Episode-Based Cost Sharing to Prospectively Guarantee Patients' Out-of-Pocket Costs.

This Viewpoint proposes episode-based cost sharing as a way to prospectively guarantee out-of-pocket costs for patients while also preventing insurers from absorbing cost differentials created by unexpected complications of care.

Healthcare price transparency in North America and Europe.

Healthcare price transparency is an effort to inform patient decision-making, but also to decrease prices and their variation across healthcare systems for equivalent medical services. The initiative is meaningful only for medical services that are shoppable-such as imaging examinations-for which patients incur out-of-pocket costs. Therefore, several countries in which patients commonly share a portion of their healthcare costs have been implementing mandates to improve healthcare price transparency. However, the provisional implementation has many issues, especially in the United States, including provider non-compliance and limited accessibility of price transparency tools by the general public. Many of the existing tools are not user-friendly, are difficult to navigate, focus on charges and health plan negotiated rates rather than patients' out-of-pocket costs, and disclose prices on the service level instead of per episode of care. As such, the disclosed amounts are often not reliable. Many price transparency tools also lack valid and measurable quality metrics, which can result in a selection of high-cost care as a proxy for high-value care, as well as an increase in healthcare prices when providers want to imply they offer high-quality care. Nevertheless, the impact of the initiatives on patients' decision-making and healthcare costs remains unclear. While transparency initiatives are patient-centric, efforts should be made to increase patient engagement, provide accurate patient-specific out-of-pocket cost information, compare available treatment and provider alternatives, and couple price information with quality metrics to enable making fully informed decisions.

The cost burden of metastatic prostate cancer in the US populations covered by employer-sponsored health insurance.

BACKGROUND: Recent advancements in the clinical management of metastatic prostate cancer include several costly therapies and diagnostic tests. The objective of this study was to provide updated information on the cost to payers attributable to metastatic prostate cancer among men aged 18 to 64 years with employer-sponsored health plans and men aged 18 years or older covered by employer-sponsored Medicare supplement insurance. METHODS: By using Merative MarketScan commercial and Medicare supplemental data for 2009-2019, the authors calculated differences in spending between men with metastatic prostate cancer and their matched, prostate cancer-free controls, adjusting for age, enrollment length, comorbidities, and inflation to 2019 US dollars. RESULTS: The authors compared 9011 patients who had metastatic prostate cancer and were covered by commercial insurance plans with a group of 44,934 matched controls and also compared 17,899 patients who had metastatic prostate cancer and were covered by employer-sponsored Medicare supplement plans with a group of 87,884 matched controls. The mean age of patients with metastatic prostate cancer was 58.5 years in the commercial samples and 77.8 years in the Medicare supplement samples. Annual spending attributable to metastatic prostate cancer was $55,949 per person-year (95% confidence interval [CI], $54,074-$57,825 per person-year) in the commercial population and $43,682 per person-year (95% CI, $42,022-$45,342 per person-year) in the population covered by Medicare supplement plans, both in 2019 US dollars. CONCLUSIONS: The cost burden attributable to metastatic prostate cancer exceeds $55,000 per person-year among men with employer-sponsored health insurance and $43,000 among those covered by employer-sponsored Medicare supplement plans. These estimates can improve the precision of value assessments of clinical and policy approaches to the prevention, screening, and treatment of prostate cancer in the United States.

Complex Billing for Nonemergency Outpatient Imaging: An Obstacle to the Success of Health Care Price Transparency Initiatives.

PURPOSE: Recent price transparency initiatives have considerable limitations, notably due to the complexity of health care products. A single care encounter often consists of several services that may be performed by numerous clinicians and health care facilities that bill independently. The objective of this study was to describe the complexity in billing for nonemergency, noninvasive outpatient imaging and its variation across care delivery settings and imaging modalities. METHODS: Using billing records from the 2019 IBM MarketScan Commercial Database, the authors examined the number of billing entities involved in outpatient imaging encounters and the sets of relevant items and services for which patients were billed. RESULTS: In total, 5,210,129 imaging encounters were analyzed. Patients received bills from multiple billing entities for 70.9% of hospital-based encounters, 4.5% of office-based encounters, and 7.6% of encounters at imaging centers. Contrast agent was billed separately from the imaging procedures in 55.9%, 71.5%, and 55.3% of encounters for contrast imaging at hospitals, offices, and imaging centers, respectively. Billing for other ancillary items and services (facility fees, 3-D reconstruction, anesthesia and sedation) was relatively rare. CONCLUSIONS: Two key aspects of billing complexity may make obtaining complete and reliable price estimates before receiving outpatient imaging difficult for patients: the number of billing entities involved in care delivery and billing for fees and ancillary services beyond the primary imaging procedure. Given that price transparency initiatives are aimed primarily at helping patients anticipate the total cost of their care, policymakers, payers, and providers should take additional steps to provide patients with reliable information on the prices of entire care experiences.

Spending on Medical Imaging by Age and Gender in the U.S. Population With Employer-Sponsored Insurance.

Demographic changes in the population are an under-studied driving force of imaging utilization and associated spending. This study used national databases to characterize variations in spending on medical imaging among individuals with primary or secondary employer-sponsored insurance. Spending on imaging generally increased with age until individuals were approximately 80-85 years old, and among those who were 14-70 years old, spending was higher among women than men. The findings provide insight into how demographic changes could impact future spending on medical imaging.

Increasing Utilization of Emergency Department Neuroimaging From 2007 Through 2017.

BACKGROUND. The volume of emergency department (ED) visits and the number of neuroimaging examinations have increased since the start of the century. Little is known about this growth in the commercially insured and Medicare Advantage populations. OBJECTIVE. The purpose of our study was to evaluate changing ED utilization of neuroimaging from 2007 through 2017 in both commercially insured and Medicare Advantage enrollees. METHODS. Using patient-level claims from Optum's deidentified Clinformatics Data Mart database, which annually includes approximately 12-14 million commercial and Medicare Advantage health plan enrollees, annual ED utilization rates of head CT, head MRI, head CTA, neck CTA, head MRA, neck MRA, and carotid duplex ultrasound (US) were assessed from 2007 through 2017. To account for an aging sample population, utilization rates were adjusted using annual relative proportions of age groups and stratified by patient demographics, payer type, and provider state. RESULTS. Between 2007 and 2017, age-adjusted ED neuroimaging utilization rates per 1000 ED visits increased 72% overall (compound annual growth rate [CAGR], 5%). This overall increase corresponded to an increase of 69% for head CT (CAGR, 5%), 67% for head MRI (CAGR, 5%), 1100% for head CTA (CAGR, 25%), 1300% for neck CTA (CAGR, 27%), 36% for head MRA (CAGR, 3%), and 52% for neck MRA (CAGR, 4%) and to a decrease of 8% for carotid duplex US (CAGR, -1%). The utilization of head CT and CTA of the head and neck per 1000 ED visits increased in enrollees 65 years old or older by 48% (CAGR, 4%) and 1011% (CAGR, 24%). CONCLUSION. Neuroimaging utilization in the ED grew considerably between 2007 and 2017, with growth of head and neck CTA far outpacing the growth of other modalities. Unenhanced head CT remains by far the dominant ED neuroimaging examination. CLINICAL IMPACT. The rapid growth of head and neck CTA observed in the fee-for-service Medicare population is also observed in the commercially insured and Medicare Advantage populations. The appropriateness of this growth should be monitored as the indications for CTA expand.

Concordance of Disclosed Hospital Prices With Total Reimbursements for Hospital-Based Care Among Commercially Insured Patients in the US.

Importance: To improve health care price transparency and promote cost-conscious selection of health care organizations and practitioners, the Centers for Medicare & Medicaid Services (CMS) required that hospitals share payer-specific negotiated prices for selected shoppable health services by January 2021. While this regulation improves price transparency, it is unclear whether disclosed prices reflect total costs of care, since many hospital-based services are delivered and billed separately by independent practitioners or other health care entities. Objective: To assess the extent to which prices disclosed under the new hospital price transparency regulation are correlated with total costs of care among commercially insured individuals. Design, Setting, and Participants: This cross-sectional study used a large database of commercial claims from 2018 to analyze encounters at US hospitals for shoppable health care services for which price disclosure is required by CMS. Data were analyzed from November 2020 to February 2021. Exposures: Whether the service was billed by the hospital or another entity. Main Outcomes and Measures: Outcomes of interest were the percentage of encounters with at least 1 service billed by an entity other than the hospital providing care, number of billing entities, amounts billed by nonhospital entities, and the correlation between hospital and nonhospital reimbursements. Results: The study analyzed 4 545 809 encounters for shoppable care. Independent health care entities were involved in 7.6% (95% CI, 6.7% to 8.4%) to 42.4% (95% CI, 39.1% to 45.6%) of evaluation and management encounters, 15.9% (95% CI, 15.8% to 16%) to 22.2% (95% CI, 22% to 22.4%) of laboratory and pathology services, 64.9% (95% CI, 64.2% to 65.7%) to 87.2% (95% CI, 87.1% to 87.3%) of radiology services, and more than 80% of most medicine and surgery services. The median (IQR) reimbursement of independent practitioners ranged from $61 ($52-$102) to $412 ($331-$466) for evaluation and management, $5 ($4-$6) to $7 ($4-$12) for laboratory and pathology, $26 ($20-$32) to $210 ($170-$268) for radiology, and $47 ($21-$103) to $9545 ($7750-$18 277) for medicine and surgery. The reimbursement for services billed by the hospital was not strongly correlated with the reimbursement of independent clinicians, ranging from r = -0.11 (95% CI, -0.69 to 0.56) to r = 0.53 (95% CI, 0.13 to 0.78). Conclusions and Relevance: This cross-sectional study found that independent practitioners were frequently involved in the delivery of shoppable hospital-based care, and their reimbursement may have represented a substantial portion of total costs of care. These findings suggest that disclosed hospital reimbursement was usually not correlated with total cost of care, limiting the potential benefits of the hospital price transparency rule for improving consumer decision-making.

U.S. Preventive Services Task Force Update and Computed Tomography for Colorectal Cancer Screening Among Privately Insured Population.

INTRODUCTION: The Affordable Care Act of 2010 mandated private health plans to fully cover the services recommended by the U.S. Preventive Services Task Force. In June 2016, the Task Force added computed tomography colonography to its list of recommended tests for colorectal cancer screening. This study evaluates the association among the updated recommendation, patient cost-sharing obligations, and the uptake of colorectal cancer screening through computed tomography colonography in the privately insured population. METHODS: Using individual claims from the 2010-2018 IBM MarketScan Commercial Database, monthly screening computed tomography colonography utilization rates per 100,000 privately insured beneficiaries aged 50-64 years and the monthly proportions of these services delivered by in-network providers for which patients had to bear a portion of the procedure costs were calculated, and an interrupted time series analysis was performed. The study was conducted between January and May 2020. RESULTS: Although the proportion of in-network procedures subject to patient cost sharing declined from 38.2% in 2010 to 10.2% in early 2016, the monthly utilization remained nearly constant. The announcement of the updated recommendation was associated with an immediate increase in the monthly screening computed tomography colonography utilization rate from 0.4 to 0.6 procedures per 100,000 individuals but with no change in the proportion of in-network procedures subject to patient cost sharing. CONCLUSIONS: In an environment of already largely eliminated patient cost sharing, the release of supportive evidence-based recommendations by a recognized credible body was associated with an immediate increase in computed tomography colonography use for colorectal cancer screening in the privately insured population.

Annual Out-Of-Pocket Spending Clusters Within Short Time Intervals: Implications For Health Care Affordability.

The distribution of out-of-pocket spending throughout the year is an important determinant of health care affordability that has received little attention. We used 2017 data from a large database of US commercial insurance claims to study the distribution of patient-level out-of-pocket spending throughout the year, highlighting potential hardship due to temporal clustering of spending. We found that although most commercially insured people had several health care encounters throughout the year, their out-of-pocket spending was mostly concentrated within short time intervals. Nearly one-third of people with above-the-median total annual health care spending (plan plus out-of-pocket spending) incurred half of their annual out-of-pocket spending in just one day. Policy makers working to improve the affordability of care should focus on innovative approaches to cost sharing that prevent dramatic financial shocks to household budgets due to medical bills.

Associations Over Time Between Paid Medical Malpractice Claims and Imaging Utilization in the United States.

PURPOSE: The aim of this study was to explore state-level relationships between the incidence and payout amounts for medical malpractice claims and Medicare imaging utilization and spending across the United States. METHODS: Using claims data from a 5% sample of Medicare beneficiaries for 2004 to 2016, annual state population-adjusted rates of imaging utilization and spending were calculated. Using National Practitioner Data Bank files, all paid physician malpractice claims were identified, and lagged state population-adjusted rolling averages of paid claim frequencies and payout amounts were calculated. Controlling for secular trends and state fixed effects with robust standard errors clustered at the state level to account for serial autocorrelation, associations between imaging utilization and lagged paid malpractice claims were assessed using multivariate regression models. Log-log model specification was used to obtain elasticity measures. RESULTS: Between 2004 and 2016, national Medicare diagnostic imaging utilization and spending declined by 31.4% and 47.2%, respectively (from 355,057 to 243,517 examinations and from $28,591,146 to $15,099,291 per 100,000 beneficiaries). Overall national paid malpractice claims and payout amounts declined by 46.4% and 39.6%, respectively (from 4.83 to 2.59 claims and from $1,803,565 to $1,089,112 per 100,000 population). After controlling for secular trends and state fixed effects, advanced imaging utilization was positively associated with the lagged number of per capita paid malpractice claims. Each 1% increase in average paid malpractice claims was associated with a subsequent 0.20% increase in advanced imaging utilization (P = .001). CONCLUSIONS: Positive associations between paid malpractice claims and advanced Medicare imaging utilization support the contention that US physicians use medical imaging as a defensive medicine strategy.

Use of Screening CT Colonography by Age and Race: A Study of Potential Access Barriers Related to Medicare Noncoverage Based on Data From the ACR's National CT Colonography Registry.

OBJECTIVE: The primary objectives of this investigation were to evaluate the use of screening CT colonography (CTC) examinations by age comparing individuals of Medicare-eligible age to younger cohorts and to determine if the association between use of CTC and Medicare-eligible age varies by race. Although the Affordable Care Act requires commercial insurance coverage of screening CTC, Medicare does not cover screening CTC. MATERIALS AND METHODS: Using the ACR's CTC registry, the distribution of procedures by age was evaluated using a negative binomial model with patient age (to capture overall trend), indicator of Medicare-eligible age (to capture immediate changes in trend at age 65), and their interaction (to capture gradual changes after age 65) as independent variables. The association between the number of screening CTCs and age was compared by racial identity. RESULTS: The CTC registry contained data on 12,648 screening examinations. Between ages 52 and 64, the number of screening examinations increased; each additional age year was associated with a 5.3% (P < .001) increase in the number of screenings. However, after age 65, the number of screening examinations decreased by -6.9% per additional year of age above 65 compared with the trend between ages 52 and 64 (P < .001). The modal age group for CTC use was 65 to 69 years in white and 55 to 59 in black individuals. CONCLUSION: After age 65, the number of screening CTC examinations decreased, likely due, at least in part, to lack of Medicare coverage. Medicare noncoverage may have a disproportionate impact on black patients and other racial minorities.

Invasive Procedural Treatments for Symptomatic Uterine Fibroids: A Cost Analysis.

PURPOSE: The aim of this study was to evaluate the contemporary use of procedural interventions to treat symptomatic uterine fibroids and assess associated health care system costs. METHODS: Using the IBM Watson MarketScan Commercial Claims and Encounters database for 2009 to 2015 and relevant International Classification of Diseases diagnosis codes, women aged 18 to 55 years with clinically significant uterine fibroids were identified. Using Current Procedural Terminology codes, relevant procedural interventions were identified (hysterectomy, endometrial ablation, myomectomy, and uterine fibroid embolization [UFE]). Costs were defined as total actual payments by insurers and patients (per procedure and per episode of care) and were adjusted and compared using generalized linear models. RESULTS: Of 241,757 invasive procedures for fibroids, hysterectomy was most common (76.5%), followed by endometrial ablation (14.5%), myomectomy (4.7%), and UFE (4.3%). Hysterectomy was more common in older women and those in rural areas (65.2% of patients <40 years of age, 77.6% of those 40-49 years of age, and 83.6% of those 50-55 years of age; 83.9% of patients outside versus 75.3% within metropolitan statistical areas). Per procedure, adjusted mean costs were $3,188 (95% confidence interval [CI], $3,114-$3,264) for hysterectomy, $2,781 (95% CI, $2,695-$2,870) for ablation, $4,436 (95% CI, $4,256-$4,623) for myomectomy, and $6,161 (95% CI, $5,736-$6,617) for UFE. Adjusted mean costs for entire episodes of care were $14,676 (95% CI, $14,496-$14,858) for hysterectomy, $6,702 (95% CI, $6,534-$6,875) for endometrial ablation, $14,791 (95% CI, $14,465-$15,125) for myomectomy, and $13,873 (95% CI, $13,182-$14,599) for UFE. CONCLUSIONS: Of invasive procedures for symptomatic uterine fibroids, hysterectomy was used more frequently than endometrial ablation, myomectomy, and UFE combined. Per procedure and per episode, ablation was least costly. Costs per episode were similar for hysterectomy, myomectomy, and UFE.

Geographic Dispersion and Rural Versus Urban Utilization of CT Colonography in the United States.

OBJECTIVE: To assess the geographic dispersion of CT colonography (CTC) as well as differences in CTC utilization in rural versus urban areas in individuals with commercial insurance. METHODS: Claims data from approximately 18.5 million commercially insured individuals across the United States were used to determine CTC utilization based on geographic area. Geographic areas were defined as metropolitan statistical areas (MSAs) and statewide non-MSAs. Utilization rates per 100,000 covered person-years were calculated for each geographic area for both screening and diagnostic CTC using 2017 data (the most recent full-year data available). Differences in CTC utilization between MSAs (urban) and non-MSAs (rural) were evaluated using weighted multivariate logistic regression. RESULTS: CTC is widely dispersed across the United States with substantial geographic variability. Utilization of screening CTC was considerably lower among individuals residing in rural areas compared with those in urban areas (adjusted odds ratio = 0.353, P = .005). For individuals aged 50 to 64 years, screening CTC utilization was 2.38 per 100,000 in rural areas versus 6.67 per 100,000 in urban areas (P = .005). Utilization of diagnostic CTC was also lower in rural compared with urban areas, though this difference was not statistically significant (8.40 per 100,000 versus 13.11 per 100,000 respectively, P = .070). CONCLUSIONS: Although CTC is performed widely across the United States, utilization is generally low and varies substantially based on geographic region. CTC utilization is lower among individuals in rural compared with urban areas.

The Introduction and Development of the H-index for Imaging Utilizers: A Novel Metric for Quantifying Utilization of Emergency Department Imaging.

OBJECTIVE: The objective was to develop a novel metric for quantifying patient-level utilization of emergency department (ED) imaging. METHODS: Using 2009 to 2015 Truven Health MarketScan commercial claims and encounters database, all ED visits and associated imaging services were identified. To measure imaging resource intensity, total imaging relative value units (RVUs) were calculated for each patient per ED visit. An individual's annual imaging h-index is defined as the largest number, h, such that h ED visits by that individual in a given year is associated with total medical imaging RVUs of a value of at least h. RESULTS: Over 7 years, in a sample of 86,506,362 privately insured individuals (232,919,808 person-years) in all 50 states and the District of Columbia, 38,973,716 ED visits were identified. A total of 9.5% of person-years had one ED visit and 2.7% had two or more (the remainder had none). From 2009 to 2015, the percentage of ED patients undergoing imaging increased from 25.1% to 34.6%. Individuals with two or more ED visits each associated with two or more imaging RVUs (ED imaging h-index ≥ 2) comprised 0.2% of the sample and 1.4% of ED visitors; however, they accounted for 4.0% of ED visits and the use of 18.6% of imaging resources. From 2009 to 2015, imaging resource allocation for such patients increased from 16.5% to 21.0%. CONCLUSIONS: The ED imaging h-index allows identification of patients who undergo significant ED imaging, based on a single-digit patient-specific metric that incorporates both annual ED visit number and medical imaging resource intensity per visit. While ED patients with an ED imaging h-index ≥ 2 represented a minuscule fraction of privately insured individuals, they were associated with one-fifth of all ED imaging resources.

Cost-Effectiveness Analysis: An Overview of Key Concepts, Recommendations, Controversies, and Pitfalls.

The field of radiology has witnessed a burst of technological advances that improve diagnostic quality, reduce harm to patients, support clinical needs, and better serve larger more diverse patient populations. One of the critical challenges with these advances is proving that value outweighs the cost. The use of cutting-edge technology is often expensive, and the reality is that our society cannot afford all the screening and diagnostic tests that are being developed. At the societal level, we need tools to help us decide which health programs should be funded. Therefore, decision makers are increasingly looking toward scientific methods to compare health technologies in order to improve allocation of resources. One of such methods is cost-effectiveness analysis. In this article, we review key features of cost-effectiveness analysis and its specific issues as they relate to radiology.

Cost-effectiveness of preexposure prophylaxis for HIV prevention for conception in the United States.

OBJECTIVE: The aim of this study was to investigate the value of coformulated Tenofovir disoproxil fumarate and emtricitabine (TDF/FTC) for preexposure prophylaxis (PrEP) for conception in the U.S. and to identify scenarios in which 'Undetectable = Untransmittable' (U = U) may not be adequate, and rather, PrEP or assisted reproduction would improve outcomes. DESIGN: We developed a Markov cohort simulation model to estimate the incremental benefits and cost-effectiveness of PrEP compared with alternative safer conception strategies, including combination antiretroviral therapy (cART) alone for the HIV-infected partner and assisted reproductive technologies. We modelled various scenarios in which HIV RNA suppression in the male partner was less than perfect. SETTING: U.S. healthcare sector perspective. PARTICIPANTS: Serodiscordant couples in the U.S. was composed of an HIV-infected male and HIV-uninfected female seeking conception. INTERVENTION: Economic analysis. MAIN OUTCOME MEASURE(S): Cumulative risks of HIV transmission to women and babies, maternal life expectancy, discounted quality-adjusted life years (QALY), discounted lifetime medical costs and incremental cost-effectiveness ratios. RESULTS: cART with condomless intercourse limited to ovulation was the preferred HIV prevention strategy among women seeking to conceive with an HIV-infected partner who is HIV-suppressed. PrEP was not cost-effective for women who had partners who were virologically suppressed. When the probability of male partner HIV suppression was low and we assumed generic pricing of PrEP, PrEP was cost-effective, and sometimes even cost-saving compared with cART alone. CONCLUSION: From a U.S. healthcare sector perspective, when the male partner was not reliably suppressed, PrEP became economically attractive, and in some cases, cost-saving.

Characteristics of State Policies Impact Health Care Delivery: An Analysis of Mammographic Dense Breast Notification and Insurance Legislation.

BACKGROUND: Increased breast tissue density may mask cancer and thus decrease the diagnostic sensitivity of mammography. A patient group advocacy led to the implementation of laws to increase the awareness of breast tissue density and to improve access to supplemental imaging in many states. Given limited evidence about best practices, variation exists in several characteristics of adopted policies. OBJECTIVE: To identify which characteristics of state-level policies with regard to dense breast tissue were associated with increased use of downstream breast ultrasound. RESEARCH DESIGN: This was a retrospective series of monthly cross-sections of screening mammography procedures before and after implementation of laws. SUBJECTS: A sample of 13,481,554 screening mammography procedures extracted from the MarketScan Research database performed between 2007 and 2014 on privately insured women aged 40-64 years that resided in a state that had implemented relevant legislation during that period. MEASURES: The outcome was an indicator of whether breast ultrasound imaging followed a screening mammography procedure within 30 days. The main independent variables were policy characteristics indicators. RESULTS: Notification of patients about issues surrounding increased breast density was associated with increased follow-up by ultrasound by 1.02 percentage points (P=0.016). Some policy characteristics such as the explicit suggestion of supplemental imaging or mandated coverage of supplemental imaging by health insurance augmented that effect. Other policy characteristics moderated the effect. CONCLUSIONS: The heterogeneous effect of state legislation with regard to dense breast tissue on screening mammography follow-up by ultrasound may be explained by specific and unique characteristics of the approaches taken by a variety of states.

Advanced Imaging Utilization Trends in Privately Insured Patients From 2007 to 2013.

OBJECTIVE: The aim of the study was to investigate whether the increase in utilization of advanced diagnostic imaging for privately insured patients in 2011 was the beginning of a new trend in imaging utilization growth, or an isolated deviation from the declining trend that began in 2008. METHODS: We extracted outpatient and inpatient CT, diagnostic ultrasound, MRI, and PET procedures from databases, for the years 2007 to 2013. This study extended previous work, covering 2012 to 2013, using the same methodology. For every year of the study period, we calculated the following: number of procedures per person-year covered by private health insurance; proportion of office and emergency visits that resulted in an imaging session; average payments per procedure; and total payments per person-year covered by private health insurance. RESULTS: Outpatient utilization of CT and PET decreased in both 2012 and 2013; outpatient utilization of MRI mildly increased in 2012, but then decreased in 2013. Outpatient utilization of diagnostic ultrasound showed a very different pattern, increasing throughout the study period. Inpatient utilization of all imaging modalities except PET decreased in both 2012 and 2013. Adjusted payments for all imaging modalities increased in 2012, and then dropped substantially in 2013, except the adjusted payments for diagnostic ultrasound that increased in 2013 again. CONCLUSIONS: The trend of increasing utilization of advanced diagnostic imaging seems to be over for some, but not all, imaging modalities. A combination of policy (eg, breast density notification laws), technologic advancement, and wider access seems to be responsible for at least part of an increasing utilization of diagnostic ultrasound.