Geraldine McGinty

Classic lobular neoplasia on core biopsy: a clinical and radio-pathologic correlation study with follow-up excision biopsy

There are no consensus guidelines for the management of lobular neoplasia diagnosed on core biopsy as the highest risk factor for cancer. This study aimed to assess the risk of upgrade (invasive carcinoma or ductal carcinoma in situ) at the site of the lobular neoplasia and any clinical, radiological or pathologic factors associated with the upgrade. We reviewed all cases with a diagnosis of lobular neoplasia on core biopsy from June 2006 to June 2011. Any cases with radio-pathologic discordance, coexistent lesion that required excision (atypical ductal hyperplasia, flat epithelial atypia, duct papilloma or radial scar) or non-classic variant of lobular carcinoma in situ (pleomorphic, mixed ductal and lobular, lobular carcinoma in situ with necrosis) were excluded from the study. Core biopsy indications included calcification in 35 (40%), non-mass like enhancement in 19 (22%), mass lesion in 31 (36%) and mass as well as calcification in two cases (2%). Follow-up excisions were studied for the presence of upgrade. The study cohort included 87 cases and showed an upgrade of 3.4% (95% confidence interval: 1–10%). Three cases showed an upgrade (one ductal carcinoma in situ and two invasive cancers). All upgraded cases were breast imaging-reporting and data system score ≥4 and associated with atypical duct hyperplasia or in situ or invasive cancer in prior or concurrent biopsies in either breast. The number of cores and lobules involved, pagetoid duct involvement, presence of microcalcification in lobular neoplasia, needle gauge and number of cores obtained showed no correlation with the upgrade. Our results suggest that with radio-pathologic concordance and no prior biopsy proven risk for breast cancer, core biopsy finding of lobular neoplasia as the highest risk lesion can be appropriately and safely managed with clinical and radiologic follow-up as an alternative to surgical excision.

Delivery of Appropriateness, Quality, Safety, Efficiency and Patient Satisfaction

Although radiology’s dramatic evolution over the last century has profoundly affected patient care for the better, the current system is too fragmented and many providers focus more on technology and physician needs rather than what really matters to patients: better value and outcomes. This latter dynamic is aligned with current national health care reform initiatives and creates both challenges andopportunitiesforradiologiststo find ways to deliver new value for patients. The ACR has responded to this challenge with the introduction of Imaging 3.0 TM , which represents a call to action to all radiologists to assume leadership roles in shaping America’s future health care system through 5 key pillars: imaging appropriateness, quality, safety, efficiency, and satisfaction. That enhanced value will require modulation of imaging work processes best understood through the concept of the imaging value chain, which is introduced in this first of a 7-part series. Further articles will then prescribe in detail the pathway forward at each link in the value chain to effect the work process changes necessary for radiologists to deliver better value and outcomes for patients.

The Bundled Payments for Care Improvement Initiative

The Affordable Care Act enters its fifth year firmly entrenched in our national consciousness. One method that has entered the vernacular for achieving cost savings is accountable care. There are other approaches that are less well known. The Bundled Payments for Care Improvement Initiative has the potential to significantly impact neurointerventionalists. We review that initiative here.

The Burwell roadmap

In January 2015 the current Secretary of the Department of Health and Human Services (HHS) outlined a bold initiative to shape the delivery of healthcare through a set of strategies aimed at improving the quality of care and reducing the growth of healthcare costs. The strategies include increasing payment incentives tied to higher value care, increasing care coordination and integration, and increasing access to information to guide patients and clinicians. Significantly, the proposal includes specific goals for alternative payment models and value-based payments for the first time in the history of the Medicare program.

Radiologist manpower considerations and Imaging 3.0: effort planning for value-based imaging.

Our specialty is seeking to establish the value of imaging in the longitudinal patient-care continuum. We recognize the need to assess the value of our contributions rather than concentrating primarily on generating revenue. This recent focus is a result of both increased cost-containment efforts and regulatory demands. Imaging 3.0 is a value-based perspective that intends to describe and facilitate value-based imaging. Imaging 3.0 includes a broad set of initiatives addressing the visibility of radiologists, and emphasizing quality and safety oversight by radiologists, which are new directions of focus for us. Imaging 3.0 also addresses subspecialty imaging and off-hours imaging, which are existing areas of practice that are emblematic of inconsistent service delivery across all hours. Looking to the future, Imaging 3.0 describes how imaging services could be integrated into the framework of accountable care organizations. Although all these efforts may be essential, they necessitate manpower expenditures, and these efforts are not directly covered by revenue. If we recognize the urgency of need in developing these concepts, we can justify the manpower and staffing expenditures each organization is willing to shoulder in reaching Imaging 3.0.

Professional Component Payment Reductions for Diagnostic Imaging Examinations When More Than One Service Is Rendered by the Same Provider in the Same Session: An Analysis of Relevant Payment Policy

PURPOSE The aim of this study was to assess potential physician work efficiencies when more than one diagnostic imaging study is interpreted by the same provider during the same session. METHODS Medicare Physician Fee Schedule data from the American Medical Association Resource-Based Relative Value Scale Data Manager for 2011 were analyzed to quantify relative contributions of preservice, intraservice, and postservice physician work to the total work of rendering diagnostic imaging services. An expert panel review identified potential duplications in preservice and postservice work when multiple examinations are performed on the same patient during the same session. Maximum potential percentage work duplication for various diagnostic imaging modalities was calculated and compared to US Government Accountability Office estimates. RESULTS The relative contributions of preservice and postservice work to total work varied by modality, ranging from 20% [computed tomography (CT)] to 33% (ultrasound). The maximum percentage of potentially duplicated preservice and postservice activity ranged from 19% (nuclear medicine) to 24% (ultrasound). Maximum mean potentially duplicated work relative value units ranged from 0.0212 for radiography to 0.0953 for magnetic resonance imaging (MRI). Maximum percentage work reduction ranged from 4.32% for CT to 8.15% for ultrasound. This corresponds to maximum professional Physician Fee Schedule reductions of only 2.96% (CT) to 5.45% (ultrasound), approximating an order of magnitude less than the Government Accountability Offices recommendations. CONCLUSION Although potential efficiencies in physician work occur when multiple services are provided to the same patient during the same session, these are highly variable and considerably less than previously estimated.

Accountable Care Organizations: what they mean for the country and for neurointerventionalists

The Affordable Care Act is celebrating its fifth anniversary and remains one of the most significant attempts to reform healthcare in US history. Prior to the federal legislation, Accountable Care Organizations had largely been part of an academic discussion about how to control rising healthcare costs, but have since become a fixture in our national healthcare landscape. A fundamental shift is underway in the relationship between healthcare delivery and payment models. Some elements of Accountable Care Organizations may remain unfamiliar to most healthcare providers, including neurointerventional specialists. In this paper we review the fundamental concepts behind and the current forms of Accountable Care Organizations, and discuss the challenges and opportunities they present for neurointerventionalists.

Original articleRadiologist Manpower Considerations and Imaging 3.0: Effort Planning for Value-Based Imaging

Our specialty is seeking to establish the value of imaging in the longitudinal patient-care continuum. We recognize the need to assess the value of our contributions rather than concentrating primarily on generating revenue. This recent focus is a result of both increased cost-containment efforts and regulatory demands. Imaging 3.0 is a value-based perspective that intends to describe and facilitate value-based imaging. Imaging 3.0 includes a broad set of initiatives addressing the visibility of radiologists, and emphasizing quality and safety oversight by radiologists, which are new directions of focus for us. Imaging 3.0 also addresses subspecialty imaging and off-hours imaging, which are existing areas of practice that are emblematic of inconsistent service delivery across all hours. Looking to the future, Imaging 3.0 describes how imaging services could be integrated into the framework of accountable care organizations. Although all these efforts may be essential, they necessitate manpower expenditures, and these efforts are not directly covered by revenue. If we recognize the urgency of need in developing these concepts, we can justify the manpower and staffing expenditures each organization is willing to shoulder in reaching Imaging 3.0.

Alternative Payment Models in Radiology: The Legislative and Regulatory Roadmap for Reform

The Medicare Access and CHIP Reauthorization Act (MACRA) replaces the sustainable growth rate with a payment system based on the Merit-Based Incentive Payment System and incentives for alternative payment model participation. It is important that radiologists understand the statutory requirements of MACRA. This includes the nature of the Merit-Based Incentive Payment System composite performance score and its impact on payments. The timeline for MACRA implementation is fairly aggressive and includes a robust effort to define episode groups, which include radiologic services. A number of organizations, including the ACR, are commenting on the structure of MACRA-directed initiatives.

Recent trends in adherence to continuous screening for breast cancer among Medicare beneficiaries

OBJECTIVE The aim of this study is to examine recent trends in adherence to continuous screening, especially the rate of subsequent screening mammography following an initial screening before and after the U.S. Preventive Services Task Force (USPSTF) revised its guidelines on breast cancer in November 2009. METHODS We retrospectively analyzed Medicare fee-for-service claims data to: 1) compare rate of subsequent screening mammography over 27 month periods for 317,150 women screened in either 2004 or 2009; and 2) examine patterns of subsequent screening by age and race. RESULTS When adjusted for age, race, state of residence, county-level covariates, and clustered on ordering provider, the rate of subsequent screening decreased in 2009 relative to 2004 (OR=0.75; 95% CI: 0.74-0.76). Adjusted odds ratios are similar for alternative follow-up windows (15 months, 0.71; 24 months, 0.70; 30 months 0.75). The decline was mostly attributable to women 75 and older who are now less likely to return for a subsequent screening. Although USPSTF guidelines call for 24 months, approximately half of women continue screening at 12-month intervals in both cohorts. CONCLUSIONS The rate of subsequent screening mammography has declined after 2009. Older women seem to follow the revised USPSTF guideline, but confusion by physicians and patients about competing guidelines may be contributing to these findings.