Faculty Bibliography

PURPOSE/OBJECTIVE:To study opioid prescribing behavior of US interventional radiologists (IRs). METHODS:Using Medicare Physician and Other Supplier Public Use File claims, we identified 2,133 radiologists whose practice in 2015 comprised predominantly interventional radiology. Cross-linking the Medicare Part D Prescriber File, their opioid prescription writing behavior was characterized. RESULTS:Most (52.2%) IRs wrote 10 or fewer prescriptions total for Medicare beneficiaries. Of the 47.8% who wrote >10 prescriptions, 87.4% prescribed an opioid, most commonly hydrocodone with acetaminophen, at least once (71.3%, 1-10 opioid prescriptions; 27.4%, 11-100; 1.3%, ≥101). Overall, 23.0% of all prescriptions by those IRs writing >10 were for opioids, with an average 8.0-day prescription. Average opioid prescriptions per IR were significantly (P ≤ .015) independently associated with their providing clinical evaluation and management (E&M) services (9.7 opioid prescriptions per IR with demonstrable E&M encounters versus 2.2 if not), practice size (12.6 for practices with ≤ 10 members versus 3.7-4.8 for larger groups), and geography (8.3 in the South versus 3.6-4.0 elsewhere). Rates were highest in Georgia (39.5) and lowest in Delaware (2.0). Higher opioid prescribing rates showed additional univariable associations with more years in practice and nonacademic practices. CONCLUSION/CONCLUSIONS:Most IRs write few, if any, prescriptions for Medicare beneficiaries. Of those who do, the large majority writes for opioids, at rates higher than national physician benchmarks. IRs' opioid prescribing varies significantly based on physician and practice characteristics and particularly whether the IR provides clinical E&M services. In light of the nation's opioid epidemic, these observations may guide education, practice improvement, and policy efforts to optimize opioid prescribing.

PURPOSE/OBJECTIVE:The aim of this study was to characterize out-of-pocket patient costs for advanced imaging across the US private insurance marketplace. METHODS:Using the 2017 CMS Health Insurance Marketplace Benefits and Cost Sharing Public Use File, which details coverage policies for qualified health plans on federally facilitated marketplaces, measures of out-of-pocket costs for advanced imaging and other essential health benefits were analyzed for all 18,429 plans. RESULTS:Independent of deductibles, 48.0% of plans required coinsurance (percentage fees) for advanced imaging, 9.7% required copayments (flat fees), and 8.0% required both; 34.3% required neither. For out-of-network services, 91.5% required coinsurance, 0.1% copayments, and 1.0% both; only 7.4% required neither. In the presence of deductibles, patient coinsurance burdens for advanced imaging in and out of network were 27.7% and 47.7%, respectively, and average in- and out-of-network copayments were $319 and $630, respectively. In the presence of deductibles, patients' average coinsurance ranged from 10.0% to 40.9% in network and from 29.1% to 75.0% out of network by state; these tended to be higher in lower income states (r = -0.332). For no-deductible policies, patients' average out-of-network coinsurance burden for advanced imaging was 99.9%. Among assessed benefits, advanced imaging had the highest in-network and second highest out-of-network copayments. CONCLUSIONS:In the US private insurance marketplace, patients very commonly pay coinsurance when undergoing advanced imaging, both in and out of network. But out-of-network services usually involve drastically higher patient financial responsibilities (potentially 100% of examination cost). To more effectively engage patients in shared decision making and mitigate the hardships of surprise balance billing, radiologists should facilitate transparent communication of advanced imaging costs with patients.

Purpose: To characterize Medicare services billed by current SSR members. Materials and Methods: With SSR Executive Committee permission, national provider identifiers (NPIs) were manually identified for all SSR members (who had all attested to >50% of one's practice in musculoskeletal [MSK] radiology). NPIs permitted member cross-linking to the 2015 CMS Physician and Other Supplier Public Use File to then identify all services each billed Medicare. Service codes were mapped to seven mapping-validated subspecialties (MSK, abdominal, breast, cardiothoracic, neuroradiology, nuclear medicine, and vascular-interventional radiology [VIR]) using the Neiman Imaging Types of Service classification system. Radiologists' percentages of work RVUs (wRVU) in each subspecialty were computed. Various subgroup analyses were performed. Results: Of 1,014 SSR members, 49.5% performed >=50% of their wRVUs in MSK. In terms of billed wRVUs, 53.4% of these radiologists mapped to a secondary subspecialty of neuroradiology in terms of billed wRVUs, 16.3% to abdominal, 11.8% to cardiothoracic, and 5.2% to VIR. Of all SSR members, 45.6% were generalists (i.e., no subspecialty crossed the majority wRVU threshold), but 37.4% of them performed a plurality of work in MSK. No other subspecialty accounted for greater than 2% of SSR members. A higher percentage of MSK wRVUs was significantly associated (p<0.001) with an academic affiliation (66.8% vs. 44.5%) as well as two different markers of greater SSR engagement: 1) attending the 2014 SSR meeting (63.5% vs. 49.9%) and 2) serving as an SSR committee member (75.7% vs. 51.6%). Of all other 27,618Medicare-participating radiologists nationally meeting inclusion criteria, 3.2% (879) had >=50% of their wRVUs in MSK but are not SSR members. Conclusion: Medicare claims-based practice classification provides unique insight into SSR membership. This information may help better understand current membership needs, plan future meeting content, and guide further society growth

PURPOSE/OBJECTIVE:To assess changing utilization of pre-biopsy prostate MRI in Medicare beneficiaries. MATERIALS AND METHODS/METHODS:Men undergoing prostate biopsy were identified in 5% Medicare Research Identifiable Files from October 2010 through September 2015. Rates of pre-biopsy prostate MRI (any pelvic MRI ≤6 months before biopsy with a prostate indication diagnosis code) were assessed. Temporal changes and variation by geography and among populations were determined. RESULTS:In male Medicare beneficiaries, pre-biopsy MRI utilization rates increased from 0.1% in 2010 to 0.7% in 2011, 1.2% in 2012, 2.9% in 2013, 4.7% in 2014, and 10.3% in 2015. In 2015, pre-biopsy prostate MRI rates varied significantly by patient age (5.7% for >80 years vs. 8.4%-9.3% for other age ranges, p=0.040), race (5.8% in blacks vs. 10.1% in whites, p=0.009), and geographic region (from 6.3% in the Midwest to 12.5% in the Northeast; p<0.001). Rates were highest in Wyoming (25.0%), New York (23.7%), and Minnesota (20.5%), but <1% in ten states. CONCLUSION/CONCLUSIONS:Historic Medicare claims provide novel insights into dramatically increasing adoption of MRI prior to prostate biopsy. Following earlier minimal usage, utilization increased sharply beginning in 2013, exceeding 10% in 2015. However, substantial racial and geographic variation in adoption exists. Continued educational, research, and policy efforts are warranted to optimize the role of pre-biopsy MRI and minimize sociodemographic and geographic disparities.

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.

RATIONALE AND OBJECTIVES/OBJECTIVE:The present study aims to assess associations of Medicare beneficiary screening mammography rates with local mammography facility and radiologist availability. MATERIALS AND METHODS/METHODS:Mammography screening rates for Medicare fee-for-service beneficiaries were obtained for US counties using the County Health Rankings data set. County-level certified mammography facility counts were obtained from the United States Food and Drug Administration. County-level mammogram-interpreting radiologist and breast imaging subspecialist counts were determined using Centers for Medicare & Medicaid Services fee-for-service claims files. Spearman correlations and multivariable linear regressions were performed using counties' facility and radiologist counts, as well as counts normalized to counties' Medicare fee-for-service beneficiary volume and land area. RESULTS:Across 3035 included counties, average screening mammography rates were 60.5% ± 8.2% (range 26%-88%). Correlations between county-level screening rates and total mammography facilities, facilities per 100,000 square mile county area, total mammography-interpreting radiologists, and mammography-interpreting radiologists per 100,000 county-level Medicare beneficiaries were all weak (r = 0.22-0.26). Correlations between county-level screening rates and mammography rates per 100,000 Medicare beneficiaries, total breast imaging subspecialist radiologists, and breast imaging subspecialist radiologists per 100,000 Medicare beneficiaries were all minimal (r = 0.06-0.16). Multivariable analyses overall demonstrated radiologist supply to have a stronger independent effect than facility supply, although effect sizes remained weak for both. CONCLUSION/CONCLUSIONS:Mammography facility and radiologist supply-side factors are only weakly associated with county-level Medicare beneficiary screening mammography rates, and as such, screening mammography may differ from many other health-care services. Although efforts to enhance facility and radiologist supply may be helpful, initiatives to improve screening mammography rates should focus more on demand-side factors, such as patient education and primary care physician education and access.

INTRODUCTION/BACKGROUND:The purpose of this study was to explore associations between CT and MRI utilization and cost savings achieved by Medicare Shared Savings Program (MSSP)-participating accountable care organizations (ACOs). METHODS:Summary data were obtained for all MSSP-participating ACOs (n = 214 in 2013; n = 333 in 2014). Multivariable regressions were performed to assess associations of CT and MRI utilization with ACOs' total savings and reaching minimum savings rates to share in Medicare savings. RESULTS:In 2014, 54.4% of ACOs achieved savings, meeting minimum rates to share in savings in 27.6%. Independent positive predictors of total savings included beneficiary risk scores (β = +20,265,720, P = .003) and MRI events (β = +19,964, P = .018) but not CT events (β = +2,084, P = .635). Independent positive predictors of meeting minimum savings rates included beneficiary risk scores (odds ratio = 2108, P = .001) and MRI events (odds ratio = 1.008, P = .002), but not CT events (odds ratio = 1.002, P = .289). Measures not independently associated with savings were total beneficiaries; beneficiaries' gender, age, race or ethnicity; and Medicare enrollment type (P > .05). For ACOs with 2013 and 2014 data, neither increases nor decreases in CT and MRI events between years were associated with 2014 total savings or meeting savings thresholds (P ≥ .466). CONCLUSION/CONCLUSIONS:Higher MRI utilization rates were independently associated with small but significant MSSP ACO savings. The value of MRI might relate to the favorable impact of appropriate advanced imaging utilization on downstream outcomes and other resource utilization. Because MSSP ACOs represent a highly select group of sophisticated organizations subject to rigorous quality and care coordination standards, further research will be necessary to determine if these associations are generalizable to other health care settings.

PURPOSE/OBJECTIVE:To explore associations between county-level measures of radiologist supply and subspecialization and county structural and health-related characteristics. METHODS:Medicare Physician and Other Supplier Public Use Files were used to subspecialty characterize 32,844 radiologists participating in Medicare between 2012 and 2014. Measures of radiologist supply and subspecialization were computed for 3,143 US counties. Additional county characteristics were identified using the 2014 County Health Rankings database. Mann-Whitney tests and Spearman correlations were performed. RESULTS:Counties with at least one (versus no) Medicare-participating radiologist had significantly (P < .001) larger populations (197,050 ± 457,056 versus 20,253 ± 23,689), lower rural percentages (39.5% ± 26.5% versus 74.6% ± 25.6%), higher household incomes ($47,608 ± $12,493 versus $42,510 ± $9,893), higher mammography screening rates (62.4% ± 7.0% versus 56.6% ± 15.3%), and lower premature deaths (7,581 ± 2,085 versus 7,784 ± 3,409 years of life lost). Counties' radiologists per 100,000 population and percent of subspecialized radiologists showed moderate positive correlations with counties' population (r = +0.505-+0.599) and moderate negative correlations with counties' rural percentage (r = -0.434 to -0.523). Radiologist supply and degree of subspecialization both showed concurrent positive or negative weak associations with counties' percent age 65+ (r = -0.256 to -0.271), percent Hispanic (r = +0.209-+0.234), and income (r = +0.230-+0.316). Radiologists per 100,000 population showed weak positive correlation with mammography screening (r = +0.214); percent of radiologists subspecialized showed weak negative correlation with premature death (r = -0.226). CONCLUSION/CONCLUSIONS:Geographic disparities in radiologist supply at the community level are compounded by superimposed variation in the degree of subspecialization of those radiologists. The potential impact of such access disparities on county-level health warrants further investigation.