Radiology Digest – October 17, 2023

October 20, 2023

Radiology Digest: News from the week of October 17, 2023.
Many High-risk Women Aren’t Getting Appropriate Breast Cancer Screening

By Amerigo Allegretto | October 12, 2023 | Included in Radiology Digest – October 17, 2023

Many women younger than 40 who are at high risk for breast cancer are not getting appropriate screening, according to findings published October 11 in the American Journal of Surgery.  

Researchers led by Christine Pestana, MD, from Wake Forest Baptist Health in Winston-Salem, NC, found that of the women younger than 40 in their study, only about 3% underwent appropriate screening despite over one in three meeting high-risk criteria.  

“This analysis highlights a significant discrepancy between those meeting criteria for high-risk screening and those who underwent appropriate screening,” the Pestana team wrote. 

Several health societies, including those in radiology, recommend annual screening mammography to start at age 40 for women with an average risk of developing breast cancer. However, guidelines by the National Comprehensive Cancer Network (NCCN) recommend screening young women with an increased breast cancer risk, meaning a 20% or greater lifetime risk. 

Pestana and colleagues evaluated their health system’s institutional rates of high-risk screening in young breast cancer patients prior to their diagnosis. They investigated risk scores from the Tyrer-Cuzick model and characteristics of breast cancer patients younger than 40, using data collected between 2013 and 2018. 

In all, the team included data from 92 women with an average age of 34.5 in the study. It found that only 3.3 % (n = 3) of the women underwent appropriate screening mammography, despite 35.8 % meeting the high-risk threshold. The group also reported that 74 of the women had their breast cancer discovered via a palpable breast mass.  

To read more, go to Aunt Minnie.
Medical Societies Representing Radiology, Emergency Medicine, and Anesthesiology Blast New NSA Guidance

By Marty Stempniak | October 10, 2023 | Included in Radiology Digest – October 17, 2023

Medical societies representing radiology, emergency medicine and anesthesiology on Monday blasted new guidance from the Centers for Medicare & Medicaid Services related to the No Surprises Act.

CMS revealed the new details on Oct. 6 the same day it partially relaunched the independent dispute resolution process for settling disagreements between payers and providers over out-of-network payments. The federal government has indicated that it is not issuing directions on how health plans should calculate the “qualifying payment amount,” which is the key starting point of such disputes. Instead, insurers will have discretion to determine this figure via their own good-faith interpretation of recent court rulings and remaining regulations.

“Our organizations are strongly opposed to this newest guidance, which further broadens the already significant discretion health plans had on how they may calculate qualifying payment amounts under the NSA’s original implementation,” the Radiology Business Management Association, American College of Radiology, American Society of Anesthesiologists, American College of Emergency Physicians and Emergency Department Practice Management Association said in a joint statement issued Oct. 9.  

RBMA et al. also took issue with plans from the federal departments of HHS, Treasury and Labor to provide limited oversight of insurers in calculating the qualifying payment amount until at least May 1, 2024, and potentially Nov. 1 of next year. A Texas judge ruled in August that the methodology insurers use to calculate the QPA is tilted in their own favor, disallowing several provisions that go into this determination. The medical groups want the federal government to incorporate this court ruling into their guidance and prevent payers from slanting the IDR process in one direction.

“Our organizations are very concerned about this delay in full enforcement,” the medical societies wrote. “There is already lax enforcement of insurer compliance with the NSA’s requirements, including the fact that many plans are seemingly being allowed to delay payment to physicians (or simply not pay at all) following an independent dispute resolution ruling, without any consequences imposed by the departments. This newest announcement providing insurers with significant enforcement relief on the QPA further erodes the critical foundations Congress built into the NSA when it passed these important consumer protections into law and seems contrary to the federal court order which stated that this could be done expeditiously.”

RBMA, ACR and the others are urging the departments to “immediately reconsider” this decision and “promptly” issue specific guidance on how health plans should calculate the QPA. They’re also “discouraged” that, despite the relaunch of IDR on Oct. 6, the ability to batch together similar payment disputes remains “in a holding pattern” after recent court rulings.

“Without any improved guidance on batching, the administrative efficiencies that come from being able to batch disputes will not be realized, thereby increasing costs for physician practices, while causing the current backlog of unresolved disputes to continue to grow,” the statement closed. “We urge the departments to quickly reopen the portal to batched determinations, and concurrently provide effective guidance to all affected parties.”

You can find the full statement on the American College of Emergency Physicians’ website here.

To read more, go to Radiology Business.
Flurpiridaz Will have a Major Impact on Cardiac PET and Nuclear Imaging

By Dave Fornell | October 10, 2023 | Included in Radiology Digest – October 17, 2023

Flurpiridaz, a novel positron emission tomography (PET) cardiac radiotracer is poised to make a major impact on nuclear cardiology. Experts in cardiac imaging say it offers much better imaging than SPECT, the current cardiac nuclear imaging workforce technology. It can be made by commercial cyclotrons and has a much longer half-life to make it available in on-demand doses that can be ordered and transported to the hospital. This may deliver a much more economic option for PET to expand, as opposed to the current standard of expensive rubidium-82 generators. 

The results of the Flurpiridaz FDA pivotal trial, AURORA (International Study to Evaluate Diagnostic Efficacy of Flurpiridaz [18F] Injection PET MPI in the Detection of Coronary Artery Disease [CAD]), were published Oct. 9 in the Journal of the American College of Cardiology.[1] The phase 3, prospective, open-label, international, multicenter study of Flurpiridaz for PET myocardial perfusion imaging (MPI) in patients with suspected CAD showed excellent results. It was compared with the current standard of care of SPECT with the radiotracer technetium-99m. The results showed Flurpiridaz significantly exceeded prespecified threshold criteria for the detection of CAD and was superior to Tc-labeled SPECT MPI for the detection of CAD in the overall population and in women and obese patients. 

These findings have paved the way for the anticipated approval of Flurpiridaz by the U.S. Food and Drug Administration (FDA). GE Healthcare, the manufacturer of Flurpiridaz, has submitted the results to the FDA for final review.

“Undoubtedly, publication of the AURORA trial is a milestone in nuclear cardiology. Publication of the AURORA trial is an important step toward FDA approval of Flurpiridaz, which has a longer half-life than currently available radiopharmaceuticals. This advantage would allow unit dosing and exercise testing,” explained American Society of Nuclear Cardiology (ASNC) President Mouaz Al-Mallah, MD, Mac, MASNC, in a letter to members on Oct. 10. 

To read more, go to Cardiovascular Business.
ACR, Coalition of Nearly 50 Provider Groups Urge Congress to Quash Controversial Code Update

By Marty Stempniak | October 9, 2023 | Included in Radiology Digest – October 17, 2023

The American College of Radiology is spearheading a drive by nearly 50 provider groups, urging Congress to help halt a controversial code update.

Healthcare Common Procedure Coding System code G2211 is a CMS-generated add on, meant to be billed with evaluation and management services. The Centers for Medicare and Medicaid Services’ intent was to help better reflect patient complexity, ACR noted in an Oct. 6 news update. However, “the code has been controversial since initially finalized for implementation in 2021.”

Given concerns from the provider community, Congress previously delayed implementation until next year. But the proposed 2024 Medicare Physician Fee Schedule includes G2211. According to CMS estimates, the code would be responsible for 90% of the overall budget neutrality reduction tied to the conversion factor.

Provider groups believe implementation of the code, and the impact it would have on certain specialties, is yet another example of how the Medicare payment system is “broken.”

“Implementing G2211 will penalize clinicians who cannot, or do not, use it with yet another budget-neutrality-related reduction to the CF,” ACR, the American Society of Neuroradiology, the Society of Interventional Radiology and the American Society for Radiation Oncology wrote to congressional leaders on Oct. 4. “We reiterate our commitment to work with you on permanent reform, including modifications to Medicare’s budget neutrality policy, the addition of an inflationary update to the MPFS and improvements in the Quality Payment Program,” they added later. “However, in the short term, we ask that you permanently halt the implementation of G2211 because it is significantly flawed and would give our clinicians the fiscal stability needed to ensure Medicare beneficiaries have access to a broad continuum of care in their communities.”

ACR et al. pointed to a 2020 analysis from Health Policy Alternatives. It estimated that, if the add-on code were implemented in 2021 as originally planned, diagnostic radiology would have faced the highest payment decrease at roughly 10.3% (vs. a 6.9% cut without code implementation). The college further supported its case by noting that both MedPAC and the AMA/ Specialty Society Relative Value Scale Update Committee believe G2211 is redundant. That’s because increased patient complexity was “already accounted for” in the outpatient E/M reevaluation implemented in 2021, ACR noted.

Read more about the advocacy push, and find the letters addressed to the House and Senate, in the college’s news update. Others signing the message included the American College of Emergency Physicians, American College of Radiation Oncology, American College of Surgeons, and the American Society of Anesthesiologists, among others.  

To read more, go to Radiology Business.
Feds Finally Relaunch IDR Under No Surprises Act Following Radiologist Concern

By Mary Stempniak | October 6, 2023 | Included in Radiology Digest – October 17, 2023

The federal government has finally relaunched the independent dispute resolution process under the No Surprises Act. The move came Friday, and it followed calls from radiologists and other specialists to kick-start the long-stalled service.

CMS shut down arbitration Aug. 3 after a judge struck down the 600% increase to the fee physicians must pay to initiate mediation between payers and providers over out-of-network bills. IDR has remained largely inactive since then, with requests from radiologists and other physicians piling up in the eight-week aftermath.

The stasis may have started to break last Monday, when the Radiology Business Management Association, American College of Radiology and other stakeholder groups pressed CMS to restart the IDR process.

“Effective October 6, 2023, the departments of Health and Human Services, Labor and the Treasury have reopened the federal independent dispute resolution portal for the initiation of certain new single and bundled disputes,” the Centers for Medicare & Medicaid Services said in an email announcement.    

The agency previously instructed IDR entities to resume processing all in-progress disputes submitted on or before the Aug. 3 ruling. But ACR, RBMA and societies representing anesthesiology and emergency medicine have implored CMS to address the eight-week backlog.

Processing of in-progress or new batched disputes “remains temporarily suspended” while the departments update guidance and operations “to align with the district court’s opinions and orders” in the recent Texas ruling.

“Disputing parties should continue to engage in open negotiation according to the required timeframes until further notice from the departments,” the notice read.

The Radiology Business Management Association praised the move Friday while noting work remains to be done.

“RBMA continues its advocacy and support for a fair IDR process that will benefit patients as intended by the No Surprises Act,” Bob Still, executive director of the association, told Radiology Business Friday. “This announcement is a step in the right direction.” 

To read more, go to Radiology Business.
Clinical Decision Support Has Little Impact on Image-ordering Behaviors, Single-center Study Finds

By Marty Stempniak | October 6, 2023 | Included in Radiology Digest – October 17, 2023

Clinical decision support appears to have little impact on image-ordering behaviors, according to a new single-center study published Thursday in the Journal of the American College of Radiology [1].

The Protecting Access to Medicare Act requires outpatient and emergency department providers to deploy such CDS systems to curb the use of unnecessary imaging. But do they actually work? Researchers with Washington University in St. Louis, Missouri, aimed to answer this question, analyzing 17,355 imaging orders logged at their ED over a six-month period.

Govind S. Mattay MD, MBA, et al. reported little impact after implementation—including not overburdening referrers—but believe AI could help improve the numbers.

“CDS alerts triggered by low [appropriate use criteria] scores caused minimal increase in time spent on imaging order entry but had a relatively marginal impact on imaging study selection,” Mattay, with WU’s Mallinckrodt Institute of Radiology, and colleagues advised. “[Artificial intelligence predictive text] implementation increased the number of scored studies and could potentially enhance [clinical decision support’s] effects.”

Washington University utilizes CareSelect Imaging CDS, which requires providers to order advanced imaging through the electronic medical record. Clinicians have the option to select from a common list of structured indications for studies or input a free-text alternative. For those that use structured reporting, CDS automatically scores the request on a scale from 1 (least appropriate) to 9 (most appropriate). It further categorizes them into color ranges including red (scores 1-3, indicating “usually not appropriate”), yellow (scores 4-6, denoting “may be appropriate”), or green (7-9, “usually appropriate”).

The CDS system triggered alerts for 3% of all imaging orders during the study period (522 of 17,355), suggesting other exams with higher appropriateness scores. Ordering providers selected an alternative study based on such suggestions for just 3% these scenarios (18/522) or about 0.1% of all imaging orders (18/17,355). Out of the 18 changed orders, 15 related to contrast administration (e.g., magnetic resonance imaging of the cervical spine with/without contrast switched to just MRI without). The other 3 pertained to ordering additional unnecessary studies for trauma cases.

In the 522 instances where CDS alerts were triggered, clinicians spent an additional 25 seconds interacting with the system. Most common reasons for not following CDS’ suggestions included disagreement with the appropriateness score (32%) or “requested by a consultant” (25%).

Washington University later implemented AI predictive text in July 2021. This model uses free-text input, crunching additional patient and provider data to suggest a structured indication. If the correlation between the free-text entry and proposed structured alternative is strong enough, the system automatically converts the former into the latter. After launch of this AI tool, the percentage of unscored studies dropped from 81% to 45%.  

Washington University experts see broader uses for artificial intelligence in fine-tuning clinical decision support.

“Future AI tools could analyze CDS-derived and EMR data on a population-level to not only reduce inappropriate imaging utilization but also make suggestions on optimal screening imaging studies for specific patient cohorts,” the authors wrote. “CDS could also be enhanced by additional AI tools that analyze data at a wholistic patient level to consider additional factors such as other diagnoses and allergies to make better imaging order suggestions. As these CDS versions emerge, it will be paramount to analyze their effect on clinical care.”

To read more, go to Radiology Business.
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