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

Prevalence of "One-Off Events" in Radiology: Implications for Radiology in Episode-Based Alternative Payment Models

OBJECTIVE

As reimbursement mechanisms become more value-based, there are questions about the applicability of these mechanisms for nonepisodic care, particularly care provided by nonpatient-facing specialists, for example, radiologists. Accordingly, this study examined the prevalence of nonepisodic care-one-off events-in diagnostic radiology.

METHODS

We conducted a multiyear (2015-2019) retrospective study of diagnostic imaging using a large commercial payer database including commercial insurance and Medicare Advantage. Using a 12-month evaluation period starting with the day of the initial imaging study/studies, we categorized imaging studies as one-off events if there were no additional studies (beyond the first day of the evaluation period) for the next 12 months in the same body region. We also evaluated an alternative, more stringent definition of a one-off event: the only imaging study during the 12-month evaluation period. We computed the percentage of one-off events overall and by body region.

RESULTS

We found that one-off events comprised 33.2%-45.8% of imaging studies depending on whether one-off events are defined as the only study in the evaluation period or imaging only on the first day of the evaluation period, respectively. This share varied widely by body region: highest for cardiac (80.9%-87.7%) and lower for chest (26.8%-35.2%). By place-of-service, the proportion was lowest for the inpatient (12.9%-29.1%) and long-term care settings (18.6%-30%).

DISCUSSION

Given the sizeable share of imaging studies categorized as one-off events, much of radiologists' workload falls outside of the framework of episodic measurement tools and value-based payment models.

Diagnostic radiology and its future: what do clinicians need and think?

OBJECTIVE

To investigate the view of clinicians on diagnostic radiology and its future.

METHODS

Corresponding authors who published in the New England Journal of Medicine and the Lancet between 2010 and 2022 were asked to participate in a survey about diagnostic radiology and its future.

RESULTS

The 331 participating clinicians gave a median score of 9 on a 0-10 point scale to the value of medical imaging in improving patient-relevant outcomes. 40.6%, 15.1%, 18.9%, and 9.5% of clinicians indicated to interpret more than half of radiography, ultrasonography, CT, and MRI examinations completely by themselves, without consulting a radiologist or reading the radiology report. Two hundred eighty-nine clinicians (87.3%) expected an increase in medical imaging utilization in the coming 10 years, whereas 9 clinicians (2.7%) expected a decrease. The need for diagnostic radiologists in the coming 10 years was expected to increase by 162 clinicians (48.9%), to remain stable by 85 clinicians (25.7%), and to decrease by 47 clinicians (14.2%). Two hundred clinicians (60.4%) expected that artificial intelligence (AI) will not make diagnostic radiologists redundant in the coming 10 years, whereas 54 clinicians (16.3%) thought the opposite.

CONCLUSION

Clinicians who published in the New England Journal of Medicine or the Lancet attribute high value to medical imaging. They generally need radiologists for cross-sectional imaging interpretation, but for a considerable proportion of radiographs, their service is not required. Most expect medical imaging utilization and the need for diagnostic radiologists to increase in the foreseeable future, and do not expect AI to make radiologists redundant.

CLINICAL RELEVANCE STATEMENT

The views of clinicians on radiology and its future may be used to determine how radiology should be practiced and be further developed.

KEY POINTS

• Clinicians generally regard medical imaging as high-value care and expect to use more medical imaging in the future. • Clinicians mainly need radiologists for cross-sectional imaging interpretation while they interpret a substantial proportion of radiographs completely by themselves. • The majority of clinicians expects that the need for diagnostic radiologists will not decrease (half of them even expect that we need more) and does not believe that AI will replace radiologists.

Utility and Costs During the Initial Year of 3D Printing in an Academic Hospital

OBJECTIVE

There is a paucity of utility and cost data regarding the launch of 3D printing in a hospital. The objective of this project is to benchmark utility and costs for radiology-based in-hospital 3D printing of anatomic models in a single, adult academic hospital.

METHODS

All consecutive patients for whom 3D printed anatomic models were requested during the first year of operation were included. All 3D printing activities were documented by the 3D printing faculty and referring specialists. For patients who underwent a procedure informed by 3D printing, clinical utility was determined by the specialist who requested the model. A new metric for utility termed Anatomic Model Utility Points with range 0 (lowest utility) to 500 (highest utility) was derived from the specialist answers to Likert statements. Costs expressed in United States dollars were tallied from all 3D printing human resources and overhead. Total costs, focused costs, and outsourced costs were estimated. The specialist estimated the procedure room time saved from the 3D printed model. The time saved was converted to dollars using hospital procedure room costs.

RESULTS

The 78 patients referred for 3D printed anatomic models included 11 clinical indications. For the 68 patients who had a procedure, the anatomic model utility points had an overall mean (SD) of 312 (57) per patient (range, 200-450 points). The total operation cost was $213,450. The total cost, focused costs, and outsourced costs were $2,737, $2,180, and $2,467 per model, respectively. Estimated procedure time saved had a mean (SD) of 29.9 (12.1) min (range, 0-60 min). The hospital procedure room cost per minute was $97 (theoretical $2,900 per patient saved with model).

DISCUSSION

Utility and cost benchmarks for anatomic models 3D printed in a hospital can inform health care budgets. Realizing pecuniary benefit from the procedure time saved requires future research.

I.C.A.R.U.S. in Flight: A Radiology Simulator Teaches Imaging Appropriateness, Anatomy, and Image Interpretation Skills

RATIONALE AND OBJECTIVES

The Interactive Clinical Anatomy and Radiology Utilization Simulator (ICARUS) was created in 2012 as a novel simulation program with 25 peer reviewed electronic modules combining simulated patient encounters, American College of Radiology appropriateness criteria, radiologic anatomy, and basic imaging interpretation and patient safety topics. ICARUS integrates a gaming approach to improve student engagement.

MATERIALS AND METHODS

ICARUS modules have been used in the undergraduate medical curriculum at the lead author's institution since its pilot in 2012. Since completion of the full complement of 25 modules, modules have been used in the radiology clerkship (2012- 2015), in the integrated longitudinal curriculum (2015-present), and in various radiology electives (2015-present), including the inaugural virtual radiology electives at all authors' institutions (July 2020-present). Student evaluations were formally solicited in 2014 and again in 2020.

RESULTS

During the introductory radiology clerkship in 2014, 107 students were enrolled. Students were assigned 4 ICARUS modules. During the 2-week virtual elective from July-October 2020, 26 students were enrolled. Students were assigned all 25 modules. The majority of survey respondents "agreed" or "strongly agreed" that the modules were interactive, enjoyable, and self-directed, fostered critical thinking, provided practical value, met goals and objectives of the course, and seemed practical to their future practice.

CONCLUSION

ICARUS integrates key educational concepts in radiology with high fidelity simulation of clinical decision support software and PACS simulation image display to create a highly engaging learning environment that most accurately reflects future clinical experiences.

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.