Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties

BACKGROUND. The federal No Surprises Act (NSA), designed to eliminate surprise medical billing for out-of-network (OON) care for circumstances beyond patients' control, established the independent dispute resolution (IDR) process to settle clinician-payer payment disputes for OON care. OBJECTIVE. The purpose of our study was to assess the fraction of OON claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the NSA IDR process, as a measure of the process's financial viability. METHODS. This retrospective study extracted claims from a national commercial database (Optum's deidentified Clinformatics Data Mart) for hospital-based specialties occurring on the same day as in-network emergency department (ED) visits or inpatient stays from January 2017 to December 2021. OON claims were identified. OON claims batching was simulated using IDR rules. Maximum potential recovered payments from the IDR process were estimated as the difference between the charges and the allowed amount. The percentages of claims for which the maximum potential payment and one-quarter of this amount (a more realistic payment recovery estimate) would exceed IDR fees were determined, using US$150 and US$450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission. RESULTS. Among 76,221,264 claims for hospital-based specialties associated with in-network ED visits or inpatient stays, 1,482,973 (1.9%) were OON. The maximum potential payment exceeded fee thresholds of US$150 and US$450 for 55.0% and 32.1%, respectively, of batched OON claims for radiologists and 76.8% and 61.3% of batched OON claims for all other hospital-based specialties combined. At payment of one-quarter of that amount, these values were 26.9% and 10.6%, respectively, for radiologists and 56.6% and 38.4% for all other hospital-based specialties combined. CONCLUSION. The IDR process would be financially unviable for a substantial fraction of OON claims for hospital-based specialists (more so for radiology than for other such specialties). CLINICAL IMPACT. Although the NSA enacted important patient protections, IDR fees limit clinicians' opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations. Therefore, IDR rulemaking may negatively impact patient access to in-network care.

"Green Fingerprint" Project: Evaluation of the Power Consumption of Reporting Stations in a Radiology Department

RATIONALE AND OBJECTIVES

To quantify the power or energy consumption of reporting stations in a radiology department and to consider a hypothetical scenario to reduce energy waste.

METHODS

We measured the energy consumption of 36 radiology reporting stations over a mean time frame of about 194 days and then extrapolated results to 1 year. Reporting stations were configured (by default) to enter a stand-by mode after 4 hours of inactivity. A hypothetical scenario was calculated in which stand-by was skipped and the reporting stations were shut down after 1 hour of inactivity.

RESULTS

Data from four stations was corrupted. The overall power consumption of the 32 remaining reporting stations was 53,170 kWh/a, equivalent to 12 family households (4500 kWh/a per household in Switzerland in 2014) or 97.2 barrels of oil. We identified three main power consumption patterns of the reporting stations: mainly off, mainly on, and always off. The on-mode consumption per year was 40,763 kWh/a, the stand-by consumption was 10,010 kWh/a, and the off-mode consumption was 2397 kWh/a. The reporting stations spent half of their on-mode time awaiting the initiation of stand-by, resulting in a wait-time consumption of 18,243 kWh/a. With the hypothetical scenario, we achieved an energy consumption saving of 23,692 kWh/a, a reduction of about 45% of the initial energy consumption, equivalent to 5 households or 40.8 barrels of oil consumed.

CONCLUSION

The power consumption of the reporting stations is not negligible. Reducing energy waste in the radiology department can be established through simple changes in device configuration which will simultaneously promote energywise habits.

ADVANCES IN KNOWLEDGE

Minor changes to the settings of the reporting stations in a radiology department can result in significant long-term energy savings and promote energy-wise habits.

Developing an Education Budget for Radiology Vice Chairs and Leaders: An ADVICER Template

RATIONALE AND OBJECTIVES

The Alliance of Directors and Vice Chairs in Education group identified the need to develop an education budget template as resource for our community. Having a framework and working knowledge of budgetary considerations is crucial to those with general oversight and executive managerial responsibility for departmental educational programs.

METHODS

An online survey was sent to all the Alliance of Directors and Vice Chairs in Education members. Survey questions included education funding sources, presence of vice chair of finance, expectation of revenue generation, existing education budget, funding decision-makers, education budget formulation and approval, vice chair of education's role in budget, education budget line items, and income statement review.

RESULTS

The survey response rate was 41/81 (51%). A majority 26/41 (63%) of respondents had an education budget that typically included funding for all medical students, residents, and fellows but only a minority of respondents report they developed 10/22 (45%), approved 6/22 (27%), or regularly reviewed 6/21 (29%) this budget. In sharp contrast was the role of department chairs and administrators, who presumably all participated in this process. To assist in education budget development and review, as well as meet the need to improve participants' financial accounting knowledge as a key tenet of faculty professional development, the authors developed sample budget templates and an income statement primer.

CONCLUSION

Our survey results suggested the need for an educational budget framework and financial accounting resources for those in radiology education posts, and resources have been provided.

Clinical decision support: practical implementation at two pediatric hospitals

Clinical decision support has been identified by the United States government as a method to decrease inappropriate imaging exams and promote judicious use of imaging resources. The adoption of this method will be incentivized by requiring appropriate use criteria to qualify for Medicare reimbursement starting in January 2020. While Medicare reimbursement is unlikely to directly impact pediatric imaging because of largely disparate patient populations, insurance providers typically use Medicare to benchmark their reimbursement guidelines. Therefore soon after their adoption these guidelines could become relevant to pediatric imaging. In this article we discuss how pediatric imaging was initially underrepresented in the clinical decision support realm, and how this was addressed by a subcommittee involving both American College of Radiology and Society for Pediatric Radiology members. We also present the experience of implementing clinical decision support software at two standalone pediatric hospitals and summarize the lessons learned from these deployments.

Comparison of Advanced Imaging Resources, Radiology Workforce, and Payment Methodologies between the United States and Canada

The purpose of this Practice Perspectives was to review the United States and Canadian approaches to health care access and payment for advanced imaging. The historical background, governmental role, workforce, coding, payment, radiologic challenges, cost, resource intensity, and overall outcomes in longevity are reviewed.

Accounting Basics, Part 2: Justify Capital Spending

Making and justifying capital expenditures can be a difficult part of a supervisory or managerial position. Understanding some basic tools for making estimates and calculating values can help simplify this process. Breaking down some of the most common accounting methods into a six-step, intuitive process allows everyone, even those with little or no accounting background, to use and understand the results of these tools. Accounting tools can seem complex when they are first used, but after walking through them step-by-step and practicing them, they can become an essential tool in working with executives and other administrators.

Defining the diagnostic divide: an analysis of registered radiological equipment resources in a low-income African country

INTRODUCTION

Diagnostic radiology is recognised as a key component of modern healthcare. However there is marked inequality in global access to imaging. Rural populations of low- and middle-income countries (LMICs) have the greatest need. Carefully coordinated healthcare planning is required to meet the ever increasing global demand for imaging and to ensure equitable access to services. However, meaningful planning requires robust data. Currently, there are no comprehensive published data on radiological equipment resources in low-income countries. The aim of this study was to conduct the first detailed analysis of registered diagnostic radiology equipment resources in a low-income African country and compare findings with recently published South African data.

METHODS

The study was conducted in Tanzania in September 2014, in collaboration with the Tanzanian Atomic Energy Commission (TAEC), which maintains a comprehensive database of the country's registered diagnostic imaging equipment. All TAEC equipment data were quantified as units per million people by imaging modality, geographical zone and healthcare sector.

RESULTS

There are 5.7 general radiography units per million people in the public sector with a relatively homogeneous geographical distribution. When compared with the South African public sector, Tanzanian resources are 3-, 21- and 6-times lower in general radiography, computed tomography and magnetic resonance imaging, respectively.

CONCLUSION

The homogeneous Tanzanian distribution of basic public-sector radiological services reflects central government's commitment to equitable distribution of essential resources. However, the 5.7 general radiography units per million people is lower than the 20 units per million people recommended by the World Health Organization.

Versatile, Reusable, and Inexpensive Ultrasound Phantom Procedural Trainers

We have constructed simple and inexpensive models for ultrasound-guided procedural training using synthetic ballistic gelatin. These models are durable, leak resistant, and able to be shaped to fit a variety of simulation scenarios to teach procedures. They provide realistic tactile and sonographic training for our learners in a safe, idealized setting.

Opportunities for Patient-centered Outcomes Research in Radiology

Recently created in 2010, the Patient-Centered Outcomes Research Institute (PCORI) supports patient-centered comparative effectiveness research with a focus on prioritizing high-impact studies and improving trial design methodology. The Association of University Radiologists Radiology Research Alliance Task Force on patient-centered outcomes research in Radiology aims to review recently funded imaging-centric projects that adhere to the methodologies established by PCORI. We provide an overview of the successful application of PCORI standards to radiology topics, highlight how these methodologies differ from other forms of radiology research, and identify opportunities for new projects as well as potential barriers for involvement. Our hope is that review of specific case examples in radiology will clarify the use and value of PCORI methods mandated and supported nationally by the Affordable Care Act.

Value of Imaging Part I: Perspectives for the Academic Radiologist

With payers and policymakers increasingly scrutinizing the value of medical imaging, opportunities abound for radiologists and radiology health services researchers to meaningfully and rigorously demonstrate value. Part one of this two-part series on the value of imaging explores the concept of value in health care from the perspective of multiple stakeholders and discusses the opportunities and challenges for radiologists and health service researchers to demonstrate value. The current absence of meaningful national value metrics also presents an opportunity for radiologists to take the lead on the discussions of these metrics that may serve as the basis for future value-based payments. As both practitioners and investigators, radiologists should consider the perspectives of multiple stakeholders in all they do-interdisciplinary support and cooperation are essential to the success of value-focused imaging research and initiatives that improve patient outcomes. Radiology departments that align their cultures, infrastructures, and incentives to support these initiatives will greatly increase their chances of being successful in these endeavors.

[Controlling in outpatient radiology]

Radiology is among the medical disciplines which require the highest investment costs in the healthcare system. The need to design efficient workflows to ensure maximum utilization of the equipment has long been known. In order to be able to establish a sound financial plan prior to a project or equipment purchase, the costs of an examination have to be broken down by modality and compared with the reimbursement rates. Obviously, the same holds true for operative decisions when scarce human resources have to be allocated. It is the task of controlling to review the economic viability of the different modalities and ideally, the results are incorporated into the management decision-making processes. The main section of this article looks at the recognition and allocation of direct and indirect costs in a medical center (Medizinisches Versorgungszentrum - MVZ) in the German North Rhine region. The profit contribution of each examination is determined by deducting the costs from the income generated by the treatment of patients with either private or statutory health insurance.

Impact of an Inexpensive Anatomy-Based Fetal Pig Simulator on Obstetric Ultrasound Training

OBJECTIVES

The purpose of this study was to construct an inexpensive anatomy-based obstetric ultrasound task trainer and investigate whether introduction of this trainer into a hands-on obstetric ultrasound course improved course participants' ultrasound scanning skills.

METHODS

The trainer was created by placing fetal pigs into preservative-filled heat-sealed polyethylene bags. Twenty-four participants in an obstetric ultrasound course at Wake Forest School of Medicine were randomized to receive hands-on scanning with pregnant women or hands-on scanning and fetal pig simulation. Biometric scans were performed before and after the course. The time to complete the scans, margin of error of biometric measurements, and number of technically adequate images per scan were compared between groups.

RESULTS

Twelve participants were randomized into each group. Although a direct comparison of postcourse biometric scans demonstrated no difference between groups, participants that received simulation training showed significant improvements in the time to complete the biometric scan (P < .05) and number of technically adequate images obtained (P < .05), whereas those who did not receive simulation training did not show significant improvements.

CONCLUSIONS

Addition of the fetal pig ultrasound task trainer resulted in improvements in the course participants' scanning efficiency even after very limited exposure. Incorporating the task trainer earlier and more broadly into obstetric ultrasound training may benefit trainees.

Using mobile electronic devices to deliver educational resources in developing countries

BACKGROUND

Developing countries have far fewer trained radiography professionals than developed countries, which exacerbates the limited access to imaging services. The lack of trained radiographers reflects, in part, limited availability of radiographer-specific educational resources. Historically, organizations that provided such resources in the developing world faced challenges related to the limited stock of current materials as well as expenses associated with shipping and delivery.

METHODS

Four mobile electronic devices (MEDs) were loaded with educational content (e-books, PDFs, and digital applications) spanning major radiography topics. The MEDs were distributed to 4 imaging departments in Ghana, India, Nepal, and Nigeria based on evidence of need for radiography-specific resources, as revealed by survey responses. A cost comparison of postal delivery vs digital delivery of educational content was performed. The effectiveness of delivering additional content via Wi-Fi transmission also was evaluated. Feedback was solicited on users' experience with the MEDs as a delivery tool for educational content.

RESULTS

An initial average per e-book expense of $30.05, which included the cost of the device, was calculated for the MED delivery method compared with $15.56 for postal delivery of printed materials. The cost of the MED delivery method was reduced to an average of $10.05 for subsequent e-book deliveries. Additional content was successfully delivered via Wi-Fi transmission to all recipients during the 3-month follow-up period. Overall user feedback on the experience was positive, and ideas for enhancing the MED-based method were identified.

CONCLUSION

Using MEDs to deliver radiography-specific educational content appears to be more cost effective than postal delivery of printed materials on a long-term basis. MEDs are more efficient for providing updates to educational materials. Customization of content to department needs, and using projector devices could enhance the usefulness of MEDs for radiographer training.

"EcoRadiology"--pulling the plug on wasted energy in the radiology department

RATIONALE AND OBJECTIVES

We sought to evaluate the power consumption of various devices around the radiology department, audit our use of recycling, and review efforts by vendors to reduce the environmental impact of their products.

MATERIALS AND METHODS

Using a readily available power monitor, we calculated the power consumption of different devices around our department. In particular, we calculated the financial and environmental cost of leaving equipment on overnight and/or at weekends. When it was not possible to measure energy usage directly, we obtained and reviewed relevant technical manuals. We contacted vendors directly to document how the environmental impact of new technology and decommissioning aging technology is being tackled.

RESULTS

We found that 29 of 43 desktop computers and 25 of 27 picture archiving and communications system (PACS) reporting stations were left on needlessly overnight and/or at weekends, resulting in estimated electrical running costs while not in use of approximately $7253 per year, and CO2 emissions equivalent to the annual emissions of over 10 passenger cars. We discovered that none of our PACS reporting stations supported energy-saving modes such as "sleep" or "hibernate." Despite encouraging staff to turn off computers when not in use, a reaudit found no improvement in results.

CONCLUSIONS

Simple steps such as turning off computers and air-conditioning units can produce very significant financial and environmental savings. Radiology can lead the way in making hospitals more energy efficient.

Defining Population Health and Implications for Radiology

Most definitions of population health include improved patient health, reduced inpatient stays and proce- dures, holistic care of the entire population of a country, and a general approach to improve the quality of healthcare. However, there seems to be no mention of payment for services and resources for reimbursement. The term population health can be considered a philosophy of a new model of healthcare based upon future expectations from current laws and studies from the federal government, most notably through the ACA, and healthcare organizations. Radiology departments may perform fewer procedures in the future and receive less money for these complet- ed procedures. Management will need to adjust budgets and staffing to reflect changes. Radiology departments will need to continue the current trend of doing more with less.

Neurointerventional research between 2003 and 2012: slow growth, high interdisciplinary collaboration, and a low level of funding

BACKGROUND AND PURPOSE

Neurointerventional therapy of cerebrovascular disease is a greatly expanding field across many specialty disciplines. The goal of this study was to analyze the characteristics and trends of scientific publications that focused on neurointervention during the past decade.

MATERIALS AND METHODS

A bibliometric evaluation of neurointerventional research published between 2003 and 2012 was conducted by using the PubMed data base. Analyzed parameters included the year of publication, type of document, language of the article, topic, declared funding, country of origin, type of collaboration between disciplines, the first author's specialty, and subject category and the Impact Factor of the publishing journal.

RESULTS

Between 2003 and 2012, a total of 2123 articles were published, of which 1107 (52.1%) were original articles, 1948 (91.8%) were written in English, 192 (9.0%) received funding, 661 (31.1%) were published by the United States, and 1060 (49.9%) resulted from interdisciplinary collaboration. Neurosurgery departments produced the most articles (n = 910, 42.9%), followed by radiology (n = 747, 35.2%) and neurology (n = 270, 12.7%). The time-trend analysis in the number of publications demonstrated slow growth from 2003 to 2012, with an average annual growth rate of +6.0%.

CONCLUSIONS

The fields of neurosurgery, radiology, and neurology have contributed substantially to neurointervention research. Slow growth, high interdisciplinary collaboration, and a low level of funding are peculiar characteristics of research in this field.

The physician payments sunshine act: what the average radiologist and manager need to know

The Physician Payments Sunshine Act (PPSA) was enacted in 2010 and requires applicable manufacturers of medical devices, drugs, biological material, or medical supplies to report payments or transfers of value that are provided to physicians or teaching hospitals. PPSA has value in creating greater transparency in the financial relationships between industry, physicians, and teaching hospitals, and in potentially reducing problematic conflicts of interest. PPSA requires that this data be published, in searchable form, on a public website. CMS has delayed the reporting under PPSA until after January 1, 2013, and has yet to issue its final rules for PPSA; however, Physician Payments data already exist in a publically searchable database. It is important to realize that names of individuals may appear in the PPSA public database, even if those individuals did not actually receive a transfer of value. As with all broad-stroke legislation, consequences not anticipated or not considered sufficiently important for our government leaders may well present a problem for individuals. It behooves all physicians and healthcare managers to carefully follow the CMS PPSA regulations. In advance of meeting or interacting with any PPSA-applicable manufacturer, obtain a clear and mutual understanding regarding what reportable value, if any, will be prepared for and provided by the applicable manufacturer. In this, as in all situations in which government regulations are at play, "knowledge is strength."

Medicare reimbursement: what R.T.s should know

Amid continued attention toward cutting the cost of Medicare, medical imaging continues to be an area that legislators focus on for reducing expenditures, which ultimately affects the amount of money available in health care facilities to provide services and pay personnel. These issues support the need for medical imaging and radiation therapy professionals to understand how the Medicare program works, the provisions health care facilities must meet to obtain payment for services provided to Medicare beneficiaries, and how recent changes in Medicare reimbursement rates affect a medical imaging or radiation therapy department's bottom line.

Clinical decision support for imaging in the era of the Patient Protection and Affordable Care Act

Imaging clinical decision support (CDS) systems provide evidence for or against imaging procedures ordered within a computerized physician order entry system at the time of the image order. Depending on the pertinent clinical history provided by the ordering clinician, CDS systems can optimize imaging by educating providers on appropriate image order entry and by alerting providers to the results of prior, potentially relevant imaging procedures, thereby reducing redundant imaging. The American Recovery and Reinvestment Act (ARRA) has expedited the adoption of computerized physician order entry and CDS systems in health care through the creation of financial incentives and penalties to promote the "meaningful use" of health IT. Meaningful use represents the latest logical next step in a long chain of legislation promoting the areas of appropriate imaging utilization, accurate reporting, and IT. It is uncertain if large-scale implementation of imaging CDS will lead to improved health care quality, as seen in smaller settings, or to improved patient outcomes. However, imaging CDS enables the correlation of existing imaging evidence with outcome measures, including morbidity, mortality, and short-term imaging-relevant management outcomes (eg, biopsy, chemotherapy). The purposes of this article are to review the legislative sequence relevant to imaging CDS and to give guidance to radiology practices focused on quality and financial performance improvement during this time of accelerating regulatory change.

Accountable care organizations for neuroradiologists: threats and opportunities

Accountable care organizations (ACOs) are one of the more interesting and (perhaps) highest impact components of the 2010 Federal health care bill. Neuroradiologists should examine them carefully for opportunities to participate and contribute to ACOs as well as to understand the potential threats. Although there are questions about the viability of the proposed models, neuroradiologists should not assume this is a fad. All specialists should pay close attention to the evolution of ACOs. It seems likely that many of their features will come to pass during the coming decades with substantial impact on the profession.

A model to correct for short-run inefficiencies in economic evaluations in healthcare

Important assumptions that underlie cost-effectiveness analysis (CEA) are that production technologies are convex and that production processes always perform at constant returns to scale. However, in the short run these assumptions are likely to be violated. Therefore, CEAs might overestimate cost-effectiveness in the short run. To come up with a more precise cost-effectiveness outcome, we present a model that is able to correct the long-run incremental net benefit (INB) for short-run inefficiencies. This provides decision makers with a more realistic view of the expected efficiency gains. This model starts by determining the initial efficiency losses inflicted by inflexible resources. Then the model is made dynamic in order to adjust the efficiency losses by allowing for refilling and writing off freed capacity. Finally, the model calculates the length of the short-run time frame in which such efficiency losses exist, and a correction term with which the usual long-run INB should be adjusted to account for short-run inefficiencies. The model is applied to two cases: dialysis and digitizing a radiography department. The dialysis case shows moderate short-run efficiency losses while in the radiography case short-run efficiency losses are sufficiently large to cause a switch in cost-effectiveness from favorable to inefficient in the short run.

Is the h-index predictive of greater NIH funding success among academic radiologists?

RATIONALE AND OBJECTIVES

Despite rapid adoption of the Hirsch index (h-index) as a measure of academic success, the correlations between the h-index and other metrics of productivity remain poorly understood. The aims of this study were to determine whether h-indices were associated with greater National Institutes of Health (NIH) funding success among academic radiologists.

MATERIALS AND METHODS

Using the Scopus database, h-indices were calculated for a random sample of academic radiologists with the rank of professor. Using the NIH tool Research Portfolio Online Reporting Tools Expenditures and Reports, we determined the number, classification, and total years of NIH grant funding as principal investigator for each radiologist. Differences in h-index, sorted by funding status, were determined using Wilcoxon's tests. Associations between h-index and funding status were determined using logistic regression. Significant correlations between h-index and grant metrics were determined using Spearman's ρ.

RESULTS

Among 210 professors of radiology, 48 (23%) secured at least one NIH grant. The mean h-index was significantly higher among individuals who secured at least one NIH grant (19.1) compared to those who did not (10.4) (P < .0001). Professors with h-indices < 10 compared to those with h-indices > 10 were significantly less likely to receive NIH funding (odds ratio, 0.07; P = .0321). However, h-indices > 10 were not significantly predictive of greater funding. No significant relationships were observed between h-index and the number of grant awards, years of prior funding, the amounts of grant awards, or grant classification.

CONCLUSION

Having obtained at least one NIH grant was associated with a higher h-index, yet multiple or large grants, such as those for program projects, were not predictive of higher h-indices.

Summary of the affordable care act

The voluminous bill known as the PPACA of 2010 enabled substantial changes to our health care delivery system, some of which remain to be enacted for several years to come. While the overarching goal is to align incentives and improve quality and access, implementing PPACA initiatives in a highly complex environment is fraught with economic and political implications. The purpose of this and future AJNR Health Care Vignettes is to provide relevant updated information as it becomes available.