Financial Impact of Imaging Examination Site of Service in the Medicare Population.

PURPOSE: The financial sustainability of the US healthcare system is a growing concern in an environment of declining reimbursement and rising costs. Variable Centers for Medicare and Medicaid (CMS) reimbursement and denial rates for specific imaging examinations exist across sites of service, adding complexity to financial planning for healthcare organizations. Understanding the financial implications of site of service in existing CMS reimbursement for imaging may be of strategic importance for organizations going forward. MATERIALS AND METHODS: Current Procedural Terminology (CPT) codes were obtained for common cross-sectional imaging examinations using the 2022 CMS Medicare Physician Fee Schedule. Using reimbursement rates with historical volumes and denial rates, a simulation was created to estimate the overall reimbursement of paired hospital outpatient departments (HOPD) and free-standing office (FSO) sites. A baseline simulation was performed with random allocation of imaging examinations between sites of service, and an optimized simulation was performed to estimate the maximum financial impact of targeted allocation between sites. These simulations were performed for paired CT and MR scanners separately. RESULTS: For CT, the baseline simulation estimated annual average reimbursement for combined HOPD and FSO was $3.25M. Reimbursement increased to $3.51M after optimized reallocation of studies between sites of service, resulting in an expected gain of $260,162 for a set of paired HOPD and FSO scanners. For MR, the same approach resulted in baseline reimbursement of $2.51M, increasing to $2.60M upon reallocation between sites for an expected gain of $87,532. Assuming a stable cost of service delivery, this approach would result in improved margins of 8% for CT and 3.5% for MR. There were 28 CT and 19 MRI daily patient imaging appointments at each respective HOPD and FSO scanners, unchanged between baseline and optimized cases. Differences in reimbursement rates between sites were the dominant driver of increased margins at low denial rates, although denial rates became dominant at values greater than 50%. CONCLUSION: Given CMS payment and denial rate variability, optimally allocating imaging studies between sites of service may improve reimbursement for the same services delivered. Although financial incentives exist for site allocation, such decisions should require physician input to assess safety and appropriate level of care. This work contributes to an understanding of financial incentives of existing reimbursement policy and may guide future policy design towards high value care.

Budget Neutrality and Medicare Physician Fee Schedule Reimbursement Trends for Radiologists, 2005 to 2021.

PURPOSE: The Medicare program, by law, must remain budget neutral. Increases in volume or relative value units (RVUs) for individual services necessitate declines in either the conversion factor or assigned RVUs for other services for budget neutrality. This study aimed to assess the contribution of budget neutrality on reimbursement trends per Medicare fee-for-service beneficiary for services provided by radiologists. METHODS: The study used aggregated 100% of Medicare Part B claims from 2005 to 2021. We computed the percentage change in reimbursement per beneficiary, actual and inflation adjusted, to radiologists. These trends were then adjusted by separately holding constant RVUs per beneficiary and the conversion factor to demonstrate the impact of budget neutrality. RESULTS: Unadjusted reimbursement to radiologists per beneficiary increased 4.2% between 2005 and 2021, but when adjusted for inflation, it declined 24.9%. Over this period, the conversion factor declined 7.9%. Without this decline, the reimbursement per beneficiary would have been 9 percentage points higher in 2021 compared with actual. RVUs per beneficiary performed by radiologists increased 13.1%. Keeping RVUs per beneficiary at 2005 levels, reimbursement per beneficiary would have been 12.1 percentage points lower than observed in 2021. CONCLUSIONS: Given budget neutrality, a substantial decline has occurred in inflation-adjusted reimbursement to radiologists per Medicare beneficiary. Decreases due to both inflation and the decline in conversion factor are only partially offset by increased RVUs per beneficiary, meaning more services per patient with less overall pay, an equation likely to heighten access challenges for Medicare beneficiaries and shortages of radiologists.

Imaging Utilization Patterns in the Follow-Up of Extremity Soft Tissue Sarcomas in the United States.

This study aimed to describe patterns of imaging utilization after resection of extremity soft tissue sarcoma in the United States, assess for potential disparities, and evaluate temporal trends. A retrospective cohort study using a national database of private payer claims data was performed to determine the utilization rate of extremity and chest imaging in a 5-year postoperative follow-up period for patients with extremity soft tissue sarcoma treated between 2007 and 2019. Imaging utilization was assessed according to patient demographics (age, sex, race and ethnicity, and region of residency), calendar year of surgery, and postoperative year. Associations of demographic variables with imaging use were assessed using chi-square tests, trends in imaging use were analyzed using the Cochran-Armitage trend test or linear regression, and associations of postoperative year with imaging use were evaluated with the Pearson Correlation coefficient. A total of 3707 patients were included. Most patients received at least 1 chest (74%) and extremity (53%) imaging examination during their follow-up period. The presence of surveillance imaging was significantly associated with age (P < 0.0001) and region (P = 0.0029). Over the study period, there was an increase in use of extremity MRI (P < 0.05) and ultrasound (P < 0.01) and chest CT (P < 0.0001) and a decrease in use of chest radiographs (P < 0.0001). Imaging use declined over postoperative years (decrease by 85%-92% from year 1-5). In conclusion, the use of surveillance imaging varied according to patient demographics and has increased for extremity MRI and ultrasound and chest CT over the study period.

Drivers of Ischemic Stroke Hospital Cost Trends Among Older Adults in the United States.

PURPOSE: The increased use of neuroimaging and innovations in ischemic stroke (IS) treatment have improved outcomes, but the impact on median hospital costs is not well understood. METHODS: A retrospective study was conducted using Medicare 5% claims data for 75,525 consecutive index IS hospitalizations for patients aged ≥65 years from 2012 to 2019 (values in 2019 dollars). IS episode cost was calculated in each year for trend analysis and stratified by cost components, including neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, and MR angiography [MRA]), treatment (endovascular thrombectomy [EVT] and/or intravenous thrombolysis), and patient sociodemographic factors. Logistic regression was performed to analyze the drivers of high-cost episodes and median regression to assess drivers of median costs. RESULTS: The median IS episode cost increased by 4.9% from $9,509 in 2012 to $9,973 in 2019 (P = .0021). Treatment with EVT resulted in the greatest odds of having a high-cost (>$20,000) hospitalization (odds ratio [OR], 71.86; 95% confidence interval [CI], 54.62-94.55), as did intravenous thrombolysis treatment (OR, 3.19; 95% CI, 2.90-3.52). Controlling for other factors, neuroimaging with CTA (OR, 1.72; 95% CI, 1.58-1.87), CTP (OR, 1.32; 95% CI, 1.14-1.52), and/or MRA (OR, 1.26; 95% CI, 1.15-1.38) had greater odds of having high-cost episodes than those without CTA, CTP, and MRA. Length of stay > 4 days (OR, 4.34; 95% CI, 3.99-4.72) and in-hospital mortality (OR, 1.85; 95% CI, 1.63-2.10) were also associated with high-cost episodes. CONCLUSIONS: From 2012 to 2019, the median IS episode cost increased by 4.9%, with EVT as the main cost driver. However, the increasing treatment cost trends have been partially offset by decreases in median length of stay and in-hospital mortality.

Association and Trends in Medicare Denials and Utilization for Brain CT: Indirect Impacts by Targeted Policy Intervention?

Twenty-five years of annual Medicare Physician/Supplier Procedure Summary (PSPS) Master File data were used to assess trends in normalized volume and claim denial rates for brain computerized tomography. Alongside growth in utilization of brain computerized tomography (services, denial rates, fell from 1999-2005 and with relatively leveled growth and less denial rate volatility thereafter. More recent trends in denial rates may be related to policy interventions initially aimed at cost and volume reduction.

Updated Trends, Disparities, and Clinical Impact of Neuroimaging Utilization in Ischemic Stroke in the Medicare Population: 2012 to 2019.

OBJECTIVE: The purpose of this study was to update trends, investigate sociodemographic disparities, and evaluate the impact on mortality of stroke neuroimaging across the United States from 2012 to 2019. METHODS: Retrospective cohort study using CMS Medicare 5% Research Identifiable Files, representing consecutive ischemic stroke emergency department or hospitalized patients aged ≥65 years. A total of 85,547 stroke episodes with demographic and clinical information were analyzed using Cochran-Mantel-Haenszel tests and logistic regression. Outcome measures were neuroimaging (CT angiography [CTA], CT perfusion [CTP], MRI, MR angiography [MRA]) utilization, acute treatment (endovascular thrombectomy [EVT] and intravenous thrombolysis [IVT]), and mortality while in the hospital and at 30 days and 1 year post discharge. RESULTS: Significantly increasing utilization trends for CTA (250%), CTP (428%) and MRI (18%), and a decreasing trend for MRA (-33%) were observed from 2012 to 2019 (P < .0001). Controlling for covariates in the logistic regression models, CTA and CTP were significantly associated with higher EVT and IVT utilization. Although CTA, MRI, and MRA were associated with lower mortality, CTP was associated with higher mortality post discharge. Less neuroimaging was performed in rural patients; older patients (≥80 years) had lower utilization of CTA, MRI, and MRA; female patients had lower rates of CTA; and Black patients had lower utilization of CTA and CTP. CONCLUSIONS: CTA and CTP utilization increased in the Medicare ischemic stroke population from 2012 to 2019 and both were associated with greater EVT and IVT use. However, disparities exist in neuroimaging utilization across all demographic groups, and further understanding of the root causes of these disparities will be crucial to achieving equity in stroke care.

Evolving Radiology Trainee Neuroimaging Workloads: A National Medicare Claims-based Analysis.

RATIONALE AND OBJECTIVES: While radiology training programs aim to prepare trainees for clinical practice, the relationship between trainee, and national radiology workforce demands is unclear. This study assesses changing radiology trainee neuroimaging workloads nationwide for neuroimaging studies. MATERIALS AND METHODS: Using aggregate Medicare claims files from 2002 to 2018, we identified all computed tomography (CT) and magnetic resonance (MR) examinations of the brain, head and neck, and spine (hereafter "neuroimaging") in Medicare fee-for-service beneficiaries nationwide. Using separate Medicare files, we calculated population utilization rates, and work relative value unit (wRVU) weights of all diagnostic neuroradiology services. Using claims modifiers, we identified services rendered by radiology trainees. Using separate national trainee enrollment files, we calculated mean annual per trainee wRVUs. RESULTS: Between 2002 and 2018, total Medicare neuroimaging claims increased for both radiologists overall (86.1%) and trainees (162.5%), including increases in both CT (102.9% vs 196.8%), and MR (59.9% vs 106.6%). The national percentage of all radiologist neuroimaging wRVUs rendered by trainees increased 46.1% (3.8% of all wRVUs nationally in 2002 to 5.6% in 2018). National trainee increases were present across all neuroimaging services but greatest for head and neck CT (+86.5%). Mean annual per radiology trainee neuroimaging Medicare wRVUs increased +174.9% (42.1 per trainee in 2002 to 115.70 in 2018). Mean per trainee wRVU increases were greatest for spine CT (+394.2%) but present across all neuroimaging services. CONCLUSION: As neuroimaging utilization in Medicare beneficiaries has grown, radiology trainee neuroimaging workloads have increased disproportionately.

Radiologist Characteristics Associated with Interpretive Performance of Screening Mammography: A National Mammography Database (NMD) Study.

Background Factors affecting radiologists' performance in screening mammography interpretation remain poorly understood. Purpose To identify radiologists characteristics that affect screening mammography interpretation performance. Materials and Methods This retrospective study included 1223 radiologists in the National Mammography Database (NMD) from 2008 to 2019 who could be linked to Centers for Medicare & Medicaid Services (CMS) datasets. NMD screening performance metrics were extracted. Acceptable ranges were defined as follows: recall rate (RR) between 5% and 12%; cancer detection rate (CDR) of at least 2.5 per 1000 screening examinations; positive predictive value of recall (PPV1) between 3% and 8%; positive predictive value of biopsies recommended (PPV2) between 20% and 40%; positive predictive value of biopsies performed (PPV3) between the 25th and 75th percentile of study sample; invasive CDR of at least the 25th percentile of the study sample; and percentage of ductal carcinoma in situ (DCIS) of at least the 25th percentile of the study sample. Radiologist characteristics extracted from CMS datasets included demographics, subspecialization, and clinical practice patterns. Multivariable stepwise logistic regression models were performed to identify characteristics independently associated with acceptable performance for the seven metrics. The most influential characteristics were defined as those independently associated with the majority of the metrics (at least four). Results Relative to radiologists practicing in the Northeast, those in the Midwest were more likely to achieve acceptable RR, PPV1, PPV2, and CDR (odds ratio [OR], 1.4-2.5); those practicing in the West were more likely to achieve acceptable RR, PPV2, and PPV3 (OR, 1.7-2.1) but less likely to achieve acceptable invasive CDR (OR, 0.6). Relative to general radiologists, breast imagers were more likely to achieve acceptable PPV1, invasive CDR, percentage DCIS, and CDR (OR, 1.4-4.4). Those performing diagnostic mammography were more likely to achieve acceptable PPV1, PPV2, PPV3, invasive CDR, and CDR (OR, 1.9-2.9). Those performing breast US were less likely to achieve acceptable PPV1, PPV2, percentage DCIS, and CDR (OR, 0.5-0.7). Conclusion The geographic location of the radiology practice, subspecialization in breast imaging, and performance of diagnostic mammography are associated with better screening mammography performance; performance of breast US is associated with lower performance. ©RSNA, 2021 Online supplemental material is available for this article.

Developmental hip dysplasia and hip ultrasound frequency in a large American payer database.

Developmental dysplasia of the hip (DDH) is an important contributor to musculoskeletal morbidity, but effective strategies to screen for DDH remain controversial. The current utilization of hip ultrasound (US) screening for DDH in the United States is not defined. This study utilized Optum's de-identified Clinformatics® Data Mart, a large commercial and Medicare Advantage claims database. The frequency of DDH and hip US utilization was estimated using billing data on an average of 2.9 million relevant beneficiaries included annually from 2007 through 2017. A total of 6806 DDH cases were identified with an average annual prevalence of 1.7 per 1000 infants, which was stable during the study period. Girls were more likely to be screened and diagnosed with DDH, comprising 72% of DDH cases with an OR of 2.55 (95% CI 2.42-2.69), p < 0.001. Hip US screening was employed in 0.9% of the infant population on average but increased substantially from 2007 (0.4%) to 2017 (2.2%). Most common billing diagnoses included hip deformity (27.4%), breech delivery (20.4%), and physical exam abnormality (17.7%). The average imaging costs per patient for all screened children was $108.94. Insurance claims reflect the current American practice of selective hip US with relative adherence to American Academy of Pediatrics guidelines based on reported diagnoses. While hip US utilization increased during the study period, prevalence of DDH diagnoses did not increase. Our results suggest that expansion of hip US screening may not effectively increase DDH detection although further investigation is needed to ascertain optimal screening strategies to improve patient outcomes.

Changes in Current Procedural Terminology Coding and Its Effect on Specialty-Level Utilization of Musculoskeletal Ultrasound.

PURPOSE: Concerns regarding increasing utilization of non-vascular extremity ultrasound (US) imaging led to the Current Procedural Terminology (CPT) Editorial Panel separating a singular billing code into distinct comprehensive and focused examination codes with differential reimbursement. We explore this policy change's temporal association with utilization. METHODS: Using Physician/Supplier Procedure Summary Master Files, we identified all nonvascular extremity US services billed for Medicare fee-for-service beneficiaries between 1994 and 2017. These included generic (CPT code 76880 from 1994 to 2010), complete (code 76881 from 2011 to 2017), and limited (code 76882 from 2011 to 2017) examinations. Annual utilization per 100,000 beneficiaries was computed and stratified by billing specialty. Compound annual growth rates were calculated. RESULTS: Radiologists and podiatrists were the top 2 billing specialties for nonvascular extremity US examinations. From 1994 to 2010, radiologist services increased 6.1% annually. Following the 2011 code separation, radiologists' utilization increased 2.7% annually for complete and 12.3% for limited exams. Between 1994 and 2017, radiologists' market share decreased 72.8% to 40.4%. From 1994 to 2010, podiatrist services increased 87.1% annually. Following the code separation, podiatrists' annual utilization growth stabilized 0.4% for complete and 0.6% for limited exams. Podiatrists' market share was 9.1% in 2001, peaked at 31.3% in 2009, and declined to 14.3% in 2017. CONCLUSIONS: Prior rapid growth in extremity nonvascular US for podiatrists slowed considerably following CPT code separation in 2011. Subsequent service growth has largely been related to less costly, focused examinations performed by radiologists. Further study may help better understand how CPT coding changes alter imaging utilization more broadly.

Disparities over Time in Volume, Day of the Week, and Patient Complexity between Paracentesis and Thoracentesis Procedures Performed by Radiologists versus Those Performed by Nonradiologists.

PURPOSE: To compare the disparities between the paracenteses and thoracenteses performed by radiologists with those performed by nonradiologists over time. Variables included the volume of procedures, the days of the week, and the complexity of the patient's condition. MATERIALS AND METHODS: Using carrier claims files for a 5% national sample of Medicare beneficiaries from 2004 to 2016, paracentesis and thoracentesis examinations were retrospectively classified by physician specialty (radiologist vs nonradiologist), day of the week (weekday vs weekend), and the complexity of the patient's condition (using Charlson comorbidity index scores). The Pearson chi-square and independent samples t-test were used for statistical analysis. RESULTS: Between 2004 and 2016, the proportion of all paracentesis and thoracentesis procedures performed by radiologists increased from 70% to 80% and from 47% to 66%, respectively. Although radiologists increasingly performed more of both services on both weekends and weekdays, the share performed by radiologists was lower on weekends. For most of the first 9 years across the study period, radiologists performed paracentesis in patients with more complex conditions than those treated by nonradiologists, but the complexity of patients' conditions was similar during recent years. For thoracentesis, the complexity of patients' conditions was similar for both specialty groups across the study period. CONCLUSIONS: The proportion of paracentesis and thoracentesis procedures performed in Medicare beneficiaries by radiologists continues to increase, with radiologists increasingly performing most of both services on weekends. Nonetheless, radiologists perform disproportionately more on weekdays than on weekends. Presently, radiologists and nonradiologists perform paracentesis and thoracentesis procedures in patients with similarly complex conditions. These interspecialty differences in timing and complexity of the patient's condition differ from those recently described for several diagnostic imaging services, reflecting the unique clinical and referral patterns for invasive versus diagnostic imaging services.

Nationwide Trends in Use of Catheter-Directed Therapy for Treatment of Pulmonary Embolism in Medicare Beneficiaries from 2004 to 2016.

PURPOSE: To evaluate changes in the use of catheter-directed therapy (CDT) for pulmonary embolism (PE) treatment with attention to primary operator specialty in the Medicare population. METHODS: Using a 5% national sample of Medicare claims data from 2004 to 2016, all claims associated with PE were identified. The annual volume of 2 billable CDT services-arterial mechanical thrombectomy and transcatheter arterial infusion for thrombolysis-were determined to evaluate changes in CDT use and primary CDT operator specialty over time. RESULTS: The total number of CDT procedures increased over the course of the study period, representing 0.457 and 5.057 service counts per 100,000 Medicare beneficiaries in 2004 and 2016, respectively. The proportion of PEs treated with CDT increased 10-fold from 2004 to 2016, increasing from 0.1% to 1.0%. Interventional radiologists performed most CDT therapies each year, with the exception of 2010 when vascular surgeons performed more. In 2016, interventional radiologists performed 3.54 CDT services for PE per 100,000 Medicare beneficiaries, which was 70% of total CDT for PE procedures, followed by interventional cardiologists and vascular surgeons performing 0.92 services (18%) and 0.60 services (12%), respectively. CONCLUSIONS: CDT is an increasingly used treatment for PE, with a 10-fold increase from 2004 to 2016. Interventional radiologists are the dominant providers of these services, followed by interventional cardiologists and vascular surgeons.

Transcatheter Dialysis Conduit Procedures: Changing National and State-Level Medicare Use Patterns over 15 Years.

PURPOSE: To evaluate the changing use of transcatheter hemodialysis conduit procedures. METHODS: Multiple Centers for Medicare & Medicaid Services datasets were used to assess hemodialysis conduit angiography. Use was normalized per 100,000 beneficiaries and stratified by specialty and site of service. RESULTS: From 2001 to 2015, hemodialysis angiography use increased from 385 to 1,045 per 100,000 beneficiaries (compound annual growth rate [CAGR], +7.4%)]. Thrombectomy use increased from 114 to 168 (CAGR, +2.8%). Angiography and thrombectomy changed, by specialty, +1.5% and -1.3% for radiologists, +18.4% and +14.4% for surgeons, and +24.0% and +17.7% for nephrologists, respectively. By site, angiography and thrombectomy changed +29.1% and +20.7% for office settings and +0.8% and -2.4% for hospital settings, respectively. Radiologists' angiography and thrombectomy market shares decreased from 81.5% to 37.0% and from 84.2% to 47.3%, respectively. Angiography use showed the greatest growth for nephrologists in the office (from 5 to 265) and the greatest decline for radiologists in the hospital (299 to 205). Across states in 2015, there was marked variation in the use of angiography (0 [Wyoming] to 1173 [Georgia]) and thrombectomy (0 [6 states] to 275 [Rhode Island]). Radiologists' angiography and thrombectomy market shares decreased in 48 and 31 states, respectively, in some instances dramatically (eg, angiography in Nevada from 100.0% to 6.7%). CONCLUSIONS: Dialysis conduit angiography use has grown substantially, more so than thrombectomy. This growth has been accompanied by a drastic market shift from radiologists in hospitals to nephrologists and surgeons in offices. Despite wide geographic variability nationally, radiologist market share has declined in most states.

State-Level Variation in Inferior Vena Cava Filter Utilization Across Medicare and Commercially Insured Populations.

OBJECTIVE. Recent research on inferior vena cava (IVC) filter utilization in the United States has largely focused on national aggregate Medicare datasets, showing recent declines. Whether these national Medicare trends are generalizable across regions and payer populations is unknown. We studied recent state-level variation in IVC filter utilization across both Medicare and private insurance populations. MATERIALS AND METHODS. Using large individual beneficiary claims-level Medicare research identifiable files and a proprietary U.S. research database of the commercially insured population, we identified all billed IVC filter placement procedures performed between 2009 and 2015. We compared population-adjusted utilization rates by state and payer type. RESULTS. Between 2009 and 2015, IVC filter utilization across the United States declined by 36.3% (from 177.9 to 113.3 procedures per 100,000 beneficiaries) in the Medicare population and by 26.6% (from 32.7 to 24.0 procedures per 100,000 beneficiaries) in the privately insured population. For the Medicare population, state-level utilization rates varied 5.2-fold, from 48.4 to 251.3 procedures per 100,000 beneficiaries in Alaska and New Jersey, respectively. For the private insurance population, rates varied 5.5-fold, from 10.8 to 59.5 procedures per 100,000 beneficiaries in Oregon and Michigan, respectively. Nationally, utilization in the Medicare population was 5.0 times higher than that in the private insurance population (range by state, from 2.0 times higher in Hawaii to 11.1 times higher in Utah). Despite the national decline, utilization in Medicare and private insurance populations increased in five and seven states, respectively. State-level IVC filter utilization rates for the Medicare population correlated strongly with those for the privately insured population (r = 0.74; p < 0.001). In both the Medicare and privately insured populations, utilization rates correlated moderately with beneficiary age (r = 0.44 and r = 0.50, respectively; p < 0.001 for both). CONCLUSION. IVC filter utilization rates vary dramatically by state and payer population, and they likely depend in part on the age of the covered population. To better identify demographic and socioeconomic drivers of utilization, future research should prioritize nonaggregate multipayer claims-level approaches.

Increasing Utilization of Chest Imaging in US Emergency Departments From 1994 to 2015.

PURPOSE: The aim of this study was to assess national and state-specific changes in emergency department (ED) chest imaging utilization from 1994 to 2015. METHODS: Using aggregate 100% Medicare Physician/Supplier Procedure Summary Master Files for 1994 to 2015, the annual frequency of chest imaging in Medicare Part B beneficiaries in the ED setting was identified, and utilization was normalized to annual Medicare enrollment as well as annual ED visits. Using individual Medicare beneficiary 5% research-identifiable files, similar determinations were performed for each state. RESULTS: Between 1994 and 2015, per 1,000 beneficiaries, ED utilization of chest radiography and CT increased by 173% (compound annual growth rate [CAGR] 4.9%) and 5,941.8% (CAGR 21.6%). Per 1,000 ED visits, utilization increased by 81% (CAGR 2.9%) and 3,915.4% (CAGR 19.2%), respectively. Across states, utilization was highly variable, with 2015 radiography utilization per 1,000 ED visits ranging from 82 (Wyoming) to 731 (Hawaii) and CT utilization ranging from 18 (Wyoming) to 76 (Hawaii). Between 2004 and 2015, most states demonstrated increases in the utilization of both radiography (maximal increase of CAGR 11.0% in Vermont) and CT (maximal increase of CAGR 21.0% in Maine). Nonetheless, utilization of radiography declined in four states and utilization of CT in a single state. CONCLUSIONS: Over the past two decades, ED utilization of chest imaging has increased. This was related not only to an increasing frequency of ED visits but also to increasing utilization per ED visit. Across states, utilization is highly variable, but with radiography and CT both increasing, the use of CT seems additive to, rather than replacing, radiography.

Invasive Procedural Versus Diagnostic Imaging and Clinical Services Rendered by Radiology Trainees Over Two Decades.

PURPOSE: To characterize evolving radiology trainee exposure to invasive procedures. METHODS: Using Physician/Supplier Procedure Summary Master Files from 1997 to 2016, we identified Medicare services performed by radiology trainees in approved programs by extracting information on services billed by diagnostic and interventional radiologists reported with "GC" modifiers. Services were categorized as (1) invasive procedures, (2) noninvasive diagnostic imaging services, or (3) clinical evaluation and management (E&M) services. Relative category trainee work effort was estimated using service-level work relative value units. RESULTS: Nationally from 1997 to 2016, invasive procedures declined from 34.2% to 14.3% of relative work effort for all Medicare-billed radiology trainee services. Radiology trainees' noninvasive diagnostic imaging services increased from 65.1% to 85.4%. Clinical E&M services remained uniformly low (0.7%-0.3%). Diagnostic radiology (DR) and interventional radiology (IR) faculty supervised 81.0% and 19.0%, respectively, of all trainee invasive procedures in 1997, versus 68.3% and 31.7%, respectively, in 2016. Despite declining relative procedural work, trainees were exposed to a wide range of both basic and complex invasive procedures in both 1997 and 2016. Over this period, trainee noninvasive diagnostic imaging services shifted away from radiography to CT and MRI. CONCLUSION: Radiology trainees' relative invasive procedural work effort has declined over time as their work increasingly focuses on CT and MRI. As DR and IR-DR residency curricula begin to diverge, it is critical that both DR and IR residents receive robust training in basic image-guided procedures to ensure broad patient access to these services.

Use and Cost of Actinic Keratosis Destruction in the Medicare Part B Fee-for-Service Population, 2007 to 2015.

Importance: Actinic keratosis is prevalent and has the potential to progress to keratinocyte carcinoma. Changes in the use and costs of actinic keratosis treatment are not well understood in the aging population. Objective: To evaluate trends in the use and costs of actinic keratosis destruction in Medicare patients. Design, Setting, and Participants: A billing claims analysis was performed of the Medicare Part B Physician/Supplier Procedure Summary Master Files and National Summary Data of premalignant skin lesion destructions performed from 2007 to 2015 among Medicare Part B fee-for-service beneficiaries. Main Outcomes and Measures: Mean number of actinic keratosis lesions destroyed and associated treatment payments in 2015 US dollars estimated per 1000 Medicare Part B fee-for-service beneficiaries. Data analysis was performed from November 2017 to July 2018. Results: More than 35.6 million actinic keratosis lesions were treated in 2015, increasing from 29.7 million in 2007. Treated actinic keratosis lesions per 1000 beneficiaries increased from 917 in 2007 to 1051 in 2015, while mean inflation-adjusted payments per 1000 patients decreased from $11 749 to $10 942 owing to reimbursement cuts. The proportion of actinic keratosis lesions treated by independently billing nurse practitioners and physician assistants increased from 4.0% in 2007 to 13.5% in 2015. Conclusions and Relevance: This study's findings suggest that actinic keratosis imposes continuously increasing levels of treatment burden in the Medicare fee-for-service population. Reimbursement decreases have been used to control rising costs of actinic keratosis treatment. Critical research may be warranted to optimize access to actinic keratosis treatment and value for prevention of keratinocyte carcinoma.

National Trends in Inferior Vena Cava Filter Placement and Retrieval Procedures in the Medicare Population Over Two Decades.

PURPOSE: To assess trends in inferior vena cava (IVC) filter placement and retrieval procedures in Medicare beneficiaries over the last two decades. METHODS: Using Physician/Supplier Procedure Summary Master Files from 1994 through 2015, we calculated utilization rates for IVC filter placement and retrieval procedures in Medicare fee-for-service beneficiaries. Services were stratified by provider specialty group and site of service. RESULTS: IVC filter placement rates increased from 1994 to 2008 (from 65.0 to 202.1 per 100,000 beneficiaries, compound annual growth rate [CAGR] +8.4%) and then decreased to 128.9 by 2015 (CAGR -6.2%). This decrease was observed across all specialty groups and sites of service. From 1994 to 2015, placement procedure market share increased for radiologists (from 45.1% to 62.7%) and cardiologists (from 2.5% to 6.7%) but decreased for surgeons (from 46.6% to 27.9%). Overall, procedures shifted slightly from the inpatient (from 94.5% to 86.5% of all procedures) to outpatient hospital (from 4.9% to 14.9%) settings. Between 2012 and 2015, retrieval rates increased from 12.0 to 17.7 (CAGR +13.9%). Retrievals as a percentage of placement procedures were similar across specialties in 2015 (range 13.0%-13.8%). CONCLUSION: Despite prior dramatic growth, the utilization of IVC filters in Medicare beneficiaries markedly declined over the last decade, likely relating to evolving views regarding efficacy and long-term safety. This decline was accompanied by several filter-related market shifts, including increasing placement by radiologists and cardiologists, increasing outpatient placement procedures, and increasing retrieval rates.