Medicaid and the Children's Health Insurance Program: an overview for the pediatric radiologist.

In terms of number of beneficiaries, Medicaid is the single largest health insurance program in the US. Along with the Children's Health Insurance Program (CHIP), Medicaid covers nearly half of all births and provides health insurance to nearly half of the children in the country. This article provides a broad introduction to Medicaid and CHIP for the pediatric radiologist with a special focus on topics relevant to pediatric imaging and population health. This includes an overview of Medicaid's structure and eligibility criteria and how it differs from Medicare. The paper examines the means-tested programs within the context of pediatric radiology, reviewing pertinent topics such as the rise of Medicaid managed care plans, Medicaid expansion, the effects of Medicaid on child health, and COVID-19. Beyond the basics of benefits coverage, pediatric radiologists should understand how Medicaid and CHIP financing and reimbursement affect the ability of pediatric practices, radiology groups, and hospitals to provide services for children in a sustainable manner. The paper concludes with an analysis of future opportunities for Medicaid and CHIP.

Current Controversies in Radiology on Cost, Reimbursement, and Price Transparency: AJR Expert Panel Narrative Review.

Many believe that fundamental reform of the U.S. health care system is overdue and necessary given rising national health care 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 large uninsured and underinsured populations. The Medicare Payment Advisory Commission, 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 repurposed in federal rulemaking to reduce reimbursement from commercial payers to certain specialties, including radiology. In this article, we examine challenges facing the U.S. health care 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 health care expenditures but has an outsized impact on patient care. The radiology community should work together to reinforce the value of medical imaging and reduce inappropriate utilization of low-value care.

Federal Out-of-Network Balance Billing Legislation: Context and Implications for Radiology Practices.

Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

The continuous lure of pediatric radiology.

Pediatric radiology is an immensely rewarding career choice. Eight pediatric radiologists, enthusiastic for their profession, were asked six questions about their career choice. Their responses illustrate the common virtues of pediatric radiology and also demonstrate the diverse paths and activities that pediatric radiologists take and pursue.

Practical Suggestions on How to Move From Peer Review to Peer Learning.

OBJECTIVE: The purpose of this article is to outline practical steps that a department can take to transition to a peer learning model. CONCLUSION: The 2015 Institute of Medicine report on improving diagnosis emphasized that organizations and industries that embrace error as an opportunity to learn tend to outperform those that do not. To meet this charge, radiology must transition from a peer review to a peer learning approach.

Quality measures and pediatric radiology: suggestions for the transition to value-based payment.

Recent political and economic factors have contributed to a meaningful change in the way that quality in health care, and by extension value, are viewed. While quality is often evaluated on the basis of subjective criteria, pay-for-performance programs that link reimbursement to various measures of quality require use of objective and quantifiable measures. This evolution to value-based payment was accelerated by the 2015 passage of the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA). While many of the drivers of these changes are rooted in federal policy and programs such as Medicare and aimed at adult patients, the practice of pediatrics and pediatric radiology will be increasingly impacted. This article addresses issues related to the use of quantitative measures to evaluate the quality of services provided by the pediatric radiology department or sub-specialty section, particularly as seen from the viewpoint of a payer that may be considering ways to link payment to performance. The paper concludes by suggesting a metric categorization strategy to frame future work on the subject.

Neurointerventional payment for out-of-network mechanical thrombectomy in the era of the No Surprises Act.

BACKGROUND: Congress enacted the No Surprises Act (NSA) in 2021. The NSA relies on the ability for providers to appeal their out-of-network (OON) payment through an arbitration process known as Independent Dispute Resolution (IDR). This study was designed to evaluate the effective access to IDR for mechanical thrombectomy (MT). METHODS: This study uses a simulation to model the likelihood that neurointerventionalists have financially viable access to the NSA IDR process to seek adequate payment for MT OON claims. RESULTS: When evaluating professional claims, for only batches of four or more claims, would the expected payment recovery exceed the expected IDR costs. For global claims (both professional and technical components), a batch size of two claims would be required for the expected payment recovery to exceed expected IDR costs.For the 1000 simulations at large MT centers (300 MT annually), there were no instances where it would have been financially viable to submit professional-only OON claims to the IDR process. For global claims, it would have been financially viable to submit to IDR for only 13.2% of these claims. For smaller stroke centers, there were also no instances where it would have been financially viable to submit professional-only claims. For global claims, it would have been financially viable for only 3.3-6.1% of claims. CONCLUSIONS: The NSA process was designed to protect patients from unexpected bills following non-elective medical services. Given the emergent nature of many neuroendovascular cases and the lack of access to the IDR process as this model illustrates, the field is at risk for under-reimbursement due to NSA legislation.

The Surprise Insurance Gap: History, Context, and Proposed Solutions.

Affordability of care is a major concern for many in the United States. Part of the affordability of care issue is unanticipated medical bills. A 2018 poll found that unexpected medical costs were the public's greatest affordability concern, ahead of prescription drug costs and even food or rent or mortgage. An important cause of unexpected medical bills is the surprise insurance network gap. The term "surprise billing" is commonly used to describe this problem of unanticipated out-of-network (OON) care, though this is a misnomer because it is actually a "surprise insurance gap." This gap can have significant consequences for patients and families. Hospital-based specialties like radiology have been implicated in the issue. Part of solving this problem includes determining an appropriate reimbursement for physicians who provide unanticipated OON care to patients. The two most commonly proposed methods to determine insurance company reimbursement to providers for OON services are use of a benchmark value and alternative dispute resolution. There is risk in trying to "price set" with a benchmark value. Establishing a predetermined value for services to mitigate against unexpected bills could have unintended and significant consequences, including disrupting good-faith negotiations between insurance companies and providers and impacting access to care. The data indicate that an alternative dispute resolution process can protect patients, lower the frequency of unexpected OON bills, and reduce costs.

Scale Can Improve the Clinical Value of Radiology Practices.

Radiology is participating in the recent consolidation trend. Larger practices can invest in the infrastructure and teams to help improve the clinical value of the services they deliver. An example of national practice is provided that leverages its scale to promote clinical best practices aimed at reducing variability in the recommendations radiologists make for common imaging findings. This is accomplished by promoting the culture of learning and collaboration. In some initiatives, developing a machine learning tool to facilitate the application of clinical algorithms at the point of dictation facilitates the adoption of the recommendations. Regular feedback on practice and individual performance promotes improvement in performance and personal satisfaction of the clinicians. Cost savings through the reduction of unnecessary imaging studies or invasive procedures as well as improved outcomes through evidence-based follow-up have been achieved. In some cases, reductions in the rupture rate of abdominal aortic aneurysms have been realized through clinical follow-up programs. Embracing a culture of continuous learning through peer learning can lay the foundation for sharing clinical best practices. Having access to the benefits of scale in the form of investment in data, analytics, project management, and machine learning tools can facilitate the process of creating clinical value for our patients.

Preparing and Delivering Your Best Radiology Lecture.

Delivering a presentation that is educational, memorable, and even inspiring is the aspiration of all speakers. Unfortunately, public speaking is an anxiety-producing experience for many. This is especially true when delivering a talk to physician colleagues. Like so many daunting activities, success is achievable if you are willing to invest the time and energy to prepare. We believe that adherence to the principles outlined in this article, including a focus on content, delivery and design, will help you to succeed.