Price Transparency in Radiology-A Model for the Future

Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US

BACKGROUND

Diagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs.

METHODS

Using national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics.

RESULTS

Among 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5093) or primary care physician ($5660), and highest when starting with an orthopedist ($9434) or acupuncturist ($9205).

CONCLUSION

The first provider seen by individuals with LBP was associated with large differences in health care utilization, opioid prescriptions, and cost while there were no differences in delays in diagnosis of serious illness.

Charges for Shoppable Musculoskeletal Imaging Examinations: CMS Transparency Compliance and Variability Among 250 U.S. Hospitals

As of January 2021, among other transparency requirements, the Centers for Medicare & Medicaid Services require that hospitals publish consumer-friendly displays of charges for shoppable health care services, including four musculoskeletal imaging examinations. Of 250 selected U.S. hospitals, all published charges for these four examinations, although 21% did not provide charges within consumer-friendly displays. Bed count was larger for compliant hospitals than for noncompliant hospitals (500 vs 384 beds). All four examinations had widely variable charges (representing a 73.8-fold difference).

Current Controversies in Radiology on Cost, Reimbursement, and Price Transparency: AJR Expert Panel Narrative Review

Many believe that fundamental reform of the U.S. healthcare system is overdue and necessary given rising national healthcare expenditures, poor performance on key population health metrics, meaningful health disparities, concerns about potential financial toxicity of care, inadequate price transparency, pending insolvency of Medicare Part A, increasing commercial insurance premiums, and significant uninsured and underinsured populations. The Medicare Payment Advisory Commission (MedPAC), an independent congressional agency, believes that part of this reform includes redistribution of reimbursements away from specialties such as radiology. Thus, despite an increase in the Medicare population and spending, Medicare payments for medical imaging have been decreasing for years. Further, the No Surprises Act, a federal law intended to curb the problem of surprise medical billing, was re-purposed in federal rule-making to reduce reimbursement from commercial payers to certain specialties including radiology. In this article, we examine challenges facing the U.S. healthcare system, focusing on cost, reimbursement, and price transparency, and the role of radiology in addressing such challenges. Medical imaging is a minor contributor to national healthcare expenditures, but provides an outsized impact on patient care. The radiology community should work together to demonstrate the value of medical imaging and reduce inappropriate utilization of low-value care.

Costs Versus Quality in Imaging Examination Decisions

PURPOSE

Emerging price transparency tools allow consumers to access individualized out-of-pocket cost (OOPC) estimates, but many lack quality metrics. The aim of this study was to evaluate how potential patients weigh imaging OOPC versus measures of quality when selecting an imaging center for a hypothetical health condition (back pain).

METHODS

Surveying 1,310 Amazon Mechanical Turk volunteers, the authors evaluated how potential patients weigh MRI OOPC ($50 vs $400 vs unknown cost at the time of the examination, with billed OOPC responsibility varying between $50 and $3,500) versus service quality surrogates using three different quality indicators (examination results accuracy, physician recommendation of an imaging center on the basis of familiarity, and facility online star ratings) in their decisions when selecting a radiology center for imaging of two hypothetical clinical conditions (mild and severe back pain), using ranking-based conjoint analyses.

RESULTS

A total of 1,025 eligible respondents completed the survey. Respondents expressed higher preference for perceived quality over cost in hypothetical severe back pain scenarios, resulting in a relative importance of 65.8% (95% confidence interval [CI], 62.2%-69.4%) for improved imaging results accuracy from 87% to 96%, 63.9% (95% CI, 60.3%-67.5%) for provider recommendations of the facility, and 80.1% (95% CI, 74.2%-85.9%) for an increase in online review star ratings from 2.5 to 4.5 (out of 5) compared with an increased cost from $50 to $400. For mild back pain, there was no statistical difference in respondents' preference for perceived quality and cost.

CONCLUSIONS

Incorporating quality metrics into price transparency tools is important. Further research is needed to identify metrics that are most comparable and easily obtainable across imaging centers that remain important to patients.

Health Care Price Transparency in Ophthalmology

Importance

Health care price transparency legislation is intended to reduce the ambiguity of hospital charges and the resultant financial stress faced by patients.

Objective

To evaluate the availability, usability, and variability of standard reported prices for ophthalmologic procedures at academic hospitals.

Design, Setting, and Participants

In this multicenter economic evaluation study, publicly available price transparency web pages from Association of American Medical Colleges affiliate hospitals were parsed for standard charges and usability metrics. Price transparency data were collected from hospital web pages that met the inclusion criteria. Geographic practice cost indices for work, practice expense, and malpractice were sourced from the Centers for Medicare & Medicaid Services. Data were sourced from February 1 to April 30, 2021. Multiple regression was used to study the geographic influence on standard charges and assess the correlation between standard charges.

Main Outcomes and Measures

Availability and variability of standard prices for Current Procedural Terminology (CPT) codes 66984 (removal of cataract with insertion of lens) and 66821 (removal of recurring cataract in lens capsule using laser).

Results

Of 247 hospitals included, 191 (77.3%) provided consumer-friendly shoppable services, most commonly in the form of a price estimator or online tool. For CPT code 66984, 102 hospital (53.4%) provided discount cash pay estimates with a mean (SD) price of $7818.86 ($5407.91). For CPT code 66821, 71 hospital (37.2%) provided discount cash pay estimates with a mean (SD) price of $2041.72 ($2106.44). The top quartile of hospitals, prices wise, listed included prices higher than $10 400 for CPT code 66984 and $2324 for CPT code 66821. Usability issues were noted for 36 hospitals (18.8%), including requirements for personal information or web page navigability barriers. Multiple regression analysis found minimal explanatory value for geographic practice cost indices for cash discount prices for CPT codes 66984 (adjusted R2 = 0.54; 95% CI, 0.41-0.67; P < .001) and 66821 (adjusted R2 = 0.64; 95% CI, 0.51-0.77; P < .001).

Conclusions and Relevance

Despite recent legislature that codified price transparency requirements, some current standard charges remain ambiguous, with substantial interhospital variability not explained by geographic variability in costs. Given the potential for ambiguous pricing to burden vulnerable, uninsured patients, additional legislation might consider allowing hospitals to defer price estimates or rigorously define standards for actionable cash discount percentages with provisions for displaying relevant benchmark prices.

Federal Out-of-Network Balance Billing Legislation: Context and Implications for Radiology Practices

Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

Primary care physician perspectives on screening for axial spondyloarthritis: A qualitative study

BACKGROUND

Many patients with axial spondylarthritis (axSpA) experience lengthy diagnostic delays upwards of 14 years. (5-14 years). Screening tools for axSpA have been proposed for use in primary care settings, but whether this approach could be implemented into busy primary care settings remains unknown.

OBJECTIVE

To solicit feedback from primary care physicians regarding questions from the Inflammatory Back Pain Assessment: the Assessment of Spondyloarthritis International Society (ASAS) Expert Criteria and gain insight about barriers and facilitators for implementing axSpA screening in primary care.

METHODS

Guided by Consolidated Criteria for reporting Qualitative Research (COREQ-criteria), we recorded, transcribed, and analyzed in-depth interviews with eight family medicine physicians and ten internists (purposeful sampling) using immersion/crystallization techniques.

RESULTS

Few physicians reported awareness of existing classification criteria for axSpA, and many reported a lack of confidence in their ability to distinguish between inflammatory and mechanical back pain. From three domains, 10 subthemes emerged: 1) typical work-up of axSpA patients in primary care, with subthemes including the clues involved in work-up and role of clinical examinations for axSpA; 2) feedback on questions from the Inflammatory Back Pain Assessment: ASAS Expert Criteria, with subthemes to evaluate contents/questions of a potential screening tool for axSpA; and 3) implementation of the screening tool in primary care settings, with subthemes of perceived barriers including awareness, time, other conditions to screen, rare disease, and lack of structured questionnaire for back pain and perceived facilitators including workflow issues and awareness.

CONCLUSIONS

Primary care physicians believed that an improved screening instrument and a strong evidence-base to support the need for screening for axSpA are required. The implementation of axSpA screening into a busy primary care practice requires integration into the practice workflow, with use of technology suggested as a possible way to improve efficiency.

Price Transparency in Radiology: Challenges and Opportunities to Improve

Increasing health care consumerism has been proposed as a solution for rising U.S. health care costs. Although price transparency initiatives aim to inform patients about outof-pocket costs (OOPCs), challenges remain regarding price transparency tools, including limited accuracy of estimates, accounting for multiple payers for the same service, the need for quality measures, optimal OOPC delivery, and psychosocial consequences of OOPC information. As radiology practices consider implementing price transparency initiatives, improvements should address enhancing patients' experience with OOPC communication.

What People Tweet about Imaging Costs

BACKGROUND

Patients may experience adverse health outcomes when they are unable to manage medical bills. It is currently unknown, however, whether patients talk about cost in the context of medical imaging services they received.

MATERIALS AND METHODS

Retrospective qualitative analysis of twitter posts related to medical imaging and cost. Tweets were extracted from twitter, inclusion and exclusion criteria were applied, and tweets were categorized as either "positive" or "negative"; none were "neutral". A qualitative thematic analysis of all included tweets was performed to develop themes and topics expressed. A single tweet may have been assigned several different codes according to its content. A random sampling of the tweets from each topic were selected by the two reviewers, verified by the remaining reviewers, and quoted (Q).

RESULTS

Here, 9.8% (n = 99) of tweets relevant to medical imaging were included in the analysis. The majority had a negative sentiment (91%, n = 90) related to themes of (1) cost of care (47%, n = 42), (2) care delivery (23%, n = 21), (3) insurance Issues (23%, n = 21), and (4) need for information (7%, n = 6). A few positive tweets (9%, n = 9) were related to themes of (1) Gratitude (44%, n = 4), (2) Affordability (33%, n = 3), and (3) Better than expected (22%, n = 2).

CONCLUSION

Among tweets related to medical imaging we found that 10% relate to cost and that these are overwhelmingly negative, mostly due to perceived high cost of care, deficient care delivery, and insurance issues.