologists interpreted 4,469,275 (99.04%) and nonradiologist physicians interpreted 43,352 (0.96%). Of 391,688 PET studies performed, radiologists interpreted 368,913 (94.19%) and nonradiologist physicians interpreted 22,775 (5.81%). Of the 2,070,861 general nuclear medicine studies performed, radiologists interpreted 1,307,543 (63.14%) and nonradiologist physicians interpreted 763,318 (36.86%). Cardiologists had the largest involvement of nonradiologist physicians, contributing approximately 3% of all advanced imaging interpretations. All other nonradiologist physicians interpreted a tiny fraction of advanced imaging studies. CONCLUSION. Besides radiologists and cardiologists, no other medical specialty provides sufficient education for their trainees and practitioners in advanced imaging interpretation to justify allowing them to interpret these studies in practice, except under carefully controlled circumstances.

The Increasing Use of Emergency Department Imaging in the United States: Is It Appropriate?

OBJECTIVE. The purpose of this study was to study trends in utilization of imaging in emergency departments (ED) in relation to trends in ED visits and the specialties of the interpreting physicians. MATERIALS AND METHODS. This study was conducted with Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004-2016 and Health Care Cost and Utilization Project (HCUP) data from 2006 to 2014. Yearly utilization was calculated per 1000 Medicare beneficiaries for different noninvasive imaging modalities performed during ED visits, and the specialties of the physicians making the interpretations were recorded. The number of ED visits by Medicare patients was obtained from the HCUP. RESULTS. The number of ED visits by Medicare fee-for-service patients increased 8.0% (from 20.0 million in 2006 to 21.6 million in 2014), and the total number of associated ED imaging examinations increased 38.4% (14.6 million to 20.2 million). The number of imaging examinations per ED visit was 0.73 in 2006, increasing to 0.94 by 2014. Utilization trends per 1000 Medicare fee-for-service enrollees in the ED for the major modalities were as follows: CT +153.0% (77.8 in 2004 to 196.7 in 2016), noncardiac ultrasound +134% (11.2 in 2004 to 26.2 in 2016), and radiography +30% (259 in 2004 to 336 in 2016). Utilization of MRI and nuclear medicine was very low. In 2016, radiologists interpreted 99.5% (CT), 99.2% (MRI), 98.0% (radiography), 87.6% (ultrasound), and 94.5% (nuclear medicine) of imaging examinations. CONCLUSION. Utilization of imaging in EDs is increasing not only in the Medicare population but also per ED visit. Radiologists strongly predominate in interpreting examinations in all modalities.

Recent Trends Suggest Possible Inappropriate Utilization of Myocardial Perfusion Imaging.

PURPOSE: The aim of this study was to analyze the utilization of elective stress nuclear myocardial perfusion imaging (MPI) in the Medicare population. METHODS: Nationwide Medicare Part B fee-for-service databases for 2004 to 2016 were reviewed. Current Procedural Terminology codes for stress MPI were selected: standard planar and single-photon emission computed tomography (STD) and PET. Utilization rates per 1,000 Medicare beneficiaries were calculated. Elective examinations were identified using place-of-service codes for private offices and hospital outpatient departments (HOPDs). Medicare physician specialty codes identified the performing physician. Because Medicare Part B databases are complete population counts, sample statistics were not required. RESULTS: Elective STD MPI utilization peaked in 2006 at 74 studies/1,000 and had declined by 36% by 2016. Cardiologists' share of STD MPI grew from 79% to 87% between 2004 and 2016. Cardiologists perform STD MPI primarily in private offices, where utilization peaked in 2008 and then demonstrated an absolute decline of 28 studies/1,000 by 2016. During this same time period, cardiologists' use of STD MPI in HOPDs demonstrated an absolute increase of 8.1 studies/1,000. From 2004 to 2016, STD MPI use by radiologists declined by 58%. Elective PET MPI maintained an upward trend, reflecting increasing use by cardiologists in private offices. CONCLUSIONS: Elective STD MPI use is declining, but cardiologists are performing an increasing share in outpatient settings. The drop in private office STD MPI among cardiologists was far greater than the corresponding increase in its use in HOPDs, suggesting that many studies previously performed in private offices were unindicated. Self-referred PET MPI utilization has rapidly grown in cardiology private offices.

Neurointerventional Radiology for the Aspiring Radiology Resident: Current State of the Field and Future Directions.

OBJECTIVE: The purposes of this study were to document recent trends in stroke intervention at a tertiary-care facility with a comprehensive stroke center and to analyze current procedure volumes and the employment of specialty providers in neurointerventional radiology (NIR). MATERIALS AND METHODS: Institutional trends in the volume of mechanical thrombectomy were analyzed on the basis of the number of patients who underwent mechanical thrombectomy from 2013 to 2017. To evaluate the current status of mechanical thrombectomy volumes in the United States, the number of patients in the Medicare fee-for-service database who underwent mechanical thrombectomy in 2016 was assessed. The specialty backgrounds of the various providers who performed mechanical thrombectomy were analyzed. Procedure volumes for intracranial stenting, embolization, and vertebral augmentation procedures were assessed. RESULTS: From 2013 to 2017, the total numbers of mechanical thrombectomy procedures for acute ischemic stroke were 19 in 2013 and 111 in 2017. The total volume of mechanical thrombectomy procedures in the Medicare fee-for-service population in 2016 was 7479. For intracranial endovascular procedures, 20,850 were performed in the U.S. Medicare population in 2015 and 22,511 in 2016. Radiologists performed 45% of procedures in 2016; neurosurgeons, 41%; and neurologists, 11%. When the total numbers of percutaneous brain and spine procedures were combined, radiologists performed 41%; neurosurgeons, 23%; and neurologists, 3%. In 2016, there were a total of 220 active NIR staff at the NIR programs with rotating residents or fellows. In these programs, 49% of staff members were neuroradiologists, 41% were neurosurgeons, and 10% were neurologists. Of the 72 NIR departments with confirmed rotating fellows or residents, 14 had only neuroradiologists on staff, six had only neurosurgeons, and one had only neurologists. CONCLUSION: Increasing radiology resident interest and participation in NIR should ensure a steady influx of radiologists into the field, continuing the strong tradition of radiology participation, leadership, and innovation in NIR.

Evaluation of a Program for Improving Advanced Imaging Interpretation.

OBJECTIVES: Self-referred imaging has grown rapidly, raising concerns about increased costs and compromised quality of care. A quality improvement program using imaging interpretation criteria was designed by a national payer to ensure that noninvasive diagnostic images are interpreted by appropriately trained physicians. The objective of this program evaluation was to compare self-referral rates before and after institution of the imaging interpretation criteria program. METHODS: The imaging interpretation criteria program allocated privileges to bill for advanced imaging interpretation according to physician specialty. Nonradiologist physicians could obtain exemptions by appeal. Some physicians were not restricted in their billing because of successful appeals of the restrictions or the timing of their contract renewals. Self-referral rates were compared between the period 12 months before and 25 months after the program was initiated using t tests. The preprogram and postprogram self-referral rate for computed tomography and magnetic resonance imaging in aggregate was calculated both for the physicians that came into contact with the program and nationally, and then was stratified based on physician appeal status and reimbursement restrictions. RESULTS: The program was associated with significantly less frequent self-referrals by physicians whose appeals were denied (17.4%-8.2%; P = 0.0011) and by physicians notified of the program but not subject to it (24.8%-18.5%; P = 0.026). Self-referrals in the program states declined from 19.9% to 13.7% (P < 0.01). CONCLUSIONS: A significant reduction in image interpretations billed by physicians working outside of the scope of their training occurred after the implementation of the imaging interpretation criteria program.

Coronary CT Angiography: Reversal of Earlier Utilization Trends.

PURPOSE: To assess recent trends in utilization of coronary CT angiography (CCTA), based upon place of service and provider specialty. MATERIALS AND METHODS: The nationwide Medicare Part B master files for 2006 through 2016 were the data source. Current Procedural Terminology, version 4 codes for CCTA were selected. The files provided procedure volume for each code. Utilization rates per 100,000 Medicare fee-for-service enrollees were then calculated. Medicare's place-of-service codes were used to identify CCTAs performed in private offices, hospital outpatient departments (HOPDs), emergency departments (EDs), and inpatient settings. Physician specialty codes were used to identify CCTAs interpreted by radiologists, cardiologists, and all other physicians as a group. Medicare practice share was defined as the percent of total Medicare utilization that was billed by each specialty. RESULTS: The total utilization rate of CCTA in the Medicare population rose sharply from 2006 to 2007, peaking at 210.3 per 100,000 enrollees in 2007. Radiologists' CCTA practice share in 2007 was 32%, compared with 60% for cardiologists. The overall utilization rate then declined to a nadir of 107.1 per 100,000 enrollees in 2013, but subsequently increased to 131.0 by 2016. By that year, radiologists' share of CCTA practice had risen to 58%, compared with 38% for cardiologists. HOPD utilization increased sharply since 2010, primarily among radiologists. In EDs and inpatient settings, greater utilization has also occurred recently, primarily among radiologists. By contrast, private office utilization has dropped sharply since 2007. CONCLUSION: After years of declining utilization, the utilization rate of CCTA is now increasing, predominantly among radiologists.