QUANTITATIVE IMAGING AND PAYMENT POLICY CONFLICT OF INTEREST

Transcription

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 1

2 CONFLICT OF INTEREST DAVID 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 APOLOGIES TO IMAGING IN THE BRONZE AGE WHARAM JAMA 2015 RADIOLOGY IN THE BRONZE AGE 2

3 INTERNATIONAL COMPARISON: IS US REALLY IN THE MIDDLE? BRADLEY, HEALTH AFFAIRS, 2017 HI STATE SOC/MED SPENDING RATIO CORRELATES WITH BETTER HEALTH 3

4 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 UCSF Source: 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 INFLATION IMAGING AND ED HIGH IN COST AND USE GROWTH! 4

5 Less than half of households can pay out of pocket costs! FRAKT NYTIMES 2015 HEALTH FINANCE Ïƛ i± 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 5

6 COMMON CONVERSATIONS WITH ENGAGED PATIENTS ADVISORY BOARD 2015 ADVISORY BOARD 2015 common conversations with pts 6

7 MEDPAC, 2017 HOW CONGRESS SEES US MEDPAC, 2017 PAYMENT REFORMS MEAN BETTER CARE e.g. LOWER MORTALITY 7

8 MEDPAC, 2017 LOSSES ON MEDICARE BUSINESS BENDING THE CURVE ON IMAGING! 8

9 MEDPAC, 2017 IS IMAGING GROWING AGAIN? MEDPAC, 2017 RADIOLOGY HAS HIGH MARKUPS 9

10 MEDPAC, 2017 RADS GET HIGH PAY MEDPAC, 2017 LOW VALUE CARE: IMAGING, CANCER SCREENING, CARDIOVASCULAR TESTS 10

11 COMMUNITY BASED HEALTHCARE NYC SUBWAY PLATFORM 2015 QUANTITATIVE IMAGING: CURRENT STATE 11

12 MIPS THYROID INCIDENTALOMA 12

13 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 falsepositives, and the invasive nature of diagnostic tests routine screening for thyroid cancer cannot be recommended at this time. INCIDENTAL FINDINGS ARE THE SAME AS SCREENING ASYMPTOMATIC POPULATION EPIDEMIOLOGY VS ETHICS 13

14 MANNERISM IN INCIDENTAL FINDINGS 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 THYROID CANCER INCIDENCE INCREASED AND MORTALITY STABLE SUGGESTS OVER DIAGNOSIS Davies, Welch; JAMA OTO H&N,

15 INCREASE IN INCIDENCE MOSTLY PAPILLARY WHICH 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,

16 AHN NEJM 2014 AHN NEJM

17 CAROTID STENOSIS MEASURE PQRI ORIGINAL IMAGING METRIC PCPI 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 17

18 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 18

19 PUBLIC COMMENT: WTF! GRANT RADIOLOGY 2003 CUTOFF FOR 70% SET AT 230 CM/SEC 19

20 GRANT RADIOLOGY 2003 PROBLEMS: NORMAL NEAR TOTAL OCCLUSION FUZZY CLUSTER ANALYSIS PQRS CAROTID IMAGING RESULTS AMONG REPORTING SITES % % % % % % 20

21 UTERINE ARTERY EMBO ENDPOINT 5 HEARTBEATS DEFINES STASIS AT ANGIO COUNT TO 5 HAMPTON ROADS 21

22 COUNT TO 5 HAMPTON ROADS UTERINE ARTERY EMBO END PT 22

23 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 NODULES ACR/PCPI DIAGNOSTIC IMAGING PUBLIC COMMENT OPEN NOW 23

24 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,

25 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?) 25

26 NISHINO, AJR, 2010 (RECIST) NISHINO, AJR, 2010 (RECIST) 26

27 NISHINO, AJR, 2010 (RECIST) IS PULMONARY ARTERY BRANCH ORDER A QUANTITATIVE IMAGING PARAMETER? *PROGNOSTIC MARKER *VALIDATED *QUANTIFIABLE 27

28 OVER DX AND RX BY IMAGING WIENER ARCH INT MED 2011 OVER DX BY IMAGING: PE DEATH NO CHANGED, INCIDENCE UP WIENER ARCH INT MED

29 COMPLICATIONS INCREASE WIENER ARCH INT MED 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 29

30 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?? 30

31 IDEAS? SUGGESTIONS? QUESTIONS? THE END 31