Faculty Bibliography

The cost of providing healthcare in the United States continues to rise. The Affordable Care Act created systems to test value-based alternative payments models. Traditionally, procedure-based specialists such as neurointerventionalists have largely functioned in, and are thus familiar with, the traditional Fee for Service system. Administrative charge data would suggest that neurointerventional surgery is an expensive specialty. The Medicare Access and CHIP Reauthorization Act consolidated pre-existing federal performance programs in the Merit-based Incentive Payments System (MIPS), including a performance category called 'cost'. Understanding cost as a dimension that contributes to the value of care delivered is critical for succeeding in MIPS and offers a meaningful route for favorably bending the cost curve.

Purpose To explore subspecialty workforce considerations surrounding invasive procedures performed by radiologists. Materials and Methods The 2015 Centers for Medicare & Medicaid Services Physician and Other Supplier Public Use File was used to identify all invasive procedures (Current Procedural Terminology code range, 10000-69999) billed by radiologists for Medicare fee-for-service beneficiaries. Radiologists were categorized by subspecialty according to the majority of their billable work-relative value units (wRVUs). Those without a single subspecialty majority work effort were deemed generalists. Procedures were categorized into three tiers of complexity (high, ≥4.0 wRVUs; mid, 1.6-3.9 wRVUs; low, ≤1.5 wRVUs). Total and tiered generalist versus subspecialist workforce composition was assessed. Results Just 25 unique services comprised more than 75% of invasive procedures performed by radiologists. Of radiologists who performed procedures, 57.5% were generalists, 15.8% were interventionalists, and 26.8% were other subspecialists. Of the radiologists who performed low-, mid-, and high-complexity procedures, generalists accounted for 46.3%, 30.9%, and 23.1%, respectively; interventionalists accounted for 35.4%, 30.9%, and 75.2%, respectively; and other subspecialists accounted for 18.3%, 14.6%, and 1.7%, respectively. Generalists were the dominant providers of six of the top 10 low-complexity and seven of the top 10 midcomplexity procedures. Interventionalists were the dominant providers of all top 10 high-complexity procedures. Nationally, over twice as many U.S. counties had local access to generalists (869 counties) for invasive procedures versus interventionalists (347 counties) or other subspecialists (380 counties). Conclusion Among radiologists, generalists perform far more procedures in more geographic locations and are more likely to serve patients with less complex service needs than are interventionalists or other subspecialists. Practices and professional societies must remain vigilant to ensure that the subspecialty evolution in radiology does not exacerbate patient access disparities.

PURPOSE/OBJECTIVE:To conduct a meta-analysis of studies investigating discrepancy rates and clinical impact of imaging secondary interpretations and to identify factors influencing these rates. METHODS:EMBASE and PubMed databases were searched for original research investigations reporting discrepancy rates for secondary interpretations performed by radiologists for imaging examinations initially interpreted at other institutions. Two reviewers extracted study information and assessed study quality. Meta-analysis was performed. RESULTS:Twenty-nine studies representing a total of 12,676 imaging secondary interpretations met inclusion criteria; 19 of these studies provided data specifically for oncologic imaging examinations. Primary risks of bias included availability of initial interpretations, other clinical information, and reference standard before the secondary interpretation. The overall discrepancy rate of secondary interpretations compared with primary interpretations was 32.2%, including a 20.4% discrepancy rate for major findings. Secondary interpretations were management changing in 18.6% of cases. Among discrepant interpretations with an available reference standard, the secondary interpretation accuracy rate was 90.5%. The overall discrepancy rates by examination types were 28.3% for CT, 31.2% for MRI, 32.7% for oncologic imaging, 43.8% for body imaging, 39.9% for breast imaging, 34.0% for musculoskeletal imaging, 23.8% for neuroradiologic imaging, 35.5% for pediatric imaging, and 19.7% for trauma imaging. CONCLUSION/CONCLUSIONS:Most widely studied in the context of oncology, imaging secondary interpretations commonly result in discrepant interpretations that are management changing and more accurate than initial interpretations. Policymakers should consider these findings as they consider the value of, and payment for, secondary imaging interpretations.

Multiparametric MR imaging provides detailed anatomic assessment of the prostate as well as information that allows the detection and characterization of prostate cancer. To obtain high-quality MR imaging of the prostate, radiologists must understand sequence optimization to overcome commonly encountered technical challenges. This review discusses the techniques that are used in state-of-the-art MR imaging of the prostate, including imaging protocols, hardware considerations, and important aspects of patient preparation, with an emphasis on the recommendations provided in the prostate imaging-reporting and data system version 2 guidelines.

PURPOSE/OBJECTIVE:To assess trends in inferior vena cava (IVC) filter placement and retrieval procedures in Medicare beneficiaries over the last two decades. METHODS:Using Physician/Supplier Procedure Summary Master Files from 1994 through 2015, we calculated utilization rates for IVC filter placement and retrieval procedures in Medicare fee-for-service beneficiaries. Services were stratified by provider specialty group and site of service. RESULTS:IVC filter placement rates increased from 1994 to 2008 (from 65.0 to 202.1 per 100,000 beneficiaries, compound annual growth rate [CAGR] +8.4%) and then decreased to 128.9 by 2015 (CAGR -6.2%). This decrease was observed across all specialty groups and sites of service. From 1994 to 2015, placement procedure market share increased for radiologists (from 45.1% to 62.7%) and cardiologists (from 2.5% to 6.7%) but decreased for surgeons (from 46.6% to 27.9%). Overall, procedures shifted slightly from the inpatient (from 94.5% to 86.5% of all procedures) to outpatient hospital (from 4.9% to 14.9%) settings. Between 2012 and 2015, retrieval rates increased from 12.0 to 17.7 (CAGR +13.9%). Retrievals as a percentage of placement procedures were similar across specialties in 2015 (range 13.0%-13.8%). CONCLUSION/CONCLUSIONS:Despite prior dramatic growth, the utilization of IVC filters in Medicare beneficiaries markedly declined over the last decade, likely relating to evolving views regarding efficacy and long-term safety. This decline was accompanied by several filter-related market shifts, including increasing placement by radiologists and cardiologists, increasing outpatient placement procedures, and increasing retrieval rates.

PURPOSE/OBJECTIVE:The aim of this study was to assess changing Medicare volumes of, and coverage for, secondary interpretations of diagnostic imaging examinations stratified by modality and body region service families. METHODS:Medicare Physician/Supplier Procedure Summary Master Files for 2003 to 2016 were obtained. Aggregate Part B fee-for-service claims frequency and payment data were isolated for noninvasive diagnostic imaging and stratified by service family. Using published Medicare payment rules, secondary interpretations were identified as studies billed using both modifiers 26 and 77. Billed and denied services volumes were calculated and compared across modality and body region service families. RESULTS:Seven service families showed a compound annual growth rate from 2003 to 2016 of >20% (an additional 12 service families, >10% growth). For select high-volume service families (chest radiography and fluoroscopy [R&F], brain MRI, and abdominal and pelvic CT), relative growth in billed secondary interpretation services exceeded that for primary interpretations. In 2016, body region and modality service families with the most billed secondary interpretations were chest R&F (674,124), abdominal and pelvic R&F (65,566), brain CT (45,642), extremity R&F (34,560), abdominal and pelvic CT (14,269), and chest CT (10,914). All service families had secondary interpretation denial rates <25% in 2016 (15 service families, <10%). CONCLUSIONS:Among Medicare beneficiaries, the frequency of billed secondary interpretation services for diagnostic imaging services increased from 2003 to 2016 across a broad range of modalities and body regions, often dramatically. Payment denial rates were consistently low across service families. As CMS continues to seek input on appropriate coverage for these services, these findings suggest increasing clinical demand for and payer acceptance of these value-added radiologist services.

OBJECTIVE:The purpose of this study was to investigate county-level geographic patterns of mammographic screening uptake throughout the United States and to determine the impact of rural versus urban settings on breast cancer screening uptake. MATERIALS AND METHODS/METHODS:This descriptive study used County Health Rankings (CHR) data to identify the percentage of Medicare enrollees 67-69 years old per county who had at least one mammogram in 2013 or 2012 (uptake). Uptake was matched with U.S. Department of Agriculture (USDA) Atlas of Rural and Small Town America categorizations along a rural-urban continuum scale from 1 to 9 based on county population size (large urban, population ≥ 20,000 people; small urban, < 20,000 people) and proximity to a metropolitan area. Univariable and multivariable analyses were performed. RESULTS:In all, 2,243,294 Medicare beneficiaries were eligible for mammograms. National mean uptake per county was 60.5% (range, 26.0-86.0%). Uptake was significantly higher in metropolitan and large urban counties in 25 states and lower in only one. County-level mammographic uptake was moderately positively correlated with percentage of residents with some college education (r = 0.40, p < 0.001) and moderately negatively correlated with age-adjusted mortality (r = -0.41, p < 0.001). Multivariable analysis showed that percentage of white and black residents and age-adjusted mortality rate were the strongest significant independent predictors of uptake. CONCLUSION/CONCLUSIONS:Uptake of mammographic screening services in a Medicare population varies widely at the county level and is generally lowest in rural counties and urban counties with fewer than 20,000 people.

The Medicare and CHIP Reauthorization Act of 2015 remains the payment policy law of the land. 2017 was the first year in which performance reporting will tangibly impact future physician payments. The Centers for Medicare & Medicaid Services (CMS) considers 2017 and 2018 transitional years before full implementation in 2019. As such, 2018 increases the reporting requirements over 2017 in the form of a gradual phase-in while introducing several key changes and new elements. Indeed, it is the nature of the transition itself that led to the somewhat unique title of this manuscript, i.e., MACRA 2.5. Stakeholder feedback to the CMS regarding the program has ranged widely from the elimination of core components to expanding reporting to non-government payers. This article explores the potential impact on neurointerventional physicians.

PURPOSE/OBJECTIVE:To evaluate transgender patient care, gender inclusivity, and transgender health-related policies at breast imaging facilities across the United States. METHODS:A survey on breast imaging facilities' policies and practices regarding transgender care was distributed to the membership of the Society of Breast Imaging, consisting of approximately 2,500 breast radiologists across the United States. The survey was conducted by e-mail in January 2018. RESULTS:There were 144 survey respondents. Responses showed that 78.5% of facilities have gender-neutral patient bathrooms, 9.0% have a separate waiting area for transgender patients, and 76.4% do not have dominant pink hues in their facilities, although 54.2% have displays with female gender content. Also, 58.0% of intake forms do not ask patients to provide their gender identity, although 25.9% automatically populate with female phrases. Within the electronic health record, 32.9% lack a distinct place to record patients' preferred names and 54.9% lack a distinct place to record patients' gender pronouns. The majority (73.4%) do not have explicit policies related to the care of transgender patients. Only 14.7% of facilities offer lesbian, gay, bisexual, and transgender training. CONCLUSION/CONCLUSIONS:Our national survey demonstrates that many breast imaging facilities do not have structures in place to consistently use patients' preferred names and pronouns, nor provide inclusive environments for transgender patients. All breast imaging facilities should recognize the ways in which their practices may intensify discrimination, exclusivity, and stigma for transgender patients and should seek to improve their transgender health competencies and foster more inclusive environments.