Initial Impact of COVID-19 on Radiology Practices: An ACR/RBMA Survey.

PURPOSE: The coronavirus disease 2019 (COVID-19) pandemic affected radiology practices in many ways. The aim of this survey was to estimate declines in imaging volumes and financial impact across different practice settings during April 2020. METHODS: The survey, comprising 48 questions, was conducted among members of the ACR and the Radiology Business Management Association during May 2020. Survey questions focused on practice demographics, volumes, financials, personnel and staff adjustments, and anticipation of recovery. RESULTS: During April 2020, nearly all radiology practices reported substantial (56.4%-63.7%) declines in imaging volumes, with outpatient imaging volumes most severely affected. Mean gross charges declined by 50.1% to 54.8% and collections declined by 46.4% to 53.9%. Percentage reductions did not correlate with practice size. The majority of respondents believed that volumes would recover but not entirely (62%-88%) and anticipated a short-term recovery, with a surge likely in the short term due to postponement of elective imaging (52%-64%). About 16% of respondents reported that radiologists in their practices tested positive for COVID-19. More than half (52.3%) reported that availability of personal protective equipment had become an issue or was inadequate. A majority (62.3%) reported that their practices had existing remote reading or teleradiology capabilities in place before the pandemic, and 22.3% developed such capabilities in response to the pandemic. CONCLUSIONS: Radiology practices across different settings experienced substantial declines in imaging volumes and collections during the initial wave of the COVID-19 pandemic in April 2020. Most are actively engaged in both short- and long-term operational adjustments.

Radiology Practice Consolidation: Fewer but Bigger Groups Over Time.

PURPOSE: The aim of this study was to assess recent trends in US radiology practice consolidation. METHODS: Radiologist practice characteristics were obtained from the Medicare Physician Compare database for 2014 and 2018. Radiologists were classified on the basis of their largest identifiable practice affiliations. Single-specialty radiology practices were identified using practice names. Temporal trends in practice sizes were assessed. RESULTS: At the individual radiologist level from 2014 to 2018, the fraction of all radiologists in groups with 1 or 2 members declined from 3.2% to 2.1%, 3 to 9 members from 10.2% to 6.7%, 10 to 24 members from 18.2% to 14.1%, 25 to 49 members from 16.6% to 15.1%, and 50 to 99 members from 13.3% to 11.5%. In contrast, the fraction in groups with 100 to 499 members increased from 15.7% to 21.8% and with ≥500 members from 22.9% to 28.7%. At the practice level, the fraction of all radiologists' practices with 1 or 2 members decreased from 26.9% to 22.8%, whereas the fraction with 100 to 499 members increased from 7.6% to 10.2% and with ≥500 members from 2.5% to 4.1%. Similar shifts were present for single-specialty radiology practices and all geographic regions nationally. The 30,492 radiologists identified in 2014 were affiliated with 4,908 group practices, including 2,812 single-specialty practices. In comparison, the 32,096 radiologists identified in 2018 were affiliated with 4,193 group practices (a 14.6% decline), including 2,216 single-specialty practices (a 21.2% decline). CONCLUSIONS: In very recent years, the US radiologist workforce has consolidated, leading to increased practice sizes and a substantial decline in the number of distinct practices, disproportionately affecting single-specialty radiology practices. The impact of this consolidation on cost, quality, and patient access merits further attention.

Medical students' critical thinking assessment with collaborative concept maps in a blended educational Strategy.

BACKGROUND: Concept maps (CMs) are tools used to represent how new knowledge is integrated into the cognitive structure. In this study, we investigated the role of collaborative CMs in improving medical students' critical thinking and knowledge acquisition. METHODS: A pre-post interventional study was conducted. In the 1st week of the clerkship rotation, a group of 10-14 students were asked by a faculty member to make a CM (CM1). After this first exposure (weeks 2/3), students learned the content through online forums. In the final week (week 4), students discussed what they had learned and made a final CM (CM2). RESULTS: A total of 104 students participated in the study, making twenty CM1 and twenty CM2. There was a statistically significant difference between CM1 and CM2 for overall scores, proposition units, and hierarchy units (P < 0.001). DISCUSSION: Collaborative CMs may be useful tools to help teachers better understand their students' critical thinking changes during a blended strategy.

National Private Payer Coverage of Prostate MRI.

PURPOSE: To investigate the national coverage landscape for prostate MRI services, assessing the presence of updated and accurate coverage requirements by private payers. METHODS: The database Policy Reporter was used to evaluate private payer coverage related to prostate MRI for 81 plans covering 149 million people in the United States. Both the indications and requirements for prostate MRI coverage were recorded in a variety of clinical scenarios, including initial diagnosis, staging, active surveillance, and suspected recurrence. RESULTS: Overall, 11.1% of payers cover prostate MRI in biopsy-naïve patients with suspected prostate cancer, with the remaining 88.9% requiring a prior negative biopsy. Nearly all payers also require either a rising prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE). Rarely, a planned future MRI-targeted biopsy serves as a basis for MRI coverage. Initial staging is covered by most payers, although typically with stringent indications (eg, PSA ≥ 20 ng/mL, Gleason score ≥7 or 8, stage T3 or T4, or ≥20% risk of nodal metastases). Only 10 payers discuss active surveillance, with 8 of these requiring a repeat biopsy before MRI. Coverage for detection of post-treatment recurrence often requires a rising PSA or abnormal DRE, and occasionally only if a CT is first performed; only 10 of 81 payers address coverage after androgen deprivation treatment. CONCLUSION: Prostate MRI coverage varies widely among private payers, fails to recognize major clinical scenarios, is overly restrictive, and is often not reflective of current clinical practice. This creates challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services.

The Use of Smartphones in Different Phases of Medical School and its Relationship to Internet Addiction and Learning Approaches.

The use of smartphones is revolutionizing the way information is acquired, leading to profound modifications in teaching medicine. Nevertheless, inadvertent use can negatively affect student learning. The present study aims to evaluate smartphone use in the educational context as well as Internet addiction and its repercussions on surface and deep learning and to compare them during the different phases of medical students' education. This is a cross-sectional study involving medical students in all phases of education. Sociodemographic data, type and frequency of smartphone use, degree of digital addiction (Internet Addiction Test - IAT), and surface and deep approaches to learning (Biggs) were analyzed. A total of 710 students were included. Almost all students had a smartphone and a total of 96.8% used it during lectures, classes, and meetings. Less than half of the students (47.3%) reported using a smartphone for more than 10 min for educational purposes, a usage that is higher among clerkship students. At least 95% reported using a smartphone in the classroom for activities not related to medicine (social media and searching for general information) and 68.2% were considered problematic Internet users according to the IAT. The most common reasons for noneducational use were that the class was uninteresting, students needed to receive or make an important call, and the educational strategy was not stimulating. The "frequency of smartphone use" and higher "internet addiction" were correlated to both higher levels of surface learning and lower levels of deep learning. Educators should advise and educate their students about conscientious use of this tool to avoid detrimental impact on the learning process.

Out-of-Pocket Costs for Advanced Imaging Across the US Private Insurance Marketplace.

PURPOSE: 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.

Radiologist Professional Payments After Mitigation of CMS's Multiple-Procedure Payment Reduction Initiatives.

PURPOSE: The aim of this study was to assess the potential impact of ACR evidence-based advocacy on radiologist professional reimbursement from individual-provider CMS multiple-procedure payment reduction (MPPR) initiatives. METHODS: CMS Physician and Other Supplier Public Use Files and 5% research-identifiable file carrier claims files from 2012 through 2014 were used to identify individual-provider MPPR-eligible services for radiologists (group practice linking unavailability in either dataset precluded quantification of different provider discounting) and then compare actual payments to Medicare Physician Fee Schedule national professional reimbursement rates to identify MPPR-discounted services. Payments attributed to MPPR-affected services and average radiologist annual MPPR discounts were calculated to estimate incremental individual radiologist payment restoration as a result of evidence-based advocacy. RESULTS: Between 2012 and 2014, a mean of 803 to 836 advanced imaging services per radiologist were potentially affected by individual-provider MPPR discounting. Approximately 23% of these services were discounted by individual-provider MPPR, resulting in approximately $2,524 to $2,893 lost per radiologist per year. The MPPR rollback from 25% to 5% is thus estimated to return $55 million to $64 million to radiologists each year for the individual component of MPPR alone. CONCLUSIONS: Individual-provider MPPR discounting resulted, on average, in more than $2,500 in lost payments per radiologist per year. Its rollback, associated with ACR evidence-based advocacy efforts, is estimated to return well over $50 million in Medicare professional payments to radiologists each year for individual-component MPPR discounting alone.

Expanding Role of Certified Electronic Health Records Technology in Radiology: The MACRA Mandate.

Radiology has historically been at the forefront of innovation and the advancement of technology for the benefit of patient care. However, challenges to early implementation prevented most radiologists from adopting and integrating certified electronic health record technology (CEHRT) into their daily workflow despite the early and potential advantages it offered. This circumstance places radiology at a disadvantage in the two payment pathways of the Medicare Access and CHIP Reauthorization Act of 2015: the Merit-Based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Specifically, not integrating CEHRT hampers radiology's ability to receive bonus points in the quality performance category of the MIPS and in parallel threatens certain threshold requirements for advanced APMs under the new Quality Payment Program. Radiology must expand the availability and use of CEHRT to satisfy existing performance measures while creating new performance measures that create value for the health care system. In addition, radiology IT vendors will need to ensure their products (eg, radiology information systems, PACS, and radiology reporting systems) are CEHRT compliant and approved. Such collective efforts will increase radiologists' quality of patient care, contribution to value driven activities, and overall health care relevance.

Double Scan CT Rates: An Opportunity for Facility-Based Radiologist Measures in the Quality Payment Program.

PURPOSE: 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: 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.

Relativity Screens for Misvalued Medical Services: Impact on Noninvasive Diagnostic Radiology.

PURPOSE: In 2006, the AMA/Specialty Society Relative Value Scale Update Committee (RUC) introduced ongoing relativity screens to identify potentially misvalued medical services for payment adjustments. We assess the impact of these screens upon the valuation of noninvasive diagnostic radiology services. METHODS: Data regarding relativity screens and relative value unit (RVU) changes were obtained from the 2016 AMA Relativity Assessment Status Report. All global codes in the 2016 Medicare Physician Fee Schedule with associated work RVUs were classified as noninvasive diagnostic radiology services versus remaining services. The frequency of having ever undergone a screen was compared between the two groups. Screened radiology codes were further evaluated regarding the RVU impact of subsequent revaluation. RESULTS: Of noninvasive diagnostic radiology codes, 46.0% (201 of 437) were screened versus 22.2% (1,460 of 6,575) of remaining codes (P < .001). Most common screens for which radiology codes were identified as potentially misvalued were (1) high expenditures (27.5%) and (2) high utilization (25.6%). The modality and body region most likely to be identified in a screen were CT (82.1%) and breast (90.9%), respectively. Among screened radiology codes, work RVUs, practice expense RVUs, and nonfacility total RVUs decreased in 20.3%, 65.9%, and 75.3%, respectively. All screened CT, MRI, brain, and spine codes exhibited decreased total RVUs. CONCLUSION: Policymakers' ongoing search for potentially misvalued medical services has disproportionately impacted noninvasive diagnostic radiology services, risking the introduction of unintended or artificial shifts in physician practice.

Contextualizing the first-round failure of the AHCA: down but not out.

On 8 November 2016 the American electorate voted Donald Trump into the Presidency and a majority of Republicans into both houses of Congress. Since many Republicans ran for elected office on the promise to 'repeal and replace' Obamacare, this election result came with an expectation that campaign rhetoric would result in legislative action on healthcare. The American Health Care Act (AHCA) represented the Republican effort to repeal and replace the Affordable Care Act (ACA). Key elements of the AHCA included modifications of Medicaid expansion, repeal of the individual mandate, replacement of ACA subsidies with tax credits, and a broadening of the opportunity to use healthcare savings accounts. Details of the bill and the political issues which ultimately impeded its passage are discussed here.

Report of the ACR's Economics Committee on Value-Based Payment Models.

A major outcome of the current health care reform process is the move away from unrestricted fee-for-service payment models toward those that are based on the delivery of better patient value and outcomes. The authors' purpose, therefore, is to critically evaluate and define those components of the overall imaging enterprise that deliver meaningful value to both patients and referrers and to determine how these components might be measured and quantified. These metrics might then be used to lobby providers and payers for sustainable payment solutions for radiologists and radiology services. The authors evaluated radiology operations and services using the framework of the imaging value chain, which divides radiology service into a number of discrete value-added activities, which ultimately deliver the primary product, most often the actionable report for diagnostic imaging or an effective outcome for interventional radiology. These value activities include scheduling and imaging appropriateness and stewardship, patient preparation, protocol design, modality operations, reporting, report communication, and clinical follow-up (eg, mammography reminder letters). Two further categories are hospital or health care organization citizenship and examination outcome. Each is discussed in turn, with specific activities highlighted.

Traditional Payment Models in Radiology: Historical Context for Ongoing Reform.

The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on quality and alternative payment model participation. The general structure of payment under MACRA is included in the statute, but the rules and regulations defining its implementation are yet to be formalized. It is imperative that the radiology profession inform policymakers on their role in health care under MACRA. This will require a detailed understanding of prior legislative and nonlegislative actions that helped shape MACRA. To that end, the authors provide a detailed historical context for payment reform, focusing on the payment quality initiatives and alternative payment model demonstrations that helped provide the foundation of future MACRA-driven payment reform.

Alternative Payment Models in Radiology: The Legislative and Regulatory Roadmap for Reform.

The Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on the Merit-Based Incentive Payment System and incentives for alternative payment model participation. It is important that radiologists understand the statutory requirements of MACRA. This includes the nature of the Merit-Based Incentive Payment System composite performance score and its impact on payments. The timeline for MACRA implementation is fairly aggressive and includes a robust effort to define episode groups, which include radiologic services. A number of organizations, including the ACR, are commenting on the structure of MACRA-directed initiatives.

Medicare Policy Initiatives and the Relative Utilization of "Double-Scan" CT.

PURPOSE: Commonly called "double scans" by the media, combined pre- and postcontrast thoracic and abdominal CT examinations have been the focus of recent CMS policy initiatives. The aim of this study was to examine trends in the relative utilization of double-scan CT before and after 2006 legislation mandating relevant Medicare reporting initiatives. METHODS: Medicare Physician Supplier Procedure Summary Master Files from 2001 through 2012 were used to identify claims for thoracic and abdominal CT examinations. Double-scan rates by billing physician specialty and place of service were analyzed over time. Rates of double-scan CT between radiologists and nonradiologists were compared using t tests. RESULTS: From 2001 to 2006, double-scan rates for thoracic and abdominal CT examinations declined by 1.7% and 7.5% for radiologists, respectively (from 6.0% to 5.9% and from 22.6% to 20.9%) but increased by 15.8% and 23.6% for nonradiologists (from 5.7% to 6.6% and from 28.8% to 35.6%). From 2006 through 2012, double-scan rates declined by 42.3% and 35.2% (from 5.9% to 3.4% and from 20.9% to 13.5%) for radiologists but only by 31.8% and 8.1% (from 6.6% to 4.5% and from 35.6% to 32.7%) for nonradiologists. Double-scan rates were significantly lower for radiologists than nonradiologists for all years for abdominal CT (P < .001) and for all years after 2006 legislation for thoracic CT (P < .05). CONCLUSIONS: Reductions in thoracic and abdominal CT double-scan rates followed legislation mandating CMS initiatives designed to reduce costs and radiation. For nonradiologists, double-scan rates were consistently higher and declined more slowly than those for radiologists. Medicare policy initiatives directed toward imaging utilization seem to influence behavior differently for radiologists compared with nonradiologists.