Radiology Digest – September 12, 2023

September 7, 2023

Radiology Digest: News from the week of September 12, 2023.

Huge Decline in Spending on Medicare Begs the Question: Why?

By Frank Diamond | September 6, 2023 | Included in Radiology Digest – September 12, 2023

Research shows that Medicare spending has leveled off for the past decade, morphing from something that experts worried might break the federal budget to an unexpected bright spot.

The New York Times spotlighted this trend in an article this week, digging into a 2019 Health Affairs study co-authored by David M. Cutler, Ph.D., an economist at Harvard University and one of the main architects of the Affordable Care Act (ACA).

“When we first wrote about the spending slowdown, there was a lot of debate about whether it was temporary—due perhaps to the Great Recession. We didn’t think so, but it wasn’t a crazy line of thought,” Cutler told Fierce Healthcare in an interview.

Cutler said that theory has since been disproven but that “most analysts at least hedge more their outlook for spending growth in the future, even if they still see some increase above the rate in the past few years. Just as we don’t know exactly why spending slowed, we also don’t know whether it will return. But the impact on the federal budget has still been immense.”

The NYT estimates that federal spending might have been $3.9 trillion more since 2011 if spending on Medicare continued in the way that it had when experts predicted it would eventually blow a hole in the budget.

In addition, federal deficits would have been more than a quarter larger, according to the article.

Cutler’s 2019 Health Affairs study lists some legislative action that might have contributed to the slowdown in Medicare spending including the ACA, which encouraged bundled payments and accountable care organizations.

However, Cutler and co-authors cited the fact that older Americans have fewer heart attacks and strokes thanks to new and fairly inexpensive medications as possibly the main reason for the spending slowdown.

“The reduction in acute cardiovascular events has been dramatic: Hospital admissions for ischemic heart disease are down 56% since 1999, and admissions for stroke have fallen by 41%,” the study said.

The Congressional Budget Office (CBO) tried to explain (PDF) in March why it overestimated Medicare spending.

“Most of the overestimate for the Medicare and Medicaid programs stemmed from an overestimate of spending per beneficiary, not an overestimate of the number of beneficiaries,” the CBO stated. “Less-than-anticipated spending for prescription drugs in Medicare Part D and for long-term services and supports … in Medicaid were two significant sources of error in CBO’s 2010 projections.”

Still, reasons for the slowdown in Medicare spending for the most part remain something of a mystery.

To read more, go to Fierce Healthcare.


Joint Commission’s Ongoing Professional Practice Evaluation Process Call ‘Costly, Ineffective and Potentially Harmful’

By Marty Stempniak | September 6, 2023 | Included in Radiology Digest – September 12, 2023

The Joint Commission’s Ongoing Professional Practice Evaluation process, or OPPE, used to pinpoint trends that impact quality and safety, is “costly, ineffective and potentially harmful,” researchers claimed in a study published Wednesday.

Imaging providers who are accredited by the commission must undergo this process, which requires collecting data to assess core competencies such as patient care, medical knowledge, professionalism and communication skills.

However, little to no research has been performed to support the effectiveness of the program, hospital leaders wrote in the Journal of the American College of Radiology [1].

“Based on the authors’ subjective experiences, our premise is that [Ongoing Professional Practice Evaluation] has added a significant administrative cost to healthcare organizations, identifies few to no outlier performers in which OPPE metrics alone result in lack of renewal, limitation, or revoking of hospital privileges, and has had a harmful effect on the culture of safety by mixing data gathered for the purpose of learning and improvement with that for the purpose identification of outlier performers,” radiologist Lane F. Donnelly, MD, a professor and director of quality at UNC Children’s Hospital, wrote Sept. 6.

To support their hypothesis, the University of North Carolina’s health system and five other such organizations partnered to evaluate labor expenses related to conducting The Joint Commission’s evaluation. Their estimates included average hours and wages paid for data analysts, medical staff office professionals, departmental physician leaders and administrative assistants, using estimates to extrapolate across the entire U.S. Donnelly and co-authors also identified the number of outlier performers who were pinpointed via the OPPE program’s metrics alone.

Across 12,854 providers evaluated by the program via the study, zero were labeled as outlier performers “solely through the OPPE process.” Hospitals spent recurring labor costs per provider of about $50.20, extrapolated for a total national cost of roughly $78.54 million. Spread across the past 15 years, researchers estimated that providers have spent some $1.178 billion during OPPE’s existence.

“These findings raise the possibility that, as currently practiced, OPPE could be viewed as predominantly administrative waste,” the authors concluded. “Further study and engagement between hospital systems, TJC, and professional societies to align regulatory goals, quality improvement, professional development, and national performance standards to produce a more effective and efficient mechanism of professional oversight is a worthy goal.”

The Joint Commission did not immediately respond to a Radiology Business request for comment on the analysis Wednesday. Other organizations involved in the study included Nemours Children’s Health, Cincinnati Children’s Hospital, Stanford Medicine Children’s Health, Texas Children’s Hospital and the Baylor College of Medicine.

To read more, go to Radiology Business.


Fewer Large Employers Opting for Self-funded Insurance

By Rylee Wilson | September 6, 2026 | Included in Radiology Digest – September 12, 2023

The number of large employers choosing self-pay over fully-insured benefits has declined since 2010, according to a brief from the Employee Benefits Research Institute published Aug. 24. 

The share of employers with more than 500 employees that offer at least one self-insured option was 72 percent in 2022, the lowest level since 2010. 

More small and medium-sized employers are opting for self-insured plans. Of employers with fewer than 100 employees, 18 percent offered at least one self-paid insurance plan in 2022, up from 13 percent in 2010.

Among employers with 100 to 499 employees, 37 percent offered at least one self-insured plan, up from 27 percent in 2010. 

Some industry analysts predicted the Affordable Care Act would drive more small employers to fund their own health benefits, as self-paid plans are subject to fewer requirements of the law that could drive up costs. 

Trendlines in self-paid plans have ebbed and flowed since 2016, according to the report, and are more clear when broken out by firm size. 

Read more here


1 in 3 Healthcare Workers Plan to Leave Their Position, Survey Finds

By Victoria Bailey | September 5, 2023 | Included in Radiology Digest – September 12, 2023

A third of surveyed healthcare workers plan to leave their job in the next year, according to new data from Tebra.
Over 500 healthcare workers responded to the online surveyin spring 2023.

While one in three workers planned to leave their position, 14 percent of respondents said they planned to leave the industry entirely within the next year.

As workforce shortages persist, recruiting and retaining staff is a key priority for many healthcare organizations.

However, consequences stemming from the COVID-19 pandemic and other administrative burdens are creating a less-than-ideal work setting for many healthcare professionals.

Six in ten healthcare workers said they are short-staffed. Staffing shortages impact both patient access to care and medical professionals’ mental and physical health. Nearly 80 percent of workers think a healthcare crisis will occur in the next year due to understaffing and burnout, the survey found.

While the pandemic prompted older workers to retire, the remaining workers have new standards for their workplace environments. Almost three-quarters (73 percent) of healthcare workers said they feel underpaid, while 59 percent reported feeling unappreciated at work.

If respondents were in charge at their workplace, they would increase workers’ pay and benefits (73 percent), increase staffing levels to reduce workload and stress (68 percent), and offer more flexible scheduling to accommodate a work-life balance (58 percent).

The pandemic has significantly impacted workers’ emotional well-being. Over half of respondents (55 percent) said they feel anxious and 35 percent said they feel depressed multiple times a week.

Exhaustion also weighs on healthcare workers, with 35 percent of respondents saying they have seen a co-worker fall asleep during a shift.

Most workers reported that patient care (82 percent) and safety (80 percent) suffer the most when a staff member is sleep-deprived. More than one in three respondents said they have made a mistake at work due to a lack of sleep. Reported mistakes ranged from forgetting to document important patient information to administering the wrong medication or dosage.

Staffing shortages and burnout have impacted the nursing workforce in particular. A survey from AMN Healthcare found that only 61 percent of nurses planned to work for their employer in a year from now, down five percentage points from 2021.

Job satisfaction among nurses also fell in 2023, with 64 percent of nurses saying they were satisfied with their current job compared to 67 percent in 2021.

Healthcare staffing was also turbulent before the pandemic hit. A study published in Annals of Internal Medicine found that the annual physician turnover rate grew by 43 percent between 2010 and 2018, rising from 5.3 percent to 7.6 percent.

To read more, go to Revcycle Intelligence.


Unavoidability of ‘One-off’ Imaging Forces Radiology to Keep One Foot in Fee-for-service World

By Dave Pearson | September 1, 2023 | Included in Radiology Digest – September 12, 2023

Radiology can participate only sporadically in CMS’s current conception of value-based care. Why?

Because the system relies heavily on episode-based reimbursement—and vast numbers of imaging studies are non-episodic by their very nature.

In fact, around 33% to almost 50% are “one-off” events. Accordingly, to maintain continuity of care at the population level, legislators will need to accommodate some iteration of fee-for-service billings for the foreseeable future.

Radiology researchers present the data and make the case in a research report published Aug. 26 in Current Problems in Diagnostic Radiology [1].

Corresponding author Casey Pelzl of the Harvey L. Neiman Health Policy Institute and colleagues reviewed records placed in Optum’s Clinformatics Data Mart from 2015 to 2015. The database contains de-identified claims made to both CMS and private payers.

To analyze the records, the team divided data into two blocks.

One block used one-year windows starting with the day of initial imaging. For this, Pelzl and co-authors categorized imaging studies as one-off events if no additional imaging claims appeared for the same body region over the subsequent 12 months.

The other block defined a one-off event even more strictly: an imaging claim with no more imaging whatsoever over the subsequent 12 months.

MIPS evolves—only to leave radiology behind?

Computing percentages of one-off events overall and by body region, the researchers found one-off events made up 33.2% to 45.8% of imaging studies.

They also found high rates of one-off imaging for cardiac indications, 80.9% to 87.7%, and low rates of one-off imaging for chest indications, 26.8% to 35.2%.

By site of service, the lowest rates of one-off imaging were in inpatient settings (12.9% to 29.1%) and long-term care (18.6% to 30.0%).

Pelzl and co-authors note CMS’s new-for-2023 MIPS-Value Pathways (MVP) program as potentially problematic going forward.   

The team notes that MVPs were conceived as a steppingstone between the strictly pay-for-performance MIPS and more advanced value-based requirements of APMs.

“While these are all Medicare programs, commercial payers often look to Medicare as a bellwether for payment policy,” the authors point out.  

The persistence of fee-for-service
Episode-based reimbursement mechanisms, they underscore, are out of touch with a major slice of the typical diagnostic radiologist’s workload.

The unavoidably high volume of one-off imaging events thwarts radiology from robust participation in value-based reimbursement or alternative payment models, the authors suggest.  

To read more, go to Health Imaging.


Radiologists Must be Aware of Side Effects from New Alzheimer’s Treatments, Study Warns

By Marty Stempniak | September 1, 2023 | Included in Radiology Digest – September 12, 2023

Radiologists must be aware of potential side effects from new Alzheimer’s treatments, experts warned in a study published Thursday.

Two years ago, the U.S. Food and Drug Administration granted accelerated approval for aducanumab, sold under the brand name Aduhelm, to address the irreversible brain disorder. The decision came after the agency determined this monoclonal antibody demonstrated success in reducing amyloid-beta plaques in the brain, producing possible benefits to patients.

However, increased Aduhelm use also comes with potential abnormalities, including swelling, effusion or hemorrhaging in the brain, experts wrote in the journal RadioGraphics [1]Such amyloid-related imaging abnormalities, or ARIA, spotted on magnetic resonance imaging, are believed to arise following the inflammatory response, leading to the leakage of blood products and other fluid in surrounding tissues, researchers noted.

“It is essential for the radiologist to recognize and monitor ARIA,” lead author Amit K. Agarwal, MD, a neuroradiologist at the Mayo Clinic in Jacksonville, Florida, said in an Aug. 31 announcement from the Radiological Society of North America. “As the use of monoclonal antibodies becomes more widespread, close collaboration between neurologists and radiologists is needed before and during therapy to plan for image monitoring per established guidelines.”

Swelling or effusion are the most common side effects from treatments such as Aduhlem, the authors noted. Previous phase 3 trials found this occurs in about 35% of patients who received the approved dose of the drug, occurring between the third and sixth months of treatment. Patients experiencing these symptoms typically did not display any outward symptoms, and the issue resolved itself 98% of the time at follow-up imaging. Meanwhile, hemorrhaging occurred in 15% to 20% of individuals treated, and this side effect commonly did not resolve itself over time.

Agarwal and colleagues advised that most patients with asymptomatic amyloid-related imaging abnormalities can continue receiving treatment, including the “vast majority” with swelling or effusion. For those experiencing hemorrhaging, treatment decisions will depend on the severity and stability of symptoms. Ten or more new microhemorrhages signal the need to permanently discontinue use of the drug, experts advised.

“A multidisciplinary approach with a small core group of neurologists and neuroradiologists with knowledge about the technical aspects and imaging appearance forms the bottom line for successful aducanumab therapy implementation,” the study advised. “It is imperative that radiologists are trained in the basics of the technical and scientific aspects of ARIA.”

To read more, go to Radiology Business.


Inflation-adjusted Medicare Pay in Radiology has Decreased by $2.8B Since 2005

By Marty Stempniak | August 31, 2023 | Included in Radiology Digest – September 12, 2023

Medicare reimbursement to radiologists has plummeted nearly 31.9% or $2.8 billion since 2005, after adjusting for inflation, according to a new analysis published Thursday in JACR.

Budget neutrality requirements under the federal payment program mean that spending increases in one place necessitate cuts elsewhere. This has resulted in the annual exercise of “robbing Peter to pay Paul,” as one industry watcher put it, with diagnostic radiology facing a proposed 4% reimbursement cut in 2024.

Imaging researchers set out to measure how such actions have impacted the specialty over the long term, using 100% of aggregated Medicare Part B claims spanning 2005 to 2021. Reimbursements to radiologists on a per-beneficiary basis increased 4.2% during the timespan (from $182 to $189). However, when factoring for inflation, Medicare pay actually dropped 24.9% (from an adjusted per-beneficiary figure of $252 in 2005).

This occurred during a period when radiologists took on an increasing workload, with relative value units leaping 13.1% during the 16-year study period.

“In conclusion, there has been a substantial decline in inflation-adjusted reimbursement to radiologists per Medicare fee-for-service beneficiary over the 2005 to 2021 period, despite the fact that each beneficiary is consuming more radiology services, as measured by RVUs,” lead author Eric W. Christensen, PhD, with the Harvey L. Neiman Health Policy Institute, and colleagues wrote Aug. 31. “This reimbursement decline is associated with the budget neutrality requirement that has caused reimbursement changes to not keep up with inflation. Declining Medicare reimbursement may further exacerbate access challenges for Medicare beneficiaries with access to radiologic care compared with patients with commercial insurance as well as shortages of radiologists.”

Meanwhile, the conversion factor—the dollar amount used to convert RVUs into payment—fell 7.9% (from $37.8975 to $34.8931) or 33.6% when adjusted for inflation. Christensen and colleagues estimated that, if RVUs per beneficiary remained at 2005 levels, real radiology reimbursement would have dropped 34% per beneficiary.

Total reimbursement to radiologists under the Medicare Physician Fee Schedule declined 5.5%, from $6.2 billion in 2005 down to $5.8 billion in 2016. Adjusting the 2005 total for inflation, radiologists earned $8.6 billion, or 48.3% more, 16 years ago than in 2021.

Medicare continues these cuts beyond the study period, with the conversion factor further declining to $34.6062 in 2022 and $33.8872 in 2023. Accounting for inflation, the figure has now fallen 43.1% from 2005 to 2023, the authors noted.

“In addition to detrimental impact on access, substantial reimbursement declines contribute to radiologist burnout,” the study noted. “Radiology practices, whether private, corporate, or academic, can preserve financial sustainability by working faster, taking fewer breaks, or lengthening the workday … Working harder for less reimbursement undoubtedly increases the risk of burnout among radiologists.”

Read more from the Journal of the American College of Radiology at the link below, and find study summary from the Neiman Health Policy Institute here.

To read more, go to Radiology Business.

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