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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!

FRAKT NYTIMES 2015HEALTH FINANCE Ïƛ£i±€β@©Z¥

• 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

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GRANT RADIOLOGY 2003PROBLEMS: NORMAL

NEAR TOTAL OCCLUSION“FUZZY CLUSTER ANALYSIS”

PQRS CAROTID IMAGING RESULTSAMONG REPORTING SITES

2010 59.5% 2011 61.7%2012 68.7% 2013 79.0%2014 84.1%2015 87.03%

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UTERINE ARTERY EMBO ENDPOINT

“5 HEARTBEATS” DEFINES STASIS AT ANGIO

COUNT TO 5HAMPTON ROADS

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COUNT TO 5HAMPTON ROADS

UTERINE ARTERY EMBO END PT

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DIRECT MIPS MEASURE VS QCDR

• DIRECT MIPS METRICS CAN BE CALCULATED DIRECTLY BY CMS FROM YOUR BILLING/CHARGE DATA

• SOME METRICS REQUIRE REGISTRY PARTICIPATION

• DATA ELEMENTS COMPLEX• NOT CAPTURED VIA ADMINISTRATIVE DATA• NOT YET FULLY TESTED, ENDORSED• INSUFFICIENT RIGOR

ADRENAL NODULESACR/PCPI DIAGNOSTIC IMAGINGPUBLIC COMMENT OPEN NOW

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CRITERIA FOR BENIGN ADRENAL NODULE (EXCLUDE > 4 CM)

• < 10 HOUNSFIELD UNITS• < 1 CM• RELATIVE WASHOUT (10 MIN, 15 MIN)• ABSOLUTE WASHOUT (10 MIN, 15 MIN)• IN/OUT OF PHASE MRI • STABLE FOR 1 YEAR• (ANY OF THE ABOVE)

RIBEIRO, DIAG IMAG, 2010

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IS FOLLOW-UP TIME INTERVAL A QUANTITATIVE IMAGING PARAMETER?TIME AND MODALITY IN ACTIONABLE

RECOMMENDATIONS

DO WE KNOW ENOUGH TO MAKE A SPECIFIC FOLLOW-UP RECOMMENDATION?

• WE KNOW LESS ABOUT THE PATIENT• WE KNOW MORE ABOUT THE CAPABILITIES OF

OUR MODALITIES (QUANTITATIVE IMAGING?)• WE KNOW MORE ABOUT THE ABILITY TO

DETECT CHANGE (QUANTITATIVE IMAGING?)• APPLICATION OF RECIST, RANO ETC. (QI?)• FLEISCHNER SOCIETY LUNG NODULE

GUIDELINES (QI?)

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NISHINO, AJR, 2010 (RECIST)

NISHINO, AJR, 2010 (RECIST)

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NISHINO, AJR, 2010 (RECIST)

IS PULMONARY ARTERY BRANCH ORDER A QUANTITATIVE IMAGING

PARAMETER?*PROGNOSTIC MARKER

*VALIDATED*QUANTIFIABLE

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OVER DX AND RX BY IMAGINGWIENER ARCH INT MED 2011

OVER DX BY IMAGING: PE DEATH NOCHANGED, INCIDENCE UP

WIENER ARCH INT MED 2011

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COMPLICATIONS INCREASEWIENER ARCH INT MED 2011

2015 SHUN YU JAMA INT MED •CALLING SMALL PE HURTS PTS-HIGHER BLEEDING RATE, MORE DRUG RX, MORE IMAGING

•CALLING SMALL PE DOESN’T HELP PTS-SAME LOW 90DAY THROMBOEMBOLISM RATE

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IS PULMONARY ARTERY BRANCH ORDER A QUANTITATIVE IMAGING

PARAMETER?*PROGNOSTIC MARKER

*VALIDATED*QUANTIFIABLE

MIPS QPP/QCDR Performance measures illustrating quantitative features

• Carotid imaging – 2007• Thyroid Incidentaloma – 2012• Uterine fibroid angiography – 2016• Adrenal incidentaloma – 2012, 2017? • Reporting actionable follow-up 2017?• Pulmonary embolus branch order 2017?• QUANTITATIVE IMAGING BIOMARKERS 2018??

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• IDEAS?•SUGGESTIONS?•QUESTIONS?

THE END