5/17/2017 1 QUANTITATIVE IMAGING AND PAYMENT POLICY • DAVID SEIDENWURM, MD • SUTTER MEDICAL GROUP • SUTTER MEDICAL FOUNDATION • SUTTER HEALTH • SACRAMENTO, CA CONFLICT OF INTEREST • RADIOLOGY FEES, MEDICAL DIRECTOR FEES, COMMITTEE CHAIR STIPEND, SMG/SMF • MEDICAL LEGAL EXPERT WITNESS FEES • ACR MRI ACCREDITATION FEES • RASMG BOARD MEMBER FEES • NQF, ACR, HSAG, CMS TRAVEL, FOOD, LODGING • WOLTERS KLUVER HONORARIUM
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QUANTITATIVE IMAGING AND PAYMENT POLICY - … · quantitative imaging and payment policy ... identify out of pocket mri cost given all needed ... • application of recist, rano etc.
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5/17/2017
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QUANTITATIVE IMAGING AND PAYMENT POLICY
• DAVID SEIDENWURM, MD• SUTTER MEDICAL GROUP• SUTTER MEDICAL FOUNDATION• SUTTER HEALTH• SACRAMENTO, CA
CONFLICT OF INTEREST
• RADIOLOGY FEES, MEDICAL DIRECTOR FEES, COMMITTEE CHAIR STIPEND, SMG/SMF
• MEDICAL LEGAL EXPERT WITNESS FEES• ACR MRI ACCREDITATION FEES• RASMG BOARD MEMBER FEES• NQF, ACR, HSAG, CMS TRAVEL, FOOD,
LODGING• WOLTERS KLUVER HONORARIUM
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CONFLICT OF INTERESTDAVID SEIDENWURM, MD
• SUTTER MEDICAL GROUP/FOUNDATION• MEDICAL LEGAL CONSULTING• ACR MRI ACCREDITATION ETC.• ASNR QUALITY, SAFETY AND VALUE• NATIONAL QUALITY FORUM• AMA PCPI • NO CONFLICT, NO INTEREST
RADIOLOGY IN THE BRONZE AGE
• APOLOGIES TO
IMAGING IN THE BRONZE AGE WHARAM JAMA 2015
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INTERNATIONAL COMPARISON: IS US REALLY IN THE MIDDLE?
BRADLEY, HEALTH AFFAIRS, 2017HI STATE SOC/MED SPENDING RATIOCORRELATES WITH BETTER HEALTH
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If We Matched Next Highest (Switzerland)
Note: Per capita spending amounts adjusted for differences in cost of living, total U.S. savings adjusted for inflation. VIA R ADAMS DUDLEY UCSFSource: D. Squires, The Road Not Taken: The Cost of 30 Years of Unsustainable Health Spending Growth in the United States, (New York: The Commonwealth Fund Blog, March 2013).
DRIVERS OF HEALTH COST INFLATIONIMAGING AND ED HIGH IN COST AND USE GROWTH!
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Less than half of households can pay out of pocket costs!
• ONLY 40% OF PRIVATELY INSURED AMERICANS COULD IDENTIFY OUT OF POCKET MRI COST GIVEN ALL NEEDED INFORMATION
• ONLY 11% COULD REPORT COST OF 4 DAY HOSPITAL STAY• 100% SAID THEY KNEW WHAT A COPAY WAS• ONLY 28% GOT ANSWER RIGHT ON MULTIPLE CHOICE• 93% SAID THEY KNEW WHAT “MAXIMUM OUT OF
POCKET” MEANT• ONLY 41% COULD DEFINE IT
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COMMON CONVERSATIONS WITH ENGAGED PATIENTS
ADVISORY BOARD 2015
ADVISORY BOARD 2015 common conversations with pts
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MEDPAC, 2017HOW CONGRESS SEES US
MEDPAC, 2017PAYMENT REFORMS MEAN BETTER
CARE e.g. LOWER MORTALITY
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MEDPAC, 2017LOSSES ON MEDICARE BUSINESS
BENDING THE CURVE ON IMAGING!
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MEDPAC, 2017IS IMAGING GROWING AGAIN?
MEDPAC, 2017RADIOLOGY HAS HIGH MARKUPS
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MEDPAC, 2017RADS GET HIGH PAY
MEDPAC, 2017LOW VALUE CARE: IMAGING, CANCER SCREENING, CARDIOVASCULAR TESTS
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COMMUNITY BASED HEALTHCARENYC SUBWAY PLATFORM 2015
QUANTITATIVE IMAGING: CURRENT STATE
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MIPS THYROID INCIDENTALOMA
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USPSTF, 1996• lack of evidence that early detection of
thyroid ca by screening improves outcome• high prevalence and uncertain clinical
significance of occult thyroid carcinoma• most positive screening tests would be false-
positives, and the invasive nature of diagnostic tests
• routine screening for thyroid cancer cannot be recommended at this time.
INCIDENTAL FINDINGS ARE THE SAME AS
SCREENINGASYMPTOMATIC
POPULATIONEPIDEMIOLOGY VS
ETHICS
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•EPIDEMIC OF NON PALPABLE PAPILLARY THYROID CANCER
•MOSTLY <1CM•ALMOST CERTAINLY ATTRIBUTABLE TO IMAGING
•CORRELATES WITH RISE OF CT AND MRI USE
•HOANG 2014 AJNR
MANNERISM IN INCIDENTAL FINDINGS
THYROID CANCER
INCIDENCE INCREASED
AND MORTALITY
STABLE SUGGESTS
OVER DIAGNOSIS
Davies, Welch; JAMA OTO H&N, 2014
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INCREASE IN
INCIDENCE MOSTLY
PAPILLARYWHICH IS
LEAST FATAL
MANY ARE INCIDENTAL
Davies, Welch; JAMA OTO H&N, 2014
THYROID CANCER IS
ALMOST ALWAYS TREATED
WITH SURGERY
AND XRT
Davies, Welch; JAMA OTO H&N, 2014
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AHN NEJM 2014
AHN NEJM 2014
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CAROTID STENOSIS MEASUREPQRI ORIGINAL IMAGING METRICPCPI AAN ACR STROKE MEASURE
Carotid Imaging
• Use the NASCET method for measuring stenosis at catheter angiogram (DSA or film)
• Validated as outcome variable in randomized trial (rare for imaging)
• All other trial data e.g. ECAS re-calculated• Persistent gap in care e.g. Rosenthal NEJM 2016• Cross-walk to other modalities e.g. ultrasound
challenging• Challenges in implementation for some sites
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HIGASHIDA STROKE 2004
DROZDA’S LAW**JOE DROZDA PERSONAL COMMUNICATON
• IF A DATA ELEMENT IS USED AS AN INCLUSION CRITERION OR OUTCOME DEFINITION IN A HIGH QUALITY TRIAL THAT JUSTIFIES A GUIDELINE STATEMENT
• THAT DATA ELEMENT IS PRESUMED VALIDATED IN THAT TRIAL
• AND IS ACCEPTABLE FOR ACCOUNTABILITY MEASURES TO THE SAME DEGREE AS THE PROCEDURE OR DRUG STUDIED IN THE TRIAL
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PUBLIC COMMENT: WTF!
GRANT RADIOLOGY 2003CUTOFF FOR 70% SET AT 230 CM/SEC