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Background: The Value-Based Healthcare (VBH) concept is designed to improve individual healthcare outcomes without increasing expenditure, and is increasingly being used to determine resourcing of and reimbursement for medical services. Radiology is a major contributor to patient and societal healthcare at many levels. Despite this, some VBH models do not acknowledge radiology's central role; this may have future negative consequences for resource allocation., Methods, Findings and Interpretation: This multi-society paper, representing the views of Radiology Societies in Europe, the USA, Canada, Australia, and New Zealand, describes the place of radiology in VBH models and the health-care value contributions of radiology. Potential steps to objectify and quantify the value contributed by radiology to healthcare are outlined., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Purpose: Despite the emergence of core-needle (percutaneous) biopsy as the standard of breast care, open surgical breast biopsies continue to be performed with variable frequency. The aim of this study was to compare trends in the use of percutaneous and open surgical breast biopsies and the relative roles of radiologists and surgeons in performing them., Methods: The nationwide Medicare Part B Physician/Supplier Procedure Summary Master Files for 2004 to 2016 were reviewed, and trends were studied in the total volume of breast biopsies performed in the Medicare fee-for-service population and in volumes of imaging-guided percutaneous biopsies (IGPBs) and open surgical biopsies. Using Medicare's physician specialty codes, the numbers of procedures performed by different specialties were determined. Trends in the type of imaging used for IGPBs were analyzed using the relevant Current Procedural Terminology codes, introduced in 2014., Results: Between 2004 and 2016, utilization of IGPBs increased from 124,423 to 187,914 (+51%), whereas the use of open surgical breast biopsies declined from to 6,605 to 2,373 (-64%). IGPBs performed by radiologists increased from 89,493 to 160,485 (+79%), and IGPBs by surgeons declined from 30,264 to 24,703 (-18%). Among IGPBs from 2014 to 2016, ultrasound-guided and MRI-guided percutaneous biopsies increased, whereas stereotactic biopsies declined., Conclusions: There is a steady upward trend in the utilization of imaging-guided breast biopsies, and a majority are performed by radiologists. Ultrasound is the primary guidance technique used in percutaneous breast biopsies., (Copyright © 2020 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Previous studies demonstrated rapid growth in payments to nonradiologist providers (NRPs) for MRI and CT in their private offices. In this study, we re-examine the trends in these payments., Methods: The nationwide Medicare Part B master files from 2004 to 2016 were accessed. They provide payment data for all Current Procedural Terminology codes. Codes for MRI and CT were selected. Global and technical component claims were counted. Medicare specialty codes identified payments made to NRPs and radiologists, and place-of-service codes identified payments directed to their private offices., Results: Medicare MRI payments to NRPs peaked in 2006 at $247.7 million. As a result of the Deficit Reduction Act, there was a sharp drop to $189.5 million in 2007, eventually declining to $101.6 million by 2016 (-59% from peak in 2006). The NRP specialty groups with the highest payments for MRI ownership include orthopedists, neurologists, primary care physicians, and hospital-based specialists (pathology, physiatry, and hospitalists). Medicare CT payments to NRPs peaked in 2008 at $284.1 million and declined to $94.7 million in 2016 (-67% from peak). Cardiologists, primary care physicians, internal medicine specialists, urologists, and medical oncologists accounted for the most payments made to NRPs. Dollars paid to radiologists for private office MRI and CT dropped substantially since they peaked in 2006., Conclusions: NRP private offices (and radiology offices also) experienced massive decreases in Medicare payments for MRI and CT since peaking in 2006 and 2008, respectively. These trends suggest the financial viability of private office practice may be in jeopardy. However, certain recent policy changes could promote a resurgence., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to analyze the utilization of elective stress nuclear myocardial perfusion imaging (MPI) in the Medicare population., Methods: Nationwide Medicare Part B fee-for-service databases for 2004 to 2016 were reviewed. Current Procedural Terminology codes for stress MPI were selected: standard planar and single-photon emission computed tomography (STD) and PET. Utilization rates per 1,000 Medicare beneficiaries were calculated. Elective examinations were identified using place-of-service codes for private offices and hospital outpatient departments (HOPDs). Medicare physician specialty codes identified the performing physician. Because Medicare Part B databases are complete population counts, sample statistics were not required., Results: Elective STD MPI utilization peaked in 2006 at 74 studies/1,000 and had declined by 36% by 2016. Cardiologists' share of STD MPI grew from 79% to 87% between 2004 and 2016. Cardiologists perform STD MPI primarily in private offices, where utilization peaked in 2008 and then demonstrated an absolute decline of 28 studies/1,000 by 2016. During this same time period, cardiologists' use of STD MPI in HOPDs demonstrated an absolute increase of 8.1 studies/1,000. From 2004 to 2016, STD MPI use by radiologists declined by 58%. Elective PET MPI maintained an upward trend, reflecting increasing use by cardiologists in private offices., Conclusions: Elective STD MPI use is declining, but cardiologists are performing an increasing share in outpatient settings. The drop in private office STD MPI among cardiologists was far greater than the corresponding increase in its use in HOPDs, suggesting that many studies previously performed in private offices were unindicated. Self-referred PET MPI utilization has rapidly grown in cardiology private offices., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Patients with high-deductible health plans will increasingly be motivated to contact their hospitals or various websites to try to obtain information about the costs of expensive services like advanced imaging. Unfortunately, they will not find price transparency but rather confusion and opaqueness. Hospital personnel and commercial websites often unwittingly provide erroneous pricing information. The reasons for this are explained. Detailed examples of the erroneous information are provided. State-mandated websites may be somewhat of an improvement, but their methodology seems to vary from state to state, and they too can be confusing. All this obviously creates problems for patients, who are left not knowing what their true costs will be. The situation also creates problems for radiologists and their hospitals. Because of misunderstandings that can occur during the information-gathering phase, the pricing information shown for many hospital facilities may be greatly inflated, placing them at a competitive disadvantage. Certain strategic solutions to the problems are available, and these are discussed., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To assess recent trends in utilization of coronary CT angiography (CCTA), based upon place of service and provider specialty., Materials and Methods: The nationwide Medicare Part B master files for 2006 through 2016 were the data source. Current Procedural Terminology, version 4 codes for CCTA were selected. The files provided procedure volume for each code. Utilization rates per 100,000 Medicare fee-for-service enrollees were then calculated. Medicare's place-of-service codes were used to identify CCTAs performed in private offices, hospital outpatient departments (HOPDs), emergency departments (EDs), and inpatient settings. Physician specialty codes were used to identify CCTAs interpreted by radiologists, cardiologists, and all other physicians as a group. Medicare practice share was defined as the percent of total Medicare utilization that was billed by each specialty., Results: The total utilization rate of CCTA in the Medicare population rose sharply from 2006 to 2007, peaking at 210.3 per 100,000 enrollees in 2007. Radiologists' CCTA practice share in 2007 was 32%, compared with 60% for cardiologists. The overall utilization rate then declined to a nadir of 107.1 per 100,000 enrollees in 2013, but subsequently increased to 131.0 by 2016. By that year, radiologists' share of CCTA practice had risen to 58%, compared with 38% for cardiologists. HOPD utilization increased sharply since 2010, primarily among radiologists. In EDs and inpatient settings, greater utilization has also occurred recently, primarily among radiologists. By contrast, private office utilization has dropped sharply since 2007., Conclusion: After years of declining utilization, the utilization rate of CCTA is now increasing, predominantly among radiologists., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Examine recent trends in the use of skeletal radiography and assess the roles of various nonradiologic specialties in the interpretations., Methods: Medicare Part B fee-for-service claims data files from 2003 to 2015 were analyzed for all Current Procedural Terminology, version 4 (CPT-4) procedure codes related to skeletal radiography. The files provide examination volume, and we calculated utilization rates per 1,000 Medicare beneficiaries. Medicare's physician specialty codes were used to determine the specialties of the providers. Total utilization rate trends were analyzed, as well as those for radiologists and nonradiologists. We determined which nonradiologist specialties were the highest users of skeletal radiography. Medicare place-of-service codes were used to identify the locations where the services were provided., Results: The total utilization rate per 1,000 of skeletal radiography within the Medicare population increased 9.5% from 2003 to 2015. The utilization rate for radiologists increased 5.5% from 2003 to 2015 versus 11.1% for nonradiologists as a group. Among nonradiologist specialties in all health care settings over the study period, orthopedic surgeons increased 10.6%, chiropractors and podiatrists together increased 14.4%, nonphysician providers (primarily nurse practitioners and physician assistants) increased 441%, and primary care physicians' rate decreased 33.5%. Although radiologists do almost all skeletal radiography interpretation in hospital settings, nonradiologists do the majority in private offices. There has been strong growth in skeletal radiography in emergency departments, but a substantial drop in inpatient settings., Conclusions: The utilization of skeletal radiography has increased more rapidly among nonradiologists than among radiologists. This raises concerns about self-referral and quality., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To ascertain the proportion of all Medicare payments to physicians under the Medicare Physician Fee Schedule (PFS) that is attributable to noninvasive diagnostic imaging (NDI)., Materials and Methods: The Medicare Part B Physician/Supplier Procedure Summary Master Files for 2003 to 2015 were the data source. Total approved payments to physicians for all medical services were determined each year. We then selected all procedure codes for NDI and determined aggregate approved payments to physicians for those codes. Also, Medicare's provider specialty codes were used to define payments to four provider categories: radiologists, cardiologists, all other physicians, and independent diagnostic testing facilities together with multispecialty groups (in this category, the specialty of the actual provider cannot be determined)., Results: Total Medicare-approved payments for all physician services under the PFS increased progressively from $92.73 billion in 2003 to $132.85 billion in 2015. In 2003, the share of those payments attributable to NDI was 9.5%, increasing to a peak of 10.8% in 2006, but then progressively declining to 6.0% in 2015. All four provider categories saw the same trend pattern-a peak in 2006 but then decline thereafter. By 2015, the shares of total PFS payments to physicians that were attributable to NDI were as follows: radiologists 3.2%, cardiologists 1.2%, all other physicians 1.2%, independent diagnostic testing facilities or multispecialty groups 0.4%., Conclusion: The proportion of Medicare PFS spending on physician services that is attributable to NDI has been declining in recent years and is now quite small., (Copyright © 2018 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: MRI and ultrasound (US) are effective diagnostic tools to evaluate extremities. In this study, we analyze utilization trends in musculoskeletal (MSK) US and MRI from 2003 to 2015 within the Medicare population., Methods: Our data sources were the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2003 to 2015. They cover all Medicare fee-for-service enrollees (37.5 million in 2015). Current Procedural Terminology codes for nonvascular, nonspine joint MRI and extremity US were selected and volumes within these codes were determined. Medicare's physician specialty codes were used to identify provider specialty. We accounted for the 2011 code change that created both complete and limited US examinations., Results: Total Medicare joint MRI volume increased from 738,509 in 2003 to 1,131,503 in 2015 (+53%), although there was little change after 2007. Radiologist MRI share in 2015 was 93%, followed by orthopedic surgeons at 5%. Total MSK US volume grew from 96,235 in 2003 to 429,695 in 2015 (+347%). Radiologists' market share of US decreased from 65% in 2003 to 37% in 2015, with nonradiologists now representing a majority of ultrasound examinations. Multiple nonradiology subspecialties also exceed radiology in volume of complete ultrasounds., Conclusion: The potential negative impact of MSK US on MSK MRI volume is likely overestimated because MRI volume has remained stable. MSK ultrasound is increasingly utilized outside radiology. If radiologists want to maintain their market share as MSK imaging leaders, more emphasis should be placed on increasing their involvement and expertise in MSK US., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to assess recent trends in Medicare reimbursements to radiologists, cardiologists, and other physicians for noninvasive diagnostic imaging (NDI)., Methods: The Medicare Part B databases for 2002 to 2015 were the data source. These files provide total allowed payments for all NDI Current Procedural Terminology codes under the Medicare Physician Fee Schedule. Medicare specialty codes were used to identify payments to radiologists, cardiologists, and all other specialists. In additional to total reimbursements, those made for global, technical component, and professional component claims were studied., Results: Total reimbursements to physicians for NDI under the Medicare Physician Fee Schedule peaked at $11.936 billion in 2006. Over the ensuing years, the Deficit Reduction Act and other cuts reduced them by 33% to $8.005 billion in 2015. Reimbursements to radiologists peaked at $5.300 billion in 2006 but dropped to $4.269 billion by 2015 (-19.5%). NDI reimbursements to cardiologists dropped from $2.998 billion in 2006 to $1.653 billion by 2015 (-44.9%). Most other specialties also saw decreases over the study period. An important reason for the large decline for cardiologists was their dependence on global reimbursement, which saw a 50.5% drop from 2006 to 2015. Radiologists' global payments also dropped sharply (40.4%), but radiologists themselves were somewhat protected by receiving a much larger proportion of their reimbursement for the professional component, which was not nearly as affected by Medicare payment reductions., Conclusions: The Deficit Reduction Act and other NDI payment cuts that followed have created huge savings for the Medicare program but have led to sharp reductions in payments received by radiologists, cardiologists, and other physicians for those services., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare trends in utilization rates of imaging in the three hospital-based settings where imaging is conducted., Methods: The nationwide Medicare Part B databases for 2004-2014 were used. All discretionary noninvasive diagnostic imaging (NDI) CPT codes were selected and grouped by modality. Procedure volumes of each code were available from the databases and converted to utilization rates per 1,000 Medicare enrollees. Medicare's place-of-service codes were used to identify imaging examinations done in hospital inpatients, hospital outpatient departments (HOPDs), and emergency departments (EDs). Trends were observed over the life of the study., Results: Trendlines were strongly affected by code bundling in echocardiography in 2009, nuclear imaging in 2010, and CT in 2011. However, even aside from these artifactual effects, important trends could be discerned. Inpatient imaging utilization rates of all modalities are trending downward. In HOPDs, the utilization rate of conventional radiographic examinations (CREs) is declining but rates of CT, MRI, echocardiography, and noncardiac ultrasound (US) are increasing. In EDs, utilization rates of CREs, CT, and US are increasing. In the 3 years after 2011, when no further code bundling occurred, the total inpatient NDI utilization rate dropped 15%, whereas the rate in EDs increased 12% and that in HOPDs increased 1%., Conclusions: The trends in utilization of NDI in the three hospital-based settings where imaging occurs are distinctly different. Radiologists and others who are involved in deciding what kinds of equipment to purchase and where to locate it should be cognizant of these trends in making their decisions., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To analyze recent trends in utilization of the various noncardiac thoracic imaging modalities in the Medicare population., Methods: The Medicare Part B databases for 2002 through 2014 were reviewed. All CPT codes pertaining to noninvasive imaging of the thorax were selected and grouped into seven categories: x-ray, CT, computed tomographic angiography (CTA), nuclear scans (noncardiac), MRI, MR angiography, and ultrasound. Yearly utilization rates per 1,000 Medicare beneficiaries were calculated. Medicare physician specialty codes were used to determine how many studies were performed by radiologists versus nonradiologist physicians., Results: The total utilization rate of all chest imaging peaked at 1,090 per 1,000 in 2005, then progressively declined to 913 by 2014 (-16%). In 2002, radiologists' share of thoracic imaging was 87% and increased to 91% by 2014. Among all providers, the total utilization rate of chest CT rose sharply, peaked at 100 in 2007, and has remained steady at around 89-91 in more recent years. The CTA utilization rate rose progressively from 2 in 2002 to 23 in 2014. Utilization rates of nuclear chest imaging decreased steadily after 2002. Chest x-ray rates reached a peak of 976 in 2005 but then declined to 790 in 2014; this change was largely responsible for the decline in total thoracic imaging., Conclusion: Overall thoracic imaging utilization rates have declined in recent years, despite an increase in use of CT and CTA. The decline largely resulted from a decrease in use of chest x-rays., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The 2009 release of updated US Preventive Services Task Force (USPSTF) recommendations on screening mammography differed sharply from those of the American Cancer Society, the ACR, and the American College of Obstetricians and Gynecologists. The aim of this study was to ascertain the effect of these recommendations on the utilization of screening mammography in the Medicare population., Methods: The Medicare Part B Physician/Supplier Procedure Summary Master Files from 2005 through 2010 were used to determine the annual utilization rate of screening mammography from 2005 to 2010. A utilization trend line was plotted for those years., Results: The utilization rate of screening mammography per 1,000 women in the Medicare population was 311.6 in 2005 and increased gradually each year to 322.9 in 2009 (a compound annual growth rate of 0.9%). However, after the USPSTF recommendations were issued in late 2009, this rate decreased abruptly to 309.1 (-4.3%) in 2010., Conclusions: The abrupt decrease in the utilization of screening mammography in 2010 was in sharp contrast to the previous slow annual increases in its utilization from 2005 to 2009. Because there are no other factors to explain a decrease of this magnitude, it would seem that the USPSTF recommendations and the ensuing publicity resulted in a decrease in the utilization of screening mammography in the Medicare population in the first year after issuance of the new recommendations., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

In addition to being a profession, the practice of radiology is a business, and marketing is an important part of that business. There are many facets to marketing a radiology practice. The authors present a number of ideas on how to go about doing this. Some marketing methods can be directed to both patients and referring physicians. Others should be directed just to patients, while still others should be directed just to referring physicians. Aside from marketing, many of them provide value to both target audiences., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Radiologists are facing uncertain times, and in this kind of environment, strategic planning is important but difficult. In particular, it is hard to know whether future imaging volume will increase, decrease, or stay approximately the same. In this article, the authors discuss a variety of factors that will influence imaging use in the coming years. Some factors will tend to increase imaging use, whereas others will tend to curtail it. Some of these factors will affect individual groups differently, depending on their locations and the circumstances of their practices. Radiologists would be well advised to become aware of and consider these factors as they go about their planning processes., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to ascertain recent trends in noninvasive imaging utilization for suspected coronary artery disease., Methods: The Medicare Part B databases for 2001 to 2013 were reviewed. Current Procedural Terminology primary codes for radionuclide myocardial perfusion imaging (MPI), stress echocardiography (SE), and coronary CT angiography (CCTA) were selected. Physician specialty codes were used to designate providers as radiologists, cardiologists, and all others as a group. Procedure volumes were tabulated, and utilization rates per 1,000 Medicare beneficiaries were calculated over the period of study., Results: Total MPI utilization rates per 1,000 rose rapidly from 63.4 in 2001 to a peak of 88.0 in 2006 but declined every year thereafter, dropping to 61.9 in 2013. SE rates generally held steady around 12 to 13 from 2001 to 2010 but then began to decline, reaching 10.8 in 2013. Cardiologists predominate in both MPI and SE. CCTA rates were far lower. They peaked at 2.1 in 2007, but then dropped before leveling off at 1.07 in both 2012 and 2013. Radiologists and cardiologists have approximately equal roles in this procedure., Conclusions: Both MPI and SE seem to be declining in use in recent years. This is likely due to unfavorable reimbursement trends caused by code bundling and resulting in the closure of many private cardiology offices. CCTA use is far lower than the two other types of imaging and has also declined in recent years. This is puzzling, as it is a new and promising procedure that has some advantages over MPI and SE. In 2013, 58 times as many MPI studies as CCTA studies were performed., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To examine recent trends in the use of duplex ultrasound and noninvasive physiologic tests (NPTs) for determining the presence of peripheral arterial disease (PAD)., Methods: Medicare Part B databases for 2001-2013 were used. The two Current Procedural Terminology, version four codes for duplex ultrasound of lower-extremity arteries, and the three codes for NPTs of extremity arteries were selected. Procedure volumes of both types of examinations were determined, and utilization rates per 100,000 beneficiaries were calculated. Medicare specialty codes were used to determine what proportions were performed by the major specialty groups involved in these examinations: surgeons, cardiologists, radiologists, and primary care physicians (PCPs)., Results: Between 2001 and 2010 (the peak year), the total utilization rates per 100,000 of duplex ultrasound and NPTs increased by 94% and 84%, respectively. During the ensuing three years, small declines occurred in both. In 2013, utilization rates of both types of tests were far higher than they had been in 2001 (88% higher for duplex ultrasound; 63% higher for NPTs). From 2001 to 2013, use of duplex ultrasound increased 235% among cardiologists, 90% among surgeons, 76% among radiologists, and 53% among PCPs. Utilization rates of NPTs among surgeons were already high in 2001 and increased an additional 23% by 2013. The NPT utilization rates increased 180% among PCPs, 179% among cardiologists, and 61% among radiologists., Conclusions: During a period when little growth occurred in the incidence of PAD, sharp growth occurred in testing for the disease., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: In 2009, the results of two randomized controlled trials refuting the effectiveness of vertebroplasty compared with sham procedures were published in a leading journal. The purpose of the present study was to evaluate the impact of these randomized trials on subsequent volume and utilization rates of vertebral augmentation (VA) in the United States., Methods: Using nationwide Medicare Part B databases, Current Procedural Terminology, version 4, codes for thoracic and lumbar vertebroplasty and kyphoplasty were studied from 2006 to 2013 (codes 22520 to 22525). The total volumes of procedures were determined and utilization rates were calculated. Volumes and rates by provider specialty were also studied., Results: The total volume of VA procedures peaked in 2008 at 101,807 and thereafter fell steadily to 80,940 in 2013. The utilization rates per 100,000 beneficiaries also showed a similar trend. Radiologists performed the largest number of VA procedures in 2013 (33,618 procedures [42%]), followed by orthopedic surgeons (19,886 procedures [25%]). After 2009, vertebroplasty volumes decreased sharply. Kyphoplasty volumes increased in 2011, after an initial decrease in 2010. The divergent trend in the volumes of the two procedures persisted through 2013., Conclusions: After the publication of the two trials' results in 2009, vertebroplasty volumes and rates decreased sharply. However, there is an emerging trend toward performing more kyphoplasty procedures, mitigating the decrease in total volume of VA procedures. Radiologists have the strongest role in performing these procedures among all medical specialties., (Copyright © 2016 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To compare recent trends in the use of percutaneous and surgical approaches to treating abdominal abscesses in a large population., Methods: The nationwide Medicare Physician/Supplier Procedure Summary Master Files for 2001 through 2013 were searched. Current Procedural Terminology-4 codes were selected for the four types of abdominal abscesses that had distinct codes for both open surgical and percutaneous drainage-appendiceal, peritoneal, subphrenic, and liver. Medicare specialty codes were used to determine if the procedures were performed by radiologists or other nonradiologist physicians. Trends in use of the two approaches were compared., Results: In 2001, a total of 14,068 abdominal abscesses were drained percutaneously. This volume increased progressively every year thereafter, reaching 28,486 in 2013 (+102%). Open surgical drainage volume was 8,146 in 2001, decreasing progressively to 6,397 in 2013 (-21%). In 2001, 63% of all abdominal abscesses had been drained percutaneously; by 2013, this figure had risen to 82%. In 2001, radiologists had performed 90% of all percutaneous abdominal abscess drainages; this percentage share increased to 97% in 2013. Of all abdominal abscesses treated in 2013 in Medicare patients, 79% were treated by radiologists., Conclusions: Use of percutaneous drainage of abdominal abscesses has steadily increased, whereas use of open surgical drainage has declined. The vast majority of these abscesses are now treated percutaneously. Radiologists are a strong majority of those performing the procedures. Although this database does not provide information on outcomes, percutaneous drainage is another good example of radiology-related value., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Cerebral catheter angiography and endovascular neurointerventions (ENIs) were developed and refined by early pioneers in neuroradiology. Recently, with developments in the safety and efficacy of ENIs, other physician specialists have expressed strong interest in performing these procedures. Our purpose was to compare volume and utilization of ENIs, among the various specialties, from 2000 to 2013., Methods: Data from the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2000 to 2013 were used to study ENI volume and utilization rates, by radiologists, neurosurgeons, neurologists, vascular surgeons, cardiologists, and other physicians., Results: From 2000 to 2013, the volume of intracranial ENIs increased: overall, from 2,439 to 7,424; for radiologists, from 1,956 to 3,993; and for neurosurgeons, from 237 to 2,900. Although cardiologists did not perform many intracranial ENIs in these years, they performed most of the carotid artery stenting procedures (4,097, which is 51% of the total 8,201 performed in 2013)., Conclusions: Radiologists continue to maintain a strong presence in the field of neurointerventional radiology, particularly in percutaneous intracranial interventions, performing 51% of all intracranial procedures in 2013, down from 80% in 2000. However, neurosurgeons have made substantial inroads into ENI procedures, with their volume increasing from 10% to 33%, from 2000 to 2013. The overall volume of ENIs rose steadily from 2000 to 2013., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To study recent outpatient imaging trends in private offices and hospital outpatient departments (HOPDs), to determine if shifting between the two has occurred. Concern is currently focused on whether reduced reimbursements and other factors might lead to a shift to higher-cost HOPDs., Methods: The nationwide Medicare Physician/Supplier Procedure Summary Master Files for 2001 to 2013 were studied. All Current Procedural Terminology codes for MRI, echocardiography, nuclear medicine, ultrasound, and CT were selected, and procedure utilization rates per 1,000 Medicare beneficiaries were determined for each year. Medicare location codes identified the settings where the scans were performed., Results: Total utilization rates, per 1,000 beneficiaries, of all these examination types in private offices, grew from 478 in 2001, to 874 in 2008 (+83%), and then declined to 503 in 2011 (-42%), primarily as a result of code bundling. No further bundling occurred in 2012 or 2013, but the decline continued in those years, to 462. In HOPDs, the total rate rose from 416 in 2001, to 523 in 2008 (+26%), followed by similar bundling-related declines, to 418 (-20%) in 2011. But in 2012 and 2013, in contrast to private office trends, the HOPD rate increased to 447. The ratio of private office to HOPD advanced imaging was 1.67 in 2008, declining to 1.03 in 2013. In addition, individual modality shifts away from offices and into HOPDs were quite apparent., Conclusions: In recent years, a shift has occurred in utilization of all advanced imaging modalities, from private offices to HOPDs. This change could portend a loss of access for patients and an increase in costs., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether MR angiography (MRA) and CT angiography (CTA) have replaced diagnostic catheter angiography (DCA) in diagnosing peripheral arterial disease., Methods: Medicare Part B databases for 2002-2013 were reviewed. Current Procedural Terminology codes for extremity MRA, CTA, and DCA were selected. Physician specialty codes were used to classify providers as radiologists, cardiologists, or surgeons. Utilization rates per 100,000 Medicare beneficiaries were calculated., Results: Among all specialties, the combined utilization rate of all 3 types of angiography increased from 917 per 100,000 in 2002 to 1,261 in 2006 (+38%), after which it remained stable until 2010, and then declined to 1,010 in 2013. The overall rate of MRA and CTA together increased from 89 in 2002 to 440 in 2006 (+394%), after which it leveled off, and then gradually decreased to 331 in 2013. In 2013, 33% of the total procedures were MRA or CTA, up from 10% in 2002. Radiologists performed >85% of MRA and CTA examinations. Among radiologists, the DCA utilization rate decreased by 75% from 2002 to 2013, whereas among cardiologists and surgeons together, the overall DCA utilization rate increased by 64% from 2002 to 2010 before dropping somewhat in 2011., Conclusions: Among radiologists, MRA and CTA have replaced DCA in diagnosing peripheral arterial disease. Although overall utilization of DCA has remained steady, it has risen sharply among cardiologists and surgeons, while dropping sharply among radiologists. Given the increased utilization of DCA among cardiologists and surgeons despite noninvasive alternatives, self-referral continues to be of concern in the setting of increasing health care costs., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To determine whether recent reimbursement cuts have resulted in a shift of outpatient MRI from private offices to hospital outpatient departments (HOPDs); and to study office MRI utilization trends among radiologists and other specialists., Methods: The Medicare Part B Physician/Supplier Procedure Summary Master Files were used. MRI codes were aggregated, and total MRI volumes from 2002 to 2012 were studied. Medicare place-of-service codes were used to identify studies performed in private offices and HOPDs and create trend lines. Specialty codes were used to categorize private office MRI users as radiologists, orthopedic surgeons, other physicians, and independent diagnostic testing facilities., Results: Medicare office and HOPD utilization of MRI (all specialties) rose rapidly from 2002 to 2006, reaching 2,727,807 in offices and 2,355,641 in HOPDs. Thereafter, office volume steadily declined, whereas HOPD volume steadily increased. By 2012, more studies were done in HOPDs than in offices. Over the entire period from 2002 and 2012, office MRI volume among radiologists increased 27%, compared with 216% among orthopedic surgeons and 124% among other physicians., Conclusions: Although the majority of Medicare outpatient MRI studies had previously been performed in private offices, recent years brought a shift, with more now being performed in HOPDs. This change will increase costs to payers, because reimbursements to HOPDs are generally higher than those to offices. Although radiologists perform the majority of MRI exams that are conducted in private offices, the rate of growth for such exams from 2002 to 2012 was considerably higher among orthopedic surgeons and other physicians than among radiologists., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to examine recent trends in imaging utilization in emergency departments (EDs) in the Medicare population., Methods: The 2002 to 2012 Medicare Part B databases were used. Imaging studies were categorized by modality. Medicare's place-of-service codes identified those studies performed in ED patients. Specialty codes identified the specialties of the interpreting physicians. Utilization rates per 1,000 Medicare beneficiaries were calculated. Trends were assessed in plain radiography (XR), CT, noncardiac ultrasound, MRI, and nuclear medicine., Results: XR and CT were the most widely used modalities in ED patients. From 2002 to 2012, the XR utilization rate per 1,000 increased from 248.7 to 320.0 (+29%), and CT increased from 57.2 to 147.9 (+159%). Utilization rates of the other modalities were much lower. Ultrasound increased from 9.5 to 21.0 (+121%), while MRI increased from 1.4 to 5.1 (+264%). Growth in these 4 modalities was continuous and did not show the flattening that has characterized the utilization trends in other places of service. Nuclear medicine use was very low and remained essentially flat. During the study period, CT accrued 91 new examinations per 1,000, followed by XR at 71 and ultrasound at 11.5. The vast majority of examinations were interpreted by radiologists., Conclusions: Despite the cessation of overall utilization growth of the various modalities in recent years, ED utilization rates continued to increase. The greatest increases, in terms of accrued new examinations per 1,000, were seen in CT and XR. This suggests that radiologists and ED physicians need to work together to better manage imaging utilization., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: A news article in June 2011 reported that Medicare claims showed considerable overuse of "double" CT scans of the thorax (ie, combined scans without contrast followed by with contrast) at a number of hospitals. Most radiologists agree that they should be done only on rare occasions. The aim of this study was to determine what proportion of all thoracic CT scans are combined scans in the Medicare population., Methods: The data sources were the Medicare Part B Physician/Supplier Procedure Summary Master Files for 2001 to 2011. The 3 Current Procedural Terminology codes for thoracic CT (with contrast, without contrast, and without plus with contrast) were selected. Utilization rates per 1,000 beneficiaries and the percentage that were combined scans were calculated., Results: The utilization rate of combined scans increased from 2001 through 2006, remained steady in 2007, but then decreased sharply thereafter. The compound annual rate of change from 2007 to 2011 was -10.4%. From 2001 through 2006, combined thoracic CT scans constituted 6.0% to 6.1% of all thoracic CT scans. However, from 2006 to 2011, this percentage progressively declined, reaching a low of 4.2% in 2011., Conclusions: Despite the 2011 news report, only a very small percentage of thoracic CT scans nationwide are done both without and with contrast. Moreover, that percentage dropped by almost one-third from 2006 to 2011, suggesting that the practice is declining. The figure of 4.2% can be used as a benchmark against which to judge radiology facilities in the future., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: In 2009, the add-on codes for spectral Doppler and color flow Doppler echocardiography were bundled into the code for primary transthoracic echocardiography. The relative value units for the new single code were substantially lower than the previous sum for the 3 codes. The purpose of this study was to see how this affected the distribution of outpatient echocardiographic studies between cardiology offices and hospital outpatient departments (HOPDs)., Methods: The 2005 to 2011 Medicare databases were used. All echocardiography Current Procedural Terminology codes were selected. Specialty codes identified those done by cardiologists (who do most echocardiographic studies). Place-of-service codes identified those done in offices and HOPDs. Procedure volumes and utilization rates per 1,000 were determined each year before and after bundling occurred in 2009., Results: Cardiologists' office echocardiography utilization rate rose from 219.5 per 1,000 in 2005 to 257.1 in 2008 (+17%), then dropped to 100.0 in 2009 (-61%) because of bundling. Their HOPD echocardiography rate rose from 72.2 in 2005 to 76.5 in 2008 (+6%), then dropped to 35.0 in 2009 (-54%). From 2009 to 2011, cardiologists' office echocardiography rate dropped again from 100.0 to 88.8 (-11%), while their HOPD rate increased from 35.0 to 46.1 (+32%)., Conclusions: Echocardiography code bundling produced the expected sharp drop in outpatient claims from cardiologists in 2009. But after bundling, office echocardiography rates continued to drop, while HOPD rates increased. It seems that in this instance, code bundling led to the closure of many cardiology offices and a resultant shift of echocardiography from that lower cost setting to the higher cost HOPD setting., (Copyright © 2014 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Recent proliferation of mobile diagnostic ultrasound (US) units and improved resolution have allowed for widespread use of US by more providers, both for diagnosis and US-guided procedures (USGP). This study aims to document recent trends in utilization for USGP in the Medicare population., Methods: Source data were obtained from the CMS Physician Supplier Procedure Summary Master Files from 2004 to 2010. Allowed billing claims submitted for USGP were extracted and volume was analyzed by provider type and setting. Compound annual growth rates were calculated., Results: The total utilization rate for all USGP was 2,425 per 100,000 in 2004 and 4,870 in 2010, an increase of 100.8% (+2,445 per 100,000) with a compound annual growth rate of 12.3%. The year 2010 represents the first year that nonradiologists as a group performed more USGP than radiologists, at 922,672 versus 794,497 examinations, respectively. Nonradiologists accounted for 72.2% (599,751 of 830,925) of the USGP volume growth from 2004 to 2010. Most 2010 claims were submitted by radiologists (n = 794,497; 46.3%) and surgeons (n = 332,294; 19.4%). The largest overall volume increases from 2004 to 2010 were observed among radiologists, surgeons, anesthesiologists, rheumatologists, midlevel providers, primary care physicians, nonrheumatologist internal medicine subspecialists, and the aggregate of all other provider types., Conclusion: The year 2010 represents the first year that nonradiologists performed more USGP than radiologists. From 2004 to 2010, radiologists and surgeons experienced only modest growth in USGP volume, whereas several other provider types experienced more rapid growth. It is likely that many procedures that were previously performed without US guidance are now being performed with US guidance., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The rate of thoracic biopsies overall and by type of biopsy from 1998 to 2010 is not known. The aim of this study was to examine the utilization rate of various types of thoracic biopsies within the Medicare population., Methods: Source data was obtained from the CMS Physician/Supplier Procedure Summary Master Files from 1998 to 2010. Allowed primary claims submitted for percutaneous thoracic biopsy, bronchoscopic thoracic biopsy, and surgical thoracic biopsy were extracted. Annual volume and utilization rates were calculated and analyzed by biopsy type and provider type., Results: Total thoracic biopsy volume in 1998 was 176,125 and in 2010 was 167,911 (-4.7%). The utilization rate for all thoracic biopsies decreased from 5.47 per 1,000 in 1998 to 4.76 per 1,000 (-13.0%) in 2010. The percutaneous biopsy utilization rate increased 3.6% from 1998 to 2010, while the rate for surgical biopsy decreased by 20.9% and the rate of bronchoscopic biopsy decreased by 19.6% during the same time period. In 2010, radiologists performed 96.4% (58,679) of all percutaneous biopsies. Radiologists' thoracic biopsy market share increased from 26.2% (46,084 of 176,125) in 1998 to 35.0% (58,700 of 167,911) in 2010 (+33.6%)., Conclusions: The overall rate of thoracic biopsy decreased from 1998 to 2010, with fewer biopsies being performed surgically and bronchoscopically and more biopsies being performed percutaneously. Radiologists are responsible for an increasing role in thoracic diagnosis, as they have increased market share of thoracic biopsies. These findings may be the result of changing trends toward less invasive procedures, changing patterns of reimbursement, and increased availability of percutaneous biopsy., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to determine what proportion of noninvasive diagnostic imaging (NDI) work done by radiologists occurred in each of the 4 primary places of service where imaging is conducted., Methods: Medicare's Physician/Supplier Procedure Summary Master Files for 2000 to 2011 were the data source. Specialty codes were used to identify radiologists, and place-of-service codes identified studies done in hospital outpatient facilities, hospital inpatient facilities, private offices, and emergency departments (EDs). The applicable total professional component relative value units (RVUs) were assigned to each NDI Current Procedural Terminology code, and RVU rates per 1,000 Medicare beneficiaries were calculated. RVU rates reflect workload and costs and are therefore a better metric than utilization rates based on volume., Results: From 2000 to 2006, radiologists' RVU rates per 1,000 Medicare beneficiaries increased in each of the 4 primary venues. However, from 2006 to 2011, rates remained essentially flat in hospital outpatient and inpatient facilities and offices but continued to increase in EDs. Absolute RVU rate increases from 2000 through 2011 were 289 in hospital outpatient facilities, 218 in EDs, 194 in private offices, and 99 in inpatient facilities. In 2011, 19% of radiologists' workload occurred in offices; the remainder was conducted in the 3 hospital settings. Twice as much elective outpatient NDI work by radiologists was done in hospital outpatient facilities as in radiologists' private offices., Conclusions: Radiologists' workload in hospital outpatient and inpatient facilities and offices grew from 2000 through 2006, but no further growth occurred thereafter. EDs were the only venue where growth continued. The vast proportion of radiology NDI RVUs (81% in 2011) are produced in hospital settings., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Diagnostic imaging services have been repeatedly targeted as a source of excess health care expenditure. In particular, MRI is considered a high-tech and high-cost imaging service that saw rapid increases in utilization in the early 2000s. However, the most recent trends in the utilization of MR are not known. The aim of this study was to quantify trends in MR utilization overall and by body system from 1998 to 2010 in the Medicare population., Methods: Medicare Part B data sets were obtained for 1998 to 2010 for all MR examinations performed in the Medicare population. Using Current Procedural Terminology codes, the total volume and utilization rates of all MR examinations were tabulated for each year of the study period. MR volume was then categorized by body system., Results: The utilization rate of MR examinations in the Medicare population was 73 per 1,000 beneficiaries in 1998, increased to a peak of 189 in 2008, and decreased to 183 in 2010. The compound annual growth rate from 1998 to 2008 was 10%. The utilization rate in 2010 represents a decrease of 3.1% from the 2009 utilization rate. The most frequently imaged body section in every year was the head, which accounted for 2,404,250 examinations in 2010, 37.3% of all MR examinations in that year., Conclusions: The overall MRI utilization rate sharply increased from 1998 until 2008 but then decreased in each of the next 2 years. A similar trend was noted for MR examinations performed in most body sections. These trends are likely to be the result of a number of possible causative factors., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aims of this study were to examine recent trends in the utilization of radionuclide myocardial perfusion imaging (MPI) and to reflect on their causes and their implications for radiologists., Methods: Nationwide Medicare Part B databases for 2000 through 2010 were used. Codes for primary MPI studies (including PET) were selected. Medicare specialty codes were used to identify MPI examinations done by radiologists, cardiologists, and other physicians. Place-of-service codes were used to identify examinations performed in offices versus hospital settings. Utilization rates per 1,000 fee-for-service beneficiaries were calculated. Trends were assessed by place of service and specialty., Results: The overall MPI utilization rate rose from 2000 through 2004, followed by a period of stabilization from 2005 to 2008. A peak of 88.0 per 1,000 was reached in 2006. In 2009 and 2010, a decline occurred, with the rate dropping by 13% to 76.9. In private offices, cardiologists' utilization grew rapidly from 2000 through 2006, but growth stopped thereafter. Their rate peaked in 2008 at 50.6 but dropped to 44.4 by 2010 (-12%). Radiologists' role in office MPI was minimal. In hospital settings, radiologists predominated in 2000. Their rate remained stable through 2004 but thereafter began to decline steadily, dropping by 35% by 2010. Cardiologists' hospital-based utilization rate rose gradually, then flattened, but began to rise in 2009 and 2010. By 2010, cardiologists performed more hospital MPI examinations than radiologists., Conclusions: Radiologists' initially predominant role in hospital-based MPI has eroded recently, while that of cardiologists has strengthened. This seems related to a shift among cardiologists away from office practice and into hospital affiliations., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The 2009 release of updated US Preventive Services Task Force (USPSTF) recommendations on screening mammography differed sharply from those of the American Cancer Society, the ACR, and the American College of Obstetricians and Gynecologists. The aim of this study was to ascertain the effect of these recommendations on the utilization of screening mammography in the Medicare population., Methods: The Medicare Part B Physician/Supplier Procedure Summary Master Files from 2005 through 2010 were used to determine the annual utilization rate of screening mammography from 2005 to 2010. A utilization trend line was plotted for those years., Results: The utilization rate of screening mammography per 1,000 women in the Medicare population was 311.6 in 2005 and increased gradually each year to 322.9 in 2009 (a compound annual growth rate of 0.9%). However, after the USPSTF recommendations were issued in late 2009, this rate decreased abruptly to 309.1 (-4.3%) in 2010., Conclusions: The abrupt decrease in the utilization of screening mammography in 2010 was in sharp contrast to the previous slow annual increases in its utilization from 2005 to 2009. Because there are no other factors to explain a decrease of this magnitude, it would seem that the USPSTF recommendations and the ensuing publicity resulted in a decrease in the utilization of screening mammography in the Medicare population in the first year after issuance of the new recommendations., (Copyright © 2013 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

In response to the current era of rapid evolution of health care delivery and financing, radiologists are increasingly considering, as well as confronting, new practice models. Hospital employment is one such opportunity. Within this report to the ACR membership, the potential advantages and risks for radiologists considering hospital employment are examined., (Published by Elsevier Inc.)

Purpose: The aim of this study was to examine recent CT utilization trends to ascertain if growth is still occurring., Methods: The nationwide Medicare Part B databases for 2000 through 2010 were used. All Current Procedural Terminology, fourth ed, codes for diagnostic CT (including CT angiography) were selected. Place-of-service codes were used to determine whether the studies were performed in inpatients, emergency department (ED) patients, hospital outpatient departments, or private offices. Utilization rates per 1,000 Medicare fee-for-service beneficiaries were calculated., Results: The total Medicare CT utilization rate increased each year from 325 per 1,000 in 2000 to 637 per 1,000 in 2009, representing a compound annual growth rate (CAGR) of 7.8%. But in 2010, the rate dropped for the first time, to 626 per 1,000 (-1.7%). For inpatient CT, the 2000 to 2009 CAGR was +5.5%, followed by a drop of 4.5% in 2010. For hospital outpatient department CT, the 2000 to 2009 CAGR was +5.1%, followed by a drop of 3.6% in 2010. For private office CT, the 2000 to 2009 CAGR was +11.3%, followed by a 7.8% drop in 2010. Emergency departments were the only location that saw continued growth, with a 2000 to 2009 CT CAGR of +15.2%, followed by another 8.4% increase in 2010., Conclusions: After years of rapid growth, CT use in the Medicare population declined by 1.7% in 2010. The proportional decline was even greater among inpatients, hospital outpatient departments, and offices. The only place of service for which growth continued was emergency departments. Without the effect of emergency departments, the decline in 2010 would have been 4.7%. This downturn should help alleviate previous concerns about overly rapid CT growth., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to examine recent trends in Medicare reimbursements for noninvasive diagnostic imaging (NDI)., Methods: The Medicare Part B databases for 2000 to 2010 were used. For each procedure code, these files provide payment and other data. All NDI codes were selected. Medicare physician specialty codes were used to identify radiologists, cardiologists, all other nonradiologist physicians as a group, and independent diagnostic testing facilities. Part B NDI payment trends were tracked., Results: Overall Part B spending for NDI rose from $5.921 billion in 2000 to $11.910 billion in 2006 (+101%). There was then a sharp drop in 2007, resulting from the implementation of the Deficit Reduction Act. This was followed by a slight rise in 2008, then successive smaller drops the next 2 years, reaching $9.457 billion in 2010 (-21% vs 2006). Radiologists' payments were $2.936 billion in 2000, rose to a peak of $5.3 billion in 2006 (+81%), then dropped to $4.712 billion in 2010 (-11% vs 2006). Cardiologists' NDI payments were $1.327 billion in 2000, peaking at $2.998 billion in 2006 (+126%), then dropping to $1.996 billion in 2010 (-33% vs 2006). Other physicians' payments were $1.106 billion in 2000, peaking at $2.378 billion in 2006 (+115%), then dropping to $1.968 billion in 2010 (-17% vs 2006). Similar trends occurred in independent diagnostic testing facilities., Conclusions: After years of rapid growth in Medicare NDI payments, an abrupt reversal occurred starting in 2007. By 2010, overall NDI costs to Medicare Part B were down 21% compared with their 2006 peak. It is unclear whether this large payment reduction will satisfy federal policymakers., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: A recent paper in the American Journal of Surgery reported that surgery is used for 30% of breast biopsies, an excessive number. The investigators' stated biopsy volume included Current Procedural Terminology(®) code 19125 ("excision of breast lesion identified by preoperative placement of radiological marker, open"). However, this code may often be used when a surgeon's primary intention is not biopsy but rather excision of a lesion. Therefore, the reported results may overstate the percentage of biopsies performed as surgical procedures. The aim of this study was to more accurately assess the use of percutaneous core needle biopsy (PNB) compared with surgical biopsy., Methods: The nationwide Medicare Part B databases for 2004 to 2009 were used. Trends in use of codes 19100 (PNB without imaging), 19102 and 19103 (PNB with imaging), 19101 (open biopsy), and the aforementioned 19125 were determined., Results: From 2004 to 2009, the volumes of PNB with imaging (codes 19102 and 19103) increased substantially, while the volume of code 19125 decreased substantially. If one includes all 19125 claims as biopsies, the 2009 frequency of surgical biopsies was 18%. If one considers all 19125 claims as excisions, the frequency of surgical biopsies was 2%., Conclusions: The previously published statement in the American Journal of Surgery that 30% of breast biopsies are done surgically is erroneous. Medicare data indicate that the true surgical breast biopsy figure is somewhere between 2% and 18%. Given that the recommended rate is 10%, it seems that surgeons and radiologists are collaborating well and that surgical breast biopsy is not being overused., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: Over the past two decades, musculoskeletal (MSK) ultrasound has emerged as an effective means of diagnosing MSK pathologies. However, some insurance providers have expressed concern about increased MSK ultrasound utilization, possibly facilitated by the low cost and ready availability of ultrasound technology. The purpose of this study was to document trends in MSK ultrasound utilization from 2000 to 2009 within the Medicare population., Methods: Source data were obtained from the CMS Physician/Supplier Procedure Summary Master Files from 2000 to 2009, and records were extracted for procedures for extremity nonvascular ultrasound. We analyzed annual volume by provider type using specialties, practice settings, and geographic regions where the studies were performed., Results: In 2000, Medicare reimbursed 56,254 MSK ultrasound studies, which increased to 233,964 in 2009 (+316%). Radiologists performed the largest number of MSK ultrasound studies in 2009, 91,022, an increase from 40,877 in 2000. Podiatrists utilized the next highest number of studies in 2009, 76,332, an increase from 3,920 in 2000. Overall, private office MSK ultrasound procedures increased from 19,372 in 2000 to 158,351 in 2009 (+717%). In 2009, podiatrists performed the largest number of private office procedures (75,544) and accounted for 51.5% of the total private office growth from 2000 to 2009. Radiologist private office procedures totaled 19,894 in 2009, accounting for 9.2% of the total private office MSK ultrasound growth., Conclusions: The MSK ultrasound volume increase among nonradiologists, especially podiatrists, was far higher than that among radiologists from 2000 and 2009, with the highest growth in private offices. These findings raise concern for self-referral., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: After the Deficit Reduction Act (DRA) took effect in 2007, there was concern that private office-based imaging facilities would close, that advanced imaging would shift to less convenient hospital-based facilities, and that access to advanced imaging might be restricted. The aim of this study was to see if these developments occurred during the years after the DRA., Methods: Using Medicare data, outpatient CT, MRI, and nuclear medicine trends before and after the DRA were studied. Procedure volumes performed in private offices and hospital outpatient departments (HOPDs) were tabulated separately. Volumes were tracked from 2000 to 2006 (before the DRA) and from 2007 to 2009 (after the DRA), and compound annual growth rates were calculated for the two periods., Results: In all 3 modalities, growth before the DRA was far more rapid than afterward. Compound annual growth rates from 2007 to 2009 in offices and HOPDs were, respectively, +2.1% and +0.5% for CT, -1.1% and +1.0% for MRI, and -1.7% and -2.5% for nuclear medicine. Growth trends in all 3 modalities showed distinct flattening beginning around 2005 to 2006., Conclusions: From 2007 to 2009 (after the DRA), there was more rapid CT volume growth in offices than in HOPDs. Concurrently, there was some loss of nuclear medicine volume in both settings, but the loss was less in offices. Thus, in CT and nuclear medicine, offices actually fared better after the DRA than HOPDs. In MRI, HOPDs fared slightly better than offices. It thus seems that there has been no shift away from offices and as yet no loss of access to CT or MRI after the DRA. However, some loss of access to nuclear medicine does seem to have occurred., (Copyright © 2012 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The use of point-of-care (POC) ultrasound by nonradiologist physicians has recently been advocated. The aim of this study was to see how widespread this practice is., Methods: The Medicare Part B databases for 2004 to 2009 were used. Global and professional component claims for noncardiac ultrasound were tabulated, and utilization rates per 1,000 beneficiaries were calculated. Provider specialty was determined. Utilization rates of ultrasound by radiologists and other specialists were compared, and changes over the years were studied., Results: In 2009, 425.3 Medicare noncardiac ultrasound examinations per 1,000 beneficiaries were performed (+21% since 2004). Of these, radiologists performed 233.7 (55%), and another 15.6 (4%) were done at independent diagnostic testing facilities, for which provider specialty could not be determined. The remaining 175.7 (41%) constituted POC ultrasound by nonradiologists. Between 2004 and 2009, radiologists' utilization rate increased by 17%, compared with 28% for nonradiologists. Radiologists' market share of noncardiac ultrasound was 56.6% in 2004 and 54.9% in 2009. Other major specialties involved in POC ultrasound and their 2009 rates per 1,000 and percentage increases since 2004 were cardiology (39.7 [+60%]), vascular surgery (34.9 [+36%]), primary care (27.2 [+11%]), general surgery (24.2 [+8%]), and urology (22.3 [+12%])., Conclusions: Between 2004 and 2009, there was a 21% increase in the overall utilization rate of noncardiac ultrasound. Point-of-care ultrasound by nonradiologists amounted to 41% of all studies done in 2009. Multiple nonradiologic specialties are involved, but radiologists' involvement is far higher than any other single specialty. Radiologists' ultrasound market share remained relatively stable between 2004 and 2009., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: To study utilization trends in the various imaging modalities in emergency departments (EDs) over a recent multiyear period., Methods: The nationwide Medicare Part B databases for 2000 to 2008 were queried. Medicare's location codes were used to identify imaging examinations done on ED patients. All diagnostic imaging Current Procedural Terminology(®) codes were grouped by modality. For each code, the database provides procedure volume; utilization rates per 1,000 beneficiaries were then calculated. Medicare's physician specialty codes were used to determine provider specialty. Utilization trends were studied between 2000 and 2008., Results: The overall utilization rate per 1,000 beneficiaries for all imaging in EDs increased from 281.0 in 2000 to 450.4 in 2008 (+60%). The radiography utilization rate rose from 227.3 in 2000 to 294.3 in 2008 (+29%, 67 accrued new studies per 1,000). The CT rate rose from 40.0 in 2000 to 130.7 in 2008 (+227%, 90.7 accrued new studies per 1,000). The ultrasound rate rose from 9.6 in 2000 to 18.7 in 2008 (+95%, 9.1 accrued new studies per 1,000). Other modalities had much lower utilization. In 2000, CT constituted 14% of all ED imaging, but by 2008, it constituted 29%. In 2008, radiologists performed 96% of all ED imaging examinations., Conclusions: The rate of utilization of imaging is increasing in EDs. Growth is by far the most pronounced in CT, in terms of both the growth rate itself and the actual number of accrued new studies per 1,000 beneficiaries. Radiologists strongly predominate as the physicians of record for all ED imaging., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The authors discuss the ways in which a single, cohesive, on-site radiology group adds value to both the processes of patient care and the success of the hospital. The value-added services fall into 6 categories: (1) patient safety, (2) quality of the images, (3) quality of the interpretations, (4) service to patients and referring physicians, (5) cost containment, and (6) helping build the hospital's business. If the hospital allows its radiology department to become fragmented by the intrusion of other specialists or teleradiology companies in remote locations, most of these added values would be lost, and chaos could ensue., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The ACGME recognizes radiology's neuroradiology fellowship programs as the pathway to neuroradiology expertise. Members of the American Society of Neuroimaging have called for the expansion of neuroradiology fellowships for neurologists with informal accreditation through the United Council for Neurologic Subspecialties. The aim of this study was to investigate the number of neuroradiologic studies read by neurologists to assess their capacity to support fellowship positions at ACGME training criteria., Methods: The numbers of neuroradiologic studies interpreted by radiologists and neurologists in the inpatient and hospital outpatient settings were determined from the CMS Physician/Supplier Procedure Summary Master Files for 1996 to 2008. The ACGME requirements of 1,500 neuroradiologic CT and 1,500 neuroradiologic MR scans per fellow per year were used to calculate the number of fellowship positions that could be supported by each specialty., Results: In 2008, in the inpatient and hospital outpatient setting, radiologists interpreted 9,287,768 (98.3% of the total) and neurologists interpreted 43,107 (0.5% of the total) neuroradiologic examinations on Medicare patients. Per ACGME requirements, on the basis of CT volumes, radiologists could potentially train 4,256 neuroradiology fellows, compared with neurologists' 12 fellows, assuming a single fellow was exposed to every Medicare case. On the basis of MR volumes, radiologists and neurologists could train 1,935 and 16 fellows, respectively., Conclusions: Radiologists are responsible for interpreting the vast majority (98.3%) of neuroradiologic studies. Neurologists have a limited exposure to neuroradiologic CT and MR and could support only 12 fellowship positions by ACGME criteria on the basis of reading available 1996 to 2008 Medicare cases., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study was to evaluate trends in the placement and removal of inferior vena cava (IVC) filters in the Medicare population., Methods: Summary Medicare claims data from 1999 through 2008 were used to identify the frequency of IVC filter placement procedures by specialty (radiology, surgery, cardiology, and all others) and site of service. Claims from 2003 (the first year the FDA cleared retrievable labeling for filters) through 2008 were used to identify intravascular foreign body retrieval procedures, and modeling was used estimate a frequency range of removal procedures. Trends over time were evaluated., Results: Between 1999 and 2008, total Medicare fee-for-service beneficiary frequency of IVC filter placement procedures increased by 111.5% (30,756 to 65,041). Volumes increased for radiologists (16,531 to 36,829 [+122.8%]), surgeons (11,295 to 22,606 [+100.1%]), and cardiologists (1,025 to 4,236 [+313.3%]). Relative specialty market shares changed little over time. Volumes increased by 114.2% (26,511 to 56,774) and 229.1% (2,286 to 7,524) for hospital inpatients and outpatients, respectively, and decreased by 62.1% (1,959 to 743) for those in all other locations combined. In 2008, with 65,041 filters placed, only an estimated 801 to 3,339 (1.2 to 5.1%) were removed., Conclusion: The frequency of IVC filter placement has doubled over the past decade, and radiologists continue to perform more than half of all procedures. Although volume has more than tripled in hospital outpatients, the inpatient setting remains by far the most common site of service. In the Medicare population, IVC filters are not commonly removed., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Accountable care organizations have received considerable attention as a component of health care reform and have been specifically addressed in recent national legislation and demonstration projects by CMS. The role or roles of radiologists in such organizations are currently unclear, as are changes to the ways in which imaging services will be delivered. The authors review concepts fundamental to accountable care organizations and describe roles for radiologists that may facilitate their success in such health care delivery systems., (Copyright © 2011 American College of Radiology. Published by Elsevier Inc. All rights reserved.)