Faculty Bibliography

PURPOSE/OBJECTIVE:To optimize the flexibility and relevancy of its Merit-Based Incentive Payment System (MIPS), CMS exempts selected physicians and groups from participation and grants others relaxed reporting requirements. We assess the practical implications of such special status determinations. METHODS:For a random sample of 1,000 Medicare-participating radiologists, the CMS MIPS Participation Lookup Tool was manually searched. Individual radiologists' and associated groups' participation requirements and special statuses were assessed. RESULTS:Although only 55% of radiologists were required to participate in MIPS as individuals when considering only one associated taxpayer identification number (TIN), 83% were required to participate as individuals when considering all associated TINs. When using the group reporting option, 97% of radiology groups were required to participate. High participation requirements persisted across generalist and subspecialist radiologists, small and rural, and both academic and nonacademic practices. Non-patient-facing and hospital-based statuses were assigned to high fractions of individual radiologists (91% and 71%, respectively), but much lower fractions of group practices (72% and 25%). Rural and health professional shortage area statuses were assigned to higher percentages of groups (27% and 39%) than individuals (13% and 23%). Small practice status was assigned to 22% of individuals versus 16% of groups. CONCLUSION/CONCLUSIONS:Although not apparent if only considering individual radiologist-TIN combinations, the overwhelming majority of radiologists will be required to participate in MIPS, at the individual or group level. Radiology groups are strongly encouraged to review their physicians' MIPS participation requirements and special statuses to ensure optimal performance scores and payment bonuses.

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/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.

In patients with metallic hip implants, distortions, and other artifacts relating to the echo-planar imaging acquisition may render prostate diffusion-weighted imaging (DWI) nondiagnostic. Reduced field-of-view (rFOV) acquisition, using parallel transmission and focused excitation, is a novel DWI approach that reduces distortions and improves images quality. This article presents images from both standard and rFOV DWI acquisitions in 2 prostate cancer patients with hip implants, showing the effect of rFOV DWI for improving tumor localization. The findings have implications for the potential application of magnetic resonance imaging for guiding targeted biopsy and planning focal therapy in the growing population of patients with hip implants.

This article reviews basic concepts of report documentation for abdominal imaging examinations, focusing on practical elements for ensuring appropriate physician reimbursement. Nuances of abdominal radiography, CT, MRI, and ultrasonography codes are highlighted. Special considerations for the coding of 3D-rendering and contrast administration are also described. Greater abdominal radiologist awareness of these codes and their reporting requirements can help ensure proper documentation within radiology reports, thereby optimizing legitimate reimbursement.

PURPOSE/OBJECTIVE:In March 2017, the ACGME relaxed resident duty-hour restrictions to allow first-year residents to work 24-hour shifts, affecting the internship experience of incoming radiology residents. The aim of this study was to assess the media response to this duty-hour change, comparing news articles with favorable and unfavorable views. METHODS:Google News was used to identify 36 relevant unique news articles published over a 4-week period after the announcement. Articles' stance was categorized as favorable, unfavorable, or neutral. Additional article characteristics were explored. RESULTS:Article sources were 58% national, 22% local, and 20% medical news. Article stance was most commonly unfavorable for national news sources (48%), compared with neutral for local (62%) and medical (72%) news sources. Most common reasons for unfavorable stance were sleep deprivation (n = 11), medical errors (n = 11), residents' health (n = 9), risk for car accidents (n = 9), a patriarchal hazing system (n = 6), and work-life balance (n = 5). Most common reasons for favorable stance were impact on resident education (n = 7) and continuity of care (n = 7). Supporting data were cited by 38% of unfavorable and 100% of favorable articles. Unfavorable articles most commonly quoted physicians affiliated with resident advocacy groups; favorable articles most commonly quoted physicians affiliated with the ACGME. CONCLUSIONS:The relaxed duty-hour restrictions received an overall unfavorable media response, particularly in nonmedical news sources, driven by concerns regarding sleep-deprived doctors. Favorable articles ubiquitously cited data supporting the safety of relaxed duty hour restrictions. Further research is warranted to better understand the impact of relaxed resident duty-hour limits on sleep deprivation, residents' health and education, and the quality of patient care.

Background: Traditional pathology reports of prostate biopsy mainly focus on presence of carcinoma but ignore other pathologic findings such as inflammation or hyperplasia. In the era of MRI-ultrasound fusion-targeted prostate biopsy (MRF-TB), where specific MRI regions of interest (ROI) are targeted for biopsy, these benign findings should be reported as they may guide decisions on when to repeat imaging or prostate biopsy. In this study, we reviewed MRF-TB prostate biopsies reported as negative for carcinoma to identify pathologic correlates to visible ROI on prostate MRI. Design: From 2012 to2016, 1595 men underwent a total of 1813 prebiopsy prostate MRI, followed by MRF-TB at our institution. We rereviewed the prostate biopsy cores for all patients with PI-RADS 4 or 5 (PI-RADS 4/5) ROI but had no cancer detected on MRF-TB. Pathologic findings were separated into two groups: significant pathologic findings (SPF, such as inflammation, hyperplasia, ASAP/HGPIN) and no significant pathologic findings (NSPF) with or without cancer in same/adjacent site on systematic biopsy (SB). Patients with repeat MRI and follow-up MRF-TB evaluation. Results: 497 men had PI-RADS 4/5 lesions out of 1595 initial biopsies. Of these 497 men, 101 (20%) had MRF-TB negative for carcinoma. Upon review, 54 had SPF and 47 had NSPF on MRF-TB. Of 54 men with SPF on initial MRF-TB, 31 had repeat MRI, 23 of 31 men downgraded in which 16 had repeat MRF-TB with 1 had cancer detect. The other 8 of 31 men had persistent PI-RADS 4/5 lesions, 3 were detected cancer on repeat MRF-TB. Of 47 men with NSPF on initial MRF-TB, 19 had PCa in the same/ adjacent site on SB and were considered as missed on MRF-TB; of the other 28, 13 underwent repeat MRI. 8 of 13 downgraded with 0 had PCa in the repeat MRF-TB and 5 of 13 men with persistent PI-RADS 4/5 lesions, 3 had PCa detect on repeat MRF-TB. Altogether, 22/47 (47%) of the cases with NSPF in the initial MRF-TB were missed cancer. Conclusions: 1/5 of the target biopsy cases on PI-RADS 4/5 ROI had negative cancer detection. Inflammation, nodular hyperplasia and HGPIN can account for some of the cases, and those were downgraded in followup MRI usually had a negative repeat biopsy. Cases with NSPF on MRF-TB for PI-RADS 4/5 lesions are likely (47%) missed PCa, high likelihood of persistent PI-RADS 4/5 ROI on repeat MRI and PCa detection on repeat biopsy. We suggest pathology findings beside cancer should be reported on MRF-TB biopsy as they can guide decisions on repeat imagine and biopsy

PURPOSE/OBJECTIVE:The Medicare Access and CHIP Reauthorization Act (MACRA) provides CMS flexibility to evaluate radiologists using hospital outpatient quality measures in place of conventional physician measures. We explore radiologist characteristics associated with variation in performance in two such measures: abdomen and chest CT "double scan" rates (percentage of total examinations performed both with and without intravenous contrast). METHODS:Radiologists' claims for abdomen and chest CT examinations in a facility setting were identified using 2014 Medicare Physician and Other Supplier data. Individual radiologist double scan rates were computed. Associations were explored between rates and radiologist characteristics extracted from the CMS public data sets using multivariable regression with cross-validation. RESULTS:Radiologists' double scan rates averaged 5.9% ± 10.0% (0.0% for 52.8% of radiologists) for abdomen CT (19,867 radiologists) and 1.0% ± 4.7% (0.0% for 91.3% of radiologists) for chest CT (18,684). At multivariable analysis, abdomen rates were best predicted by geography (lowest in Northeast, greatest in West), practice size (greatest for small practices), and specialty practice pattern (lowest for general radiologists; greatest for nuclear medicine physicians). Agreement for double scan rates among radiologists within the same practice was moderate, though slightly higher for chest (intraclass correlation = 0.70) than abdomen (0.59). CONCLUSION/CONCLUSIONS:Radiologists' facility double scan rates vary systematically based on an array of professional characteristics. MACRA grants CMS the authority to use these measures for evaluating radiologists, thereby aligning Medicare's hospital and physician performance programs and better incentivizing population radiation dose and cost reduction. Greater variation in abdomen CT double scan rates, compared with ubiquitously excellent chest CT performance, supports a particular role for abdomen rates in distinguishing disparities in radiologist performance.