Predicted Cost Savings Achieved by the Radiology Support, Communication and Alignment Network from Reducing Medical Imaging Overutilization in the Medicare Population

OBJECTIVE

The Radiology Support, Communication and Alignment Network (R-SCAN) is a quality improvement program through which patients, referring clinicians, and radiologists collaborate to improve imaging appropriateness based on Choosing Wisely recommendations and ACR Appropriateness Criteria. R-SCAN was shown previously to increase the odds of obtaining an appropriate, higher patient or diagnostic value, imaging study. In the current study, we aimed to estimate the potential imaging cost savings associated with R-SCAN use for the Medicare population.

MATERIAL AND METHODS

The R-SCAN data set was used to determine the proportion of appropriate and lesser value imaging studies performed, as well as the percent change in the total number of imaging studies performed, before and after an R-SCAN educational intervention. Using a separate CMS data set, we then identified the total number of relevant imaging studies and associated total costs using a 5% sample of Medicare beneficiaries in 2017. We applied R-SCAN proportions to the CMS data set to estimate the potential impact of the R-SCAN interventions across a broader Medicare population.

RESULTS

We observed a substantial reduction in the costs associated with lesser value imaging in the R-SCAN cohort, totaling $260,000 over 3.5 months. When extrapolated to the Medicare population, the potential cost reductions associated with the decrease in lesser value imaging totaled $433 million yearly.

CONCLUSION

If expanded broadly, R-SCAN interventions can result in substantial savings to the Medicare program.

Assessment of the Radiology Support, Communication and Alignment Network to Reduce Medical Imaging Overutilization: A Multipractice Cohort Study

PURPOSE

The aim of this study was to determine whether participation in Radiology Support, Communication and Alignment Network (R-SCAN) results in a reduction of inappropriate imaging in a wide range of real-world clinical environments.

METHODS

This quality improvement study used imaging data from 27 US academic and private practices that completed R-SCAN projects between January 25, 2015, and August 8, 2018. Each project consisted of baseline, educational (intervention), and posteducational phases. Baseline and posteducational imaging cases were rated as high, medium, or low value on the basis of validated ACR Appropriateness Criteria®. Four cohorts were generated: a comprehensive cohort that included all eligible practices and three topic-specific cohorts that included practices that completed projects of specific Choosing Wisely topics (pulmonary embolism, adnexal cyst, and low back pain). Changes in the proportion of high-value cases after R-SCAN intervention were assessed for each cohort using generalized estimating equation logistic regression, and changes in the number of low-value cases were analyzed using Poisson regression.

RESULTS

Use of R-SCAN in the comprehensive cohort resulted in a greater proportion of high-value imaging cases (from 57% to 79%; odds ratio, 2.69; 95% confidence interval, 1.50-4.86; P = .001) and 345 fewer low-value cases after intervention (incidence rate ratio, 0.45; 95% confidence interval, 0.29-0.70; P < .001). Similar changes in proportion of high-value cases and number of low-value cases were found for the pulmonary embolism, adnexal cyst, and low back pain cohorts.

CONCLUSIONS

R-SCAN participation was associated with a reduced likelihood of inappropriate imaging and is thus a promising tool to enhance the quality of patient care and promote wise use of health care resources.

Improving diagnosis in health care: perspectives from the American College of Radiology

In September of 2014, the American College of Radiology joined a number of other organizations in sponsoring the 2015 National Academy of Medicine report, Improving Diagnosis In Health Care. Our presentation to the Academy emphasized that although diagnostic errors in imaging are commonly considered to result only from failures in disease detection or misinterpretation of a perceived abnormality, most errors in diagnosis result from failures in information gathering, aggregation, dissemination and ultimately integration of that information into our patients' clinical problems. Diagnostic errors can occur at any point on the continuum of imaging care from when imaging is first considered until results and recommendations are fully understood by our referring physicians and patients. We used the concept of the Imaging Value Chain and the ACR's Imaging 3.0 initiative to illustrate how better information gathering and integration at each step in imaging care can mitigate many of the causes of diagnostic errors. Radiologists are in a unique position to be the aggregators, brokers and disseminators of information critical to making an informed diagnosis, and if radiologists were empowered to use our expertise and informatics tools to manage the entire imaging chain, diagnostic errors would be reduced and patient outcomes improved. Heath care teams should take advantage of radiologists' ability to fully manage information related to medical imaging, and simultaneously, radiologists must be ready to meet these new challenges as health care evolves. The radiology community stands ready work with all stakeholders to design and implement solutions that minimize diagnostic errors.

CPT: an open system that describes all that you do

The American Medical Association, with the cooperation of multiple major medical specialty societies, including the ACR, responded in 1966 to the need for a complete coding system for describing medical procedures and services with the first publication of Current Procedural Terminology (CPT). This system, now CPT IV, forms the basis of reporting of virtually all inpatient and outpatient services performed by physicians and nonphysician health care providers as well as facilities. This coding system and its maintenance process have evolved in complexity and sophistication, particularly in the past decade, such that it is now integral to all facets of health care, including tracking new and investigational procedures and reporting and monitoring performance measures (read "pay for performance"), in addition to its long-standing use for reporting for reimbursement. To paraphrase a recent automobile commercial, "This is not your father's CPT." The author describes the development of CPT as it exists today, examining the forces that molded its current form, the input opportunities available to medical specialty societies and others, the ever increasing transparency of the CPT maintenance process, and the availability of resources allowing all to stay current. Understanding this system, critical to the practice of all of medicine, including radiology, will aid all health care providers in maintaining the quality, efficiency, and accuracy of their practices' business operations as well as assist them in a world of increasingly complex reporting requirements.

The Crisis in Academic Radiology: Will We Help Ourselves?

The overall health of academic radiology suffers from insufficient funds and manpower. Although the largest academic programs in the country may have sufficient resources to maintain robust academic environments, one third to half of the academic radiology programs in the United States are struggling to maintain stable academic environments. The impact of an impaired academic radiology enterprise on the specialty of radiology is far reaching. As academic departments falter, the quantity and quality of research and educational programs deteriorate. In the short term, this situation makes our specialty vulnerable to predatory strikes by other specialists who covet our field; in the long term, it leads to obsolescence. Fortunately, radiology is a lucrative specialty, and we have the wherewithal to help ourselves. To ensure a vibrant future for our specialty each of us must accept an obligation to invest in our academic foundation. In particular, private practice radiologists must recognize this obligation and pledge their time and/or resources to help shore up the academic departments.

Get Paid for What You Do: Dictation Patterns and Impact on Billing Accuracy

No one would knowingly invest in a business whose principal executives knew little or nothing about the key components determining reimbursement for the services provided. Superimpose on that lack of knowledge a regulatory environment in that business sector that places owners and key employees at risk for accusations of fraud and abuse as well as in jeopardy of large fines and potential exclusion from the marketplace for the largest consumer of a company's product if billing is done incorrectly. Yet this is exactly the case in many radiology practices today. A significant number of radiologists who provide excellent quality medical care produce dictated reports that demonstrate complete ignorance of the parameters used by their billing personnel to generate accurately coded claims, thus losing significant legitimate clinical practice revenues while placing themselves and their practices in jeopardy. This article does not outline ways to game the system or inappropriately augment practice revenues. Rather, it describes many of the basic elements needed in the dictated reports produced by radiologists in their daily work, calculates examples of the financial impact of medically correct but poorly documented reports, and provides dictation guidelines for radiology residents and radiologists in practice that, if adopted, should ensure that you get paid properly for what you do.

Reimbursement risks with radiologist extenders: there is no free lunch!

There is great allure in the concept of using qualified health care providers to assist radiologists and radiation oncologists, increasing efficiency and possibly even improving patient care delivery. However, physician services are most commonly reimbursed under a system that is resource based, and the physician work and practice expense components of reimbursement for existing procedure codes are periodically reexamined to ensure their appropriate rank in this "relative value system." Also, as new codes are developed, demonstrable physician work and practice expenses will determine the relative values for the new procedures. In both cases, the type of individual who actually performs different portions of a procedure will determine the reimbursement level. In addition, the total reimbursement must be appropriately apportioned between the physician involved and the facility where the service is delivered. This article examines some of the potential impacts on procedure coding and radiologist and radiation oncologist reimbursement schedules if physician extenders perform work previously performed by physicians. It also examines possible shifts in reimbursement from physician to facility if an extender is employed by a facility.

From concept to CPT code to compensation: how the payment system works

All radiologists and radiation oncologists provide medical services to patients every day with the full anticipation that these services will be appropriately reimbursed. Yet most take this process for granted. Few have even a rudimentary idea how the system works by which a coding mechanism and reimbursement schedule are developed and maintained for the vast array of services they provide. Clearly, this is not good business. You need not stay in the dark any longer! This article describes (1) the fundamental structure of reimbursement for radiology and radiation oncology services; (2) the multiple steps required as a new procedure advances from a research concept to the assignment of a code in the American Medical Association's Current Procedural Terminology; (3) the process by which the new procedure and code are assigned a reimbursement value in the Medicare Fee Schedule, which acts as the base for over 75% of current medical reimbursement; and (4) the maintenance of this system for existing procedures.

Polyarteritis nodosa in hairy cell leukemia

A patient with polyarteritis nodosa (PAN) developing after splenectomy and previously diagnosed hairy cell leukemia is presented. This rare association may provide an insight into the nature of PAN.