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Background Missed appointments can have an adverse impact on health outcomes by delaying appropriate imaging, which can be critical in influencing treatment decisions. Objective To assess for socioeconomic and imaging exam factors associated with missed appointments among children scheduled for diagnostic imaging. Materials and methods We retrospectively analyzed children (21 days (OR=3.7; 95% CI=2.9–4.8). The use of radiation, intravenous contrast agent or sedation was not associated with increased likelihood of missed appointments. Conclusion Expanding our knowledge of how different socioeconomic and imaging-related factors influence missed appointments among children can serve as a foundational step to better understand existing and emerging disparities and inform strategies to advance health equity efforts in radiology.

Rationale and Objectives In 2019, Centers for Medicare and Medicaid Services enforced regulation from the Affordable Care Act, requiring all U.S. hospitals to publish standard hospital charges annually. This study assesses top U.S academic hospitals’ chargemasters for selected advanced diagnostic imaging services and the usability of publicly available information to allow consumers to determine out-of-pocket costs. Materials and Methods Publicly available chargemasters and associated websites for the top 20 ranked hospitals in U.S. News and World Report were assessed for several features including: file format, inclusion of CPT codes, disclaimers on charges versus costs and professional fees, and tools allowing determination of actual out-of-pocket costs for selected advanced diagnostic imaging examinations. Results All hospitals had publicly available chargemasters, 90% of which were in Microsoft Excel format. Ten percent of chargemasters included CPT codes. All chargemaster websites had disclaimers regarding differences between charges versus patient costs; 20% had disclaimers regarding professional fees. 20% of hospitals provided out-of-pocket costs for uninsured patients or tools allowing out-of-pocket cost determination. Median (range) MR exam charges were: brain with and without contrast: $5375 ($834–$13,857), noncontrast knee: $3402 (4530–$6924); noncontrast lumbar spine: $ 3449 ($473–$7367). Median (range) CT exam charges were: noncontrast head: $1923 ($165–$4974), noncontrast chest: $1947 ($282–$2991); contrast abdomen/pelvis: $4307 ($486–$11,726). Conclusion While all top-ranked hospitals had publicly available chargemasters, they rarely provided transparent information to allow patients to determine out-of-pocket costs for advanced diagnostic imaging services.

Purpose To determine the variability in out-of-pocket costs of lung cancer screening (LCS) for uninsured patients and assess accessibility of this information by telephone or Internet. Methods LCS centers from the ACR’s LCS database were randomly selected. Centers were called between July and August 2019 to determine out-of-pocket cost. Telephone call variables, accessibility of cost information on screening centers’ websites, screening centers’ chargemasters, and publicly available facility and state insurance coverage variables were obtained. Cost information was summarized using descriptive analyses. Multiple variable linear regression analyses were conducted to evaluate effects of facility and state-level characteristics on out-of-pocket costs. Results Fifty-five ACR-accredited LCS centers were included with 78% (43 of 55) willing to provide out-of-pocket cost. Average out-of-pocket cost was $583 ± $607 (mean ± standard deviation), range $49 to $2,409. Average telephone call length 6 ± 3.8 min. Two of fifty-five screening centers’ websites provided out-of-pocket cost information, and one matched cost given over the telephone. A chargemaster was found for 30 of 55 screening centers. No statistically significant differences in out-of-pocket costs were found by geographic region, state percentages of uninsured residents, state percentages of residents with public insurance, or facility safety net hospital affiliation. Discussion Out-of-pocket LCS costs for uninsured patients and availability of this information is highly variable. Radiology practices should be aware of this variability that may influence participation rates among uninsured patients.

Purpose For health care organizations engaged in risk-shared insurance contracts, leakage of advanced diagnostic imaging to imaging sites not affiliated with the risk-sharing organization may undermine performance on financial and quality metrics. The goal of this study was to identify factors that are predictive of leakage of MRI examinations among patients attributed to an academic health care organization’s risk-shared commercial insurance contract. Methods Administrative claims data from 2015 through 2016 for patients attributed to a single risk-shared commercial insurance contract at a large academic medical center (AMC) were analyzed. Primary outcome was MRI leakage: an outpatient MRI study performed at a site not affiliated with the AMC’s integrated health care system. Ordering provider alignment with the AMC’s risk-shared insurance contract was categorized as strong, weak, or none. Multivariate regression analyses were conducted to evaluate the relationship between provider alignment and MRI leakage, while adjusting for selected covariates. Results Among 8,215 patients meeting inclusion criteria, there were 13,272 MRI encounters. The overall proportion of leaked MRI studies was 12.7%. MRI studies ordered by providers with weak AMC alignment (odds ratio, 3.16; 95% confidence interval, 2.49-4.02) or no AMC alignment (odds ratio, 3.68; 95% confidence interval, 3.12-4.33) were more likely to leak than MRI studies ordered by providers with strong AMC alignment. Conclusions An ordering provider with no alignment with an AMC’s commercial risk-shared insurance contract was the strongest predictor of MRI leakage. Population health management initiatives aimed at reducing leakage should consider the impact of provider networks and clinical referral patterns that drive imaging utilization.

To assess temporal trends and utilization patterns of diagnostic imaging performed for substance use disorder (SUD)-related indications in an academic radiology emergency department (ED).Retrospective analyses of ED imaging examinations acquired from 2005 to 2015 were performed. Imaging examinations performed for suspected SUD-related indications, based on the order history, were compared with those without a SUD-related indication. Unadjusted analyses comparing demographic and imaging characteristics between SUD-related versus non-SUD-related indications used Wilcoxon and Pearson's χAmong 938,245 examinations, 0.17% had an SUD-related indication. Patients with SUD-related indications were younger (mean 37.2 ± 11.1 versus 53.5 ± 22.4, P.001) and more commonly male (65% versus 52%, P.001). The proportions of MR (17%), spine (17%), and extremities (33%) studies performed for SUD-related indications were larger among SUD than non-SUD indications (6%, 8%, 26%, respectively, all P.001). Regression analysis demonstrated the odds of acquiring an ED imaging examination with an SUD-related indication significantly increased over time (P.001, adjusted odds ratio [aOR] = 1.06), which was most pronounced among MR (P.001, aOR = 1.23). For all regression models, younger age, male gender, and body part being imaged were identified as independent predictors of an SUD-related indication for ED imaging.Imaging performed for an SUD-related indication represented a small but increasing subset of overall ED imaging. Utilization of MR for SUD-related indications significantly outpaced growth of MR without SUD-related indications.

The aim of this study was to assess the differences in timeliness to MRI appointments and missed MRI appointment rates before and after the implementation of a rideshare program.Retrospective analysis of a rideshare program was performed 9 months after implementation to compare the effects before and after implementation. Variables obtained included demographics, MRI appointment variables, and data related to rideshare use. Descriptive statistics and linear and logistic regression analyses were used to compare demographic characteristics among patients using the rideshare program with (1) those who did not use the rideshare program after implementation and (2) patients before rideshare implementation. Rates of missed appointments derived from patient-related, same-day appointment cancellations were analyzed using logistic regression analyses. Timeliness was analyzed using linear regression analyses. All analyses were adjusted for potential confounders.Of 7,707 patients scheduled for MRI appointments during the postintervention period, 151 patients used the rideshare service (1.95%). There were no statistically significant differences in missed appointment rates after rideshare implementation (adjusted odds ratio, 1.09; 95% confidence interval, 0.93-1.27; P = .275). Patients using the rideshare service were more likely to be on time (adjusted coefficient = 13.0; 95% confidence interval, 5.4-20.5; P = .001). Older patients (P = .001), unemployed patients (P.001), and patients without commercial insurance (P.001) were more likely to use the rideshare service.Implementation of a rideshare program did not significantly decrease missed appointment rates, but it significantly improved timeliness to MRI appointments while assisting at-risk patient populations reporting transportation barriers.

PURPOSE The aim of this study was to assess changing Medicare volumes of, and coverage for, secondary interpretations of diagnostic imaging examinations stratified by modality and body region service families. METHODS Medicare Physician/Supplier Procedure Summary Master Files for 2003 to 2016 were obtained. Aggregate Part B fee-for-service claims frequency and payment data were isolated for noninvasive diagnostic imaging and stratified by service family. Using published Medicare payment rules, secondary interpretations were identified as studies billed using both modifiers 26 and 77. Billed and denied services volumes were calculated and compared across modality and body region service families. RESULTS Seven service families showed a compound annual growth rate from 2003 to 2016 of >20% (an additional 12 service families, >10% growth). For select high-volume service families (chest radiography and fluoroscopy [R&F], brain MRI, and abdominal and pelvic CT), relative growth in billed secondary interpretation services exceeded that for primary interpretations. In 2016, body region and modality service families with the most billed secondary interpretations were chest R&F (674,124), abdominal and pelvic R&F (65,566), brain CT (45,642), extremity R&F (34,560), abdominal and pelvic CT (14,269), and chest CT (10,914). All service families had secondary interpretation denial rates

The extent to which racial and socioeconomic disparities exist in accessing clinically appropriate, advanced diagnostic imaging has not been well studied. This study assesses the relationship between demographic and socioeconomic factors and the incidence of imaging missed care opportunities (IMCOs).We performed a retrospective review of outpatient CT and MRI appointments at a quaternary academic medical center and affiliated outpatient facilities during a 12-month period. Missed appointments not rescheduled in advance were classified as IMCOs. Appropriateness criteria scores and demographics were also obtained. Univariate and multivariate analyses were performed to determine if demographic and socioeconomic factors were predictive of IMCOs.Overall, 57,847 patients met inclusion criteria, representing 89,943 scheduled unique imaging appointments of which 5,840 (6.1%) were IMCOs; 0.8% of IMCO appointments had low appropriateness scores compared with 1.2% of completed appointments (P.01). Appointments covered by commercial insurance (5.2%) had a significantly lower rate of IMCOs than other payers: Medicare = 6.3%, Medicaid = 14.5%, self-pay = 12.0% (P.05). The following factors were independent predictors of a patient having ≥ 1 IMCO: noncommercial insurance [odds ratio (OR) = 1.7-2.6], African American (OR = 1.8), Hispanic (OR = 1.2), other race (OR = 1.1), language other than English or Spanish (OR = 1.2), male gender (OR = 1.2), age ≥ 65 (OR = 0.71), and median household income of patient home zip code$50,000 (OR = 1.4).Race and socioeconomic status are independent predictors of IMCOs. In efforts to enhance patient engagement, radiologists should be aware of the impact of race and socioeconomic status on access to clinically appropriate advanced diagnostic imaging.

Purpose Traditional radiology productivity metrics do not account for noninterpretive tasks (NITs). This study aimed to systematically quantify NITs and their impact on report turn-around time (RTAT) during solo academic neuroradiology overnight coverage in the emergency department. Methods Retrospective analysis of 1 week of data, including phone call quantity and duration, clinician identification badge access to the reading room ("badge swipes"), suspected acute strokes, imaging examination volume, and emergency department patient volume, was performed. Univariate analyses were employed to quantify NITs. Multivariate linear regression was used to determine if NITs within an hour are predictive of RTAT of studies completed within that hour. Results Sixty-three hours of overnight neuroradiology coverage were analyzed. The mean number of phone calls per hour was 8.7 (SD: 5.7), and mean duration of phone calls per hour was 12 min (SD: 9.6 min, range 1-46). The mean number of badge swipes per hour was 2.1 (SD 1.6). The mean number of examinations (CT and MRI) performed per hour was 2.2 (SD: 1.7). Regression analyses found total duration of phone calls in an hour as the strongest independent predictor of RTAT (unstandardized β = 4.25, P P R 2 = 0.596; adjusted R 2 = 0.578). Conclusions For every 1-min increase in total duration of calls in an hour, mean RTAT increased by 4.25 min. Standardizing capture of NITs may aid development of strategies that address productivity, communication, and value in radiology.

Introduction Emergency Department Observation Units (EDOUs) are a valuable alternative to inpatient admissions for Emergency Department (ED) patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU. Methods This Institutional Review Board-approved, retrospective study was performed at a 999-bed quaternary care academic Level 1 adult and pediatric trauma center, with approximately 114,000 ED visits annually and a 32-bed adult EDOU. The EDOU patient database was retrospectively reviewed for all MRI examinations done from October 1st, 2013 to September 30th, 2015. We sought to describe the most frequent uses for MRI during EDOU admissions and reviewed EDOU length of stay (LOS) to determine whether the use of MRI was associated with any change in LOS. Results 22,840 EDOU admissions were recorded during the two-year study period, and 4,437 (19%) of these patients had a least one MRI examination during their stay. 2,730 (62%) of these studies were of the brain, head, or neck and an additional 1,392 (31%) were of the spine. There was no significant difference between the median LOS of admissions in which an MRI study was performed (17.5 hours) and the median LOS (17.7 hours) of admissions in which an MRI study was not performed [p=0.33]. Conclusion Neuroimaging makes up the clear majority of MRI examinations from our EDOU, and the use of MRI does not appear to prolong EDOU LOS. Future work should focus on the appropriateness of these MRI examinations to determine potential resource and cost savings.

Purpose To characterize the management, outcomes, and emergency department (ED) length of stay (LOS) following iodinated contrast media extravasation events in the ED. Methods All ED patients who developed iodinated contrast media extravasation following contrast-enhanced CT (CECT) from October 2007–December 2016 were retrospectively identified. Medical records were reviewed and management, complications, frequency of surgical consultation, and ED LOS were quantified using descriptive statistics. The Wilcoxon rank sum test was used to compare ED LOS in patients who did and did not receive surgical consultation. Results A total of 199 contrast extravasation episodes occurred in ED patients during the 9-year study period. Of these, 42 patients underwent surgical consultation to evaluate the contrast extravasation event. No patient developed progressive symptoms, compartment syndrome, or tissue necrosis, and none received treatment beyond supportive care (warm/cold packs, elevation, compression). Median ED LOS for patients who did and did not receive surgical consultation was 11.3 h versus 9.0 h, respectively (p Conclusion Close observation and supportive care are sufficient for contrast extravasation events in the ED without concerning symptoms (progressive pain/swelling, altered tissue perfusion, sensory changes, or blistering/ulceration). Routine surgical consultation is likely unnecessary in the absence of these symptoms – concordant with the current American College of Radiology guidelines – and may be associated with longer ED LOS without impacting management.

Millions of women undergo mammography screening each year, presenting an opportunity for radiologists to identify women eligible for lung cancer screening (LCS) with low-dose chest CT and smoking cessation counseling. The purpose of our study was to estimate the proportion of women eligible for LCS and tobacco cessation counseling among women reporting mammography screening within the previous 2 years using nationally representative cross-sectional survey data.Women between the ages of 55 and 74 years in the 2015 National Health Interview Survey without history of lung or breast cancer who reported mammography use in the previous 2 years were included. The primary outcome was the weighted proportion of women eligible for LCS. Secondary outcomes included self-reported receipt of LCS and current smoking. Bivariate and multiple variable logistic regression analyses were performed to evaluate the association between primary and secondary outcomes and sociodemographics, accounting for complex survey design elements.Among 3,806 women meeting inclusion criteria, 7.1% were eligible for LCS and 9.8% were current smokers. Multivariable analyses demonstrated that LCS-eligible women were more likely to be white, younger, and non-college-educated and have lower household incomes (all P.001). Among all LCS-eligible women, 58% reported undergoing mammography screening within the previous 2 years. Among LCS-eligible women who underwent screening mammography, 7.9% reported undergoing LCS.The majority of LCS-eligible women received mammography screening but did not receive LCS. Mammography encounters may represent prime opportunities to increase LCS participation among patients already receiving imaging-based screening services.

Objective: The aim of this study was to determine the association between the presence of chronic medical disease and mammography screening adherence. Materials and Methods: We performed a...

Purpose One in five US women report that they have been victims of intimate partner violence (IPV) during their lifetime. With millions of women presenting for mammography every year, breast imaging centers may represent ideal venues to identify women at risk for IPV and refer them to appropriate support services. Our purpose was to evaluate implementation of a novel IPV screening and referral system for women presenting for mammography. Methods A question was added to intake questionnaire (“Do you feel safe in your home?”) for adult women presenting for screening or diagnostic mammography from 2016 to 2017 at our hospital outpatient breast imaging sites. The proportion of women presenting for screening or diagnostic mammogram who felt unsafe was calculated. Bivariate logistic regression analyses were performed to compare baseline characteristics of women who stated that they felt unsafe at home versus women who did not state that they felt unsafe at home. Results In all, 99,029 examinations were performed (68,158 unique patients). Of these patients, 71 stated that they felt unsafe at home (71 of 68,158, 0.1%). Women presenting for their first mammogram were more likely to report feeling unsafe at home (odds ratio 3.03, 95% confidence interval 1.31-7.06, P = .01). No differences were found in age (P = .148), ethnicity (P = .271), gravida (P = .676), parity (P = .752), age at menarche (P = .775), and history of breast cancer (P = .726). Conclusions Our results demonstrate the feasibility of a screening and referral system for IPV in radiology departments.

Regular contact with a primary care physician (PCP) is associated with increased participation in screening mammography. Older studies suggested that PCP interaction may have a smaller effect on screening mammography uptake among racial and ethnic minorities compared with whites, but there is limited contemporary evidence about the effect of PCP interaction on screening mammography uptake across different racial and ethnic groups. The purpose of this study was to evaluate the association between PCP contact and longitudinal adherence with screening mammography guidelines over a 10-year period across different racial/ethnic groups.This HIPAA-compliant and institutional review board-approved retrospective single-institution study included women between the ages of 50 and 64 years who underwent screening mammography in the calendar year of 2005. The primary outcome of interest was adherence to recommended screening mammography guidelines (yes or no) at each 2-year interval from their index screening mammographic examination in 2005 until 2015. Patients were defined as having a high level of PCP interaction if their PCPs were listed in the electronic medical record within the top three providers with whom the patients had the most visits during the study period. Generalized estimating equation models were used to estimate the effect of high PCP interaction on screening mammography adherence while adjusting for correlated observations and patient characteristics.Patients in the high PCP interaction group had increased longitudinal adherence to recommended screening mammography (adjusted odds ratio [OR], 1.51; 95% confidence interval [CI], 1.42-1.73; P.001). This was observed in stratified analyses for all self-reported racial groups, including white (adjusted OR, 1.51; 95% CI, 1.36-1.68; P.001), black (adjusted OR, 1.93; 95% CI, 1.31-2.86; P = .001), Hispanic (adjusted OR, 1.92; 95% CI, 1.27-2.87; P = .002), Asian (adjusted OR, 1.55; 95% CI, 1.01-2.39; P = .045), and other (adjusted OR, 2.18; 95% CI, 1.32-3.56; P = .002), with no evidence of effect modification by race/ethnicity (P = .342). Medicaid (adjusted OR, 0.41; 95% CI, 0.31-0.53) and self-pay or other (adjusted OR, 0.39; 95% CI, 0.27-0.56) insurance categories were associated with decreased longitudinal adherence to recommended screening mammography (P.001 for both).High levels of PCP interaction result in similar improvements in longitudinal screening mammography adherence for all racial/ethnic minority groups. Future efforts will require targeted outreach to assist Medicaid and uninsured patient populations overcome barriers to screening mammography adherence.

Purpose To conduct a meta-analysis of studies investigating discrepancy rates and clinical impact of imaging secondary interpretations and to identify factors influencing these rates. Methods EMBASE and PubMed databases were searched for original research investigations reporting discrepancy rates for secondary interpretations performed by radiologists for imaging examinations initially interpreted at other institutions. Two reviewers extracted study information and assessed study quality. Meta-analysis was performed. Results Twenty-nine studies representing a total of 12,676 imaging secondary interpretations met inclusion criteria; 19 of these studies provided data specifically for oncologic imaging examinations. Primary risks of bias included availability of initial interpretations, other clinical information, and reference standard before the secondary interpretation. The overall discrepancy rate of secondary interpretations compared with primary interpretations was 32.2%, including a 20.4% discrepancy rate for major findings. Secondary interpretations were management changing in 18.6% of cases. Among discrepant interpretations with an available reference standard, the secondary interpretation accuracy rate was 90.5%. The overall discrepancy rates by examination types were 28.3% for CT, 31.2% for MRI, 32.7% for oncologic imaging, 43.8% for body imaging, 39.9% for breast imaging, 34.0% for musculoskeletal imaging, 23.8% for neuroradiologic imaging, 35.5% for pediatric imaging, and 19.7% for trauma imaging. Conclusion Most widely studied in the context of oncology, imaging secondary interpretations commonly result in discrepant interpretations that are management changing and more accurate than initial interpretations. Policymakers should consider these findings as they consider the value of, and payment for, secondary imaging interpretations.

Author(s): Glover, McKinley; Gottumukkala, Ravi; Sanchez, Yadiel; Yun, Brian J.; Benzer, Theodore I.; White, Benjamin A.; Prabhakar, Anand M.; Raja, Ali S. | Abstract: Introduction: Emergency departments (ED) and hospitals face increasing challenges related to capacity, throughput, and stewardship of limited resources while maintaining high quality. Appropriate utilization of extremity magnetic resonance imaging (MRI) examinations within the emergency setting is not well known. Therefore, this study aimed to determine indications for and appropriateness of MRI of the extremities for musculoskeletal conditions in the ED observation unit (EDOU).Methods: We conducted this institutional review board-approved, retrospective study in a large, quaternary care academic center and Level I trauma center. An institutional database was queried retrospectively to identify all adult patients undergoing an extremity MRI while in the EDOU during the two-year study period from October 2013 through September 2015. We compared clinical history with the American College of Radiology (ACR) Appropriateness Criteria® for musculoskeletal indications. The primary outcome was appropriateness of musculoskeletal MRI exams of the extremities; examinations with an ACR Criteria score of seven or higher were deemed appropriate. Secondary measures included MRI utilization and imaging findings. Results: During the study period, 22,713 patients were evaluated in the EDOU. Of those patients, 4,409 had at least one MRI performed, and 88 MRIs met inclusion criteria as musculoskeletal extremity examinations (2% of all patients undergoing an MRI exam in the EDOU during the study period). The most common exams were foot (27, 31%); knee (26, 30%); leg/femur (10, 11%); and shoulder (10, 11%). The most common indications were suspected infection (42, 48%) and acute trauma (23, 26%). Fifty-six percent of exams were performed with intravenous contrast; and 83% (73) of all MRIs were deemed appropriate based on ACR Criteria. The most common reason for inappropriate imaging was lack of performance of radiographs prior to MRI. Conclusion: The majority of musculoskeletal extremity MRI examinations performed in the EDOU were appropriate based on ACR Appropriateness Criteria. However, the optimal timing and most-appropriate site for performance of many clinically appropriate musculoskeletal extremity MRIs performed in the EDOU remains unclear. Potential deferral to the outpatient setting may be a preferred population health management strategy.

Purpose The aim of this study was to investigate the impact of wait days (WDs) on missed outpatient MRI appointments across different demographic and socioeconomic factors. Methods An institutional review board–approved retrospective study was conducted among adult patients scheduled for outpatient MRI during a 12-month period. Scheduling data and demographic information were obtained. Imaging missed appointments were defined as missed scheduled imaging encounters. WDs were defined as the number of days from study order to appointment. Multivariate logistic regression was applied to assess the contribution of race and socioeconomic factors to missed appointments. Linear regression was performed to assess the relationship between missed appointment rates and WDs stratified by race, income, and patient insurance groups with analysis of covariance statistics. Results A total of 42,727 patients met the inclusion criteria. Mean WDs were 7.95 days. Multivariate regression showed increased odds ratio for missed appointments for patients with increased WDs (7-21 days: odds ratio [OR], 1.39; >21 days: OR, 1.77), African American patients (OR, 1.71), Hispanic patients (OR, 1.30), patients with noncommercial insurance (OR, 2.00-2.55), and those with imaging performed at the main hospital campus (OR, 1.51). Missed appointment rate linearly increased with WDs, with analysis of covariance revealing underrepresented minorities and Medicaid insurance as significant effect modifiers. Conclusions Increased WDs for advanced imaging significantly increases the likelihood of missed appointments. This effect is most pronounced among underrepresented minorities and patients with lower socioeconomic status. Efforts to reduce WDs may improve equity in access to and utilization of advanced diagnostic imaging for all patients.

Many practice groups are considering adopting new practice models, primarily to secure their practices by adapting to new payment models, government compliance and regulation, and increasing IT and infrastructure costs. As we move toward value-based care and capitation, the value equation (value = quality/cost) will lead us to also compete on cost to improve value. No matter what payment models ultimately dominate, we need to be prepared to lead in a value-based care environment. Measures of value will either be defined by radiologists or imposed by outside entities. It is critical to our continued success that practices and practice leaders continue to fully and strongly support the ACR to avoid the possibility of a decline in membership that may accompany a lack of practice engagement. Consolidation appears inevitable, but with the help of the ACR, radiologists should have a vibrant future if investments are made now in determining appropriate radiology-specific value measures that are meaningful in consolidated health care environments.