This piece was originally published in the June 2016 issue of ei, the magazine of the electroindustry.
Ernesto A. Cerdena, PHDc, RT, CRA, FAHRA, Director of Diagnostic Imaging/Radiology Services, Waterbury Hospital
In the era of the Affordable Care Act (ACA), sustainable and thriving healthcare operations are paramount. Effective healthcare operations require diagnostic medical imaging to play a major role in controlling cost, improving quality, and achieving superior patient outcomes.
From the cost perspective, literature reviews and observed practices indicate that medical imaging is the most widely used service in healthcare operations. A study involving a retrospective analysis of advanced diagnostic imaging tests from six large integrated health systems revealed annual increases of 7.8 percent for computed tomography (CT), 10 percent for magnetic resonance imaging (MRI), and 3.9 percent for ultrasound scanners during the 15-year period 1996–2010.
This study also revealed that the use of CT scans performed during emergency department visits increased 330 percent between 1996 and 2007. The increase of imaging services was validated by the U.S. Preventive Services Task Force, using the evidence-based preventive care screening guidelines.
The cost of imaging exams is substantial for both beneficiaries and insurance companies. As a result, private insurers have become increasingly dependent on radiology benefit management firms (RBMs) to control the use of expensive tests such as CT and MRI scans. The RBM review process includes assessment of the clinical information and medical necessity to determine the appropriateness of the physician requests and their approval or denial based on contracted individual payor guidelines. While curbing imaging use may control costs, any drop in volume has a negative impact on a hospital’s bottom line. Most of our imaging departments still live in a fee-for-service world.
Shifting from volume to value
The reality of shifting from volume- to value-based healthcare is a difficult predicament for many imaging leaders. An estimated 75 million baby boomers are retiring and will enroll in Medicare in the next few years. Seventy percent of this population, because of physical and cognitive impairment, will require diagnostic medical imaging services. For example, approximately one million elderly people will develop dementia by 2025. The diagnosis and management of this condition will require MRI and other imaging modalities.
The intense focus on the use of imaging studies has also precipitated a governmental focus on quality, in addition to costs. The Centers for Medicare and Medicaid Services and other government agencies and healthcare organizations have teamed up to develop myriad cost-containment and quality-improvement initiatives.
For example, the required implementation of clinical-decision support systems will serve as an important tool to assist ordering physicians in selecting the most appropriate imaging tests, which should ensure that the right exam is always ordered for the right reasons. This enactment will require additional information to be collected on the Medicare claim forms. Once implemented, the software may be useful in achieving best practices and clinical workflow through the continuity of provision of care, but working through the operational challenges will require a great deal of time and resources. It is also important to recognize that the required cultural changes may be as challenging to implement as the system changes.
Compliance Includes Equipment Costs
NEMA XR 29-2013 is already affecting medical imaging operations. As part of the Protecting Access to Medicare Act of 2014 (PAMA), CMS is reducing payment for the technical component of CT scans performed on outpatients by five percent this year and 15 percent in 2017 and beyond. The biggest challenge for imaging leaders is that full compliance may require excessive capital cost for equipment upgrades and replacements. There is still a significant number of hospitals that do not have access to capital funds to replace or upgrade their equipment, so they have opted to absorb the reduction in payment (see figure 1).
Another new government initiative affecting medical imaging operations includes the Consolidated Appropriations Act, which reduces the payment of diagnostic x-rays performed in analog film, effective next year. Perhaps the greatest challenge, both operationally and financially, will be the impending reductions that will hit organizations that fail to convert performing x-ray tests from computerized radiography to direct digital radiography (see figure 2).
The reduction on reimbursement rates and high scrutiny on use and quality assurance to control costs and improve efficiencies will have a significant impact on the leadership who will implement the changes.
Amidst new regulations and a chaotic healthcare environment, medical imaging leaders will need to be forward thinking and shift into a high-value healthcare mindset. This will help bridge the gap between cost and quality issues, particularly in medical imaging.
Dr. Cerdena is the 2015–2016 president of AHRA, the Association for Medical Imaging Management.