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Public transparency Web sites for radiology practices: prevalence of price, clinical quality, and service quality information
Clinical Imaging 40 (2016) 531–534
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Original Article
Public transparency Web sites for radiology practices: prevalence of price, clinical quality, and service quality information☆ Andrew B. Rosenkrantz ⁎, Ankur M. Doshi Department of Radiology, NYU Langone Medical Center, New York, NY 10016 USA
a r t i c l e
i n f o
Article history: Received 5 October 2015 Received in revised form 10 November 2015 Accepted 18 November 2015 Keywords: Radiology practice Price Quality Value Transparency
a b s t r a c t Purpose: To assess information regarding radiology practices on public transparency Web sites. Methods: Eight Web sites comparing radiology centers' price and quality were identified. Web site content was assessed. Results: Six of eight Web sites reported examination prices. Other reported information included hours of operation (4/8), patient satisfaction (2/8), American College of Radiology (ACR) accreditation (3/8), on-site radiologists (2/8), as well as parking, accessibility, waiting area amenities, same/next-day reports, mammography follow-up rates, examination appropriateness, radiation dose, fellowship-trained radiologists, and advanced technologies (1/8 each). Conclusion: Transparency Web sites had a preponderance of price (and to a lesser extent service quality) information, risking fostering price-based competition at the expense of clinical quality. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Recent efforts to promote greater value in healthcare have fostered a surge of interest in transparency initiatives [1,2]. An ability to directly compare providers in terms of both quality and price is anticipated to influence informed decision making by patients regarding where to seek their care [3]. Such rational decision making by patients is encouraged by the increasing out-of-pocket costs that patients are facing for their healthcare, in part related to generally higher deductibles [4,5]. This behavior by patients, bolstered by the greater availability of information on which to base decisions, is expected to, in turn, drive providers in a competitive fashion to raise their offered value by improving quality, lowering costs, or both [6,7]. A primary mechanism for achieving transparency has been the development of Web sites that provide publicly available data regarding practices' price and quality [8,9]. Such Web sites offer an easy and straightforward way for costaware patients to become aware of regional benchmarks and perform “comparison shopping” among practices [3]. Concern has been raised regarding the current status of the transparency movement as relevant to radiology practices [3]. Specifically, there is the potential for imbalance between the level of mature,
☆ Conflicts of interest: All authors: No disclosures related to the work under consideration or outside of the submitted work. ⁎ Corresponding author. Department of Radiology, Center for Biomedical Imaging, NYU School of Medicine, NYU Langone Medical Center, 660 First Avenue, 3rd Floor, New York, NY 10016. E-mail addresses: [email protected] (A.B. Rosenkrantz), [email protected] (A.M. Doshi). http://dx.doi.org/10.1016/j.clinimag.2015.11.020 0899-7071/© 2016 Elsevier Inc. All rights reserved.
comprehensive information regarding price and quality. Price information for individual imaging examination encounters in outpatient centers is readily extracted and summarized using automated processes [3,10]. On the other hand, methods for measuring and disseminating the quality of radiology practices remain immature in comparison with the quality information available for some other disciplines [3]. With some exceptions, currently applied schemes for assessing quality tend to rely on surrogate measures that do not directly relate to radiologists' diagnostic performance and are commonly poorly defined, applied inconsistently among practices, and unrelated to patient outcomes [11,12]. This disparity between price and quality information risks competition among radiology practices largely based on price, such that quality ultimately suffers as further investment by practices in quality becomes disincentivized [7]. In this framework, radiology practice becomes a commodity [13], with a push by centers to drive their prices as low as possible in order to gain market share. Despite such concern, a systematic evaluation of the content of comparison Web sites as relevant to radiology practices remains lacking. Such an assessment could provide insights that guide radiology practices, as well as the specialty as a whole, in taking future actions to help achieve better overall value transparency. Therefore, we performed this study in order to assess the price and quality information regarding radiology practices that is available on public transparency Web sites.
2. Materials and methods This study did not involve human subjects research and therefore did not require institutional review board approval. Two radiologists
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Table 1 Web sites included in study analysis on basis of providing price or quality information for individual imaging examinations at specific imaging centers in various geographic regions in the United States Web site
Ownership
Price data
Quality/Service data
Providers may pay for enhanced listing features
www.okcopay.com www.affordascan.com www.clearhealthcosts.com www.newchoicehealth.com www.medicare.gov/hospitalcompare www.pokitdok.com/marketplace www.saveonmedical.com www.yelp.com
Private Private Private Private Federal government Private Private Private
⁎ ⁎ ⁎ ⁎
⁎ ⁎
⁎
⁎ ⁎
⁎ ⁎
⁎
⁎ ⁎
⁎ ⁎
⁎ Three additional Web sites providing suggested fair or average price or quality information for individual imaging examinations in various geographic regions in the United States, although not at the level of specific imaging centers, were not included: www.castlighthealth.com/price-variation-map, www.healthcarebluebook.com, www.nerdwallet.com.
independently performed Internet searches using Google, Bing, and Yahoo to identify transparency Web sites that provide either price or quality information for individual imaging examinations at specific radiology centers in various geographic regions across the United States. Searches generally comprised a term related to radiologic imaging (i.e., radiology, radiology center, or a particular imaging examinations such as MRI or knee MRI) in combination with a term related to price or quality that patients may potentially search (i.e., price, cost, best, top, cheap, compare, quality, best quality, highest rated, where to get). Approximately, the first 100 search results resulting from individual searches were assessed for individual Web sites potentially meeting our study's inclusion criteria. Transparency Web sites referenced by news articles identified by the initial Web searches were also included. Web sites providing information for individual imaging examinations in various geographic regions, but not at the level of specific imaging centers, were recorded but not included for more detailed evaluation. The two radiologists in consensus recorded the features of individual radiology practices provided by the Web sites. Content pertaining to the frequency of potentially unindicated “combination” computed tomography (CT) scans (i.e., combination CT scans of the brain and sinus or combination pre- and postcontrast CT scans of the chest), reflecting metrics incorporated in Medicare's Hospital Outpatient Quality Reporting Program [14], was inferred to provide information relating to CT dose. Features listed by a Web site as a search option, but that returned no centers when selected, were not counted. Recorded features were grouped by a number of broad categories: price, patient satisfaction, other aspects of the patient experience, radiologists' performance, and other aspects of quality. The radiologists also recorded additional content related to individual radiology practices that was identified on the Web sites, although not fitting within these categories. The number of Web sites providing information regarding individual practice features was computed, and the most commonly provided information was tabulated. 3. Results A total of eight Web sites providing information comparing individual radiology centers, stratified by individual geographic regions across Table 2 Features of radiology practices reported by at least two of the included transparency Web sites Number of reporting Web sites
Radiology practice feature
6/8 4/8
Price of imaging examination Hours of operation (i.e., early morning, evening, and weekend hours) ACR accreditation Internally developed value score Capability for patient reviews in free-response form Radiologists on-site
3/8 2/8
the country, were identified (Table 1). The most commonly included information was the price of specified imaging examinations at individual imaging centers (six of eight Web sites). Provided information relating to patient satisfaction included the capability to enter reviews in free response form (2/8) and numeric patient satisfaction scores (1/8); one additional Web site provided patient satisfaction scores for the overall facility via Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results, although not specifically for imaging services. Provided information regarding other aspects of the patient experience included hours of operation (4/8), WiFi availability (1/8), Spanish language availability (1/8), free parking (1/8), parking within 100 feet (1/8), wheelchair accessibility (1/8), provision of transportation (1/8), refreshments in the lobby (1/8), television in the lobby (1/8), and availability of images online or on DVD (1/8). Provided information regarding radiologists' performance included same- or next-day reports (1/8) and screening mammography follow-up rates (1/8). Provided information regarding other aspects of quality included American College of Radiology (ACR) accreditation (3/8), on-site radiologist (2/8), fellowship-trained radiologists (1/8), examination volume (1/8), imaging appropriateness (1/8), inferred radiation dose (1/8), availability of advanced imaging technology such as digital mammography (1/8), and physician portal (1/8). None of the Web sites provided information regarding radiologists' diagnostic accuracy. Three of eight Web sites provided an internally developed composite score reflecting a combination of price and quality factors (i.e., a “docometer” score provided by one site), although precise explanations were not given regarding how these hybrid scores were derived. Three of eight Web sites provided direct links for scheduling an appointment at specific imaging centers. Table 2 summarizes the most commonly available information across these various categories. An additional three Web sites, not included in these eight, provided suggested fair or average prices for individual imaging examinations within specific geographic regions, although it did not provide information comparing price or quality between individual imaging centers within specific geographic regions. 4. Discussion In this study, we assessed transparency Web sites providing public information regarding radiology practices. The most consistently provided information related to the prices of imaging examinations, which was reported by the majority of Web sites. Information relating to quality or service was provided by a minority of Web sites and most commonly related to patient satisfaction, scheduling, and ACR accreditation. A broad range of other aspects of the patient experience, for instance relating to parking or the waiting area, was also occasionally reported. Other, more clinically oriented, aspects of quality were less commonly reported, rarely related to radiologists' performance, and never related to diagnostic accuracy or clinical outcomes. These observations validate existing concerns regarding the imbalance between publicly available price and quality information for radiology centers.
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Radiologists should be aware (if not already) of this dichotomy and recognize the resulting threat to radiologic quality in the current reality in which patients increasingly make informed decisions within a competitive healthcare marketplace. In addition, radiologists must recognize the need to take and support actions to provide patients with more complete and representative information on which to base decisions. We acknowledge that it is natural for comparison Web sites to provide that content which is most readily obtained. For instance, patient reviews, practices' hours of operations, and ACR accreditation status represent information that can be collected, organized, and presented in a straightforward fashion. Nonetheless, a proliferation of Web sites providing similar sets of incomplete metrics may establish a suboptimal norm in terms of the level of meaningful information that consumers come to expect. Such provided information is likely to drive, to some extent, the behaviors of patients, and thus of providers as well, thereby leading to a focus on these particular measures and a potential shift away from other important aspects of quality and service. Rather, patients would be better served if the developers of transparency Web sites, as well as of the metrics on which such Web sites are based, attempt to collect and distribute more revealing information. While several of the Web sites did provide composite measures of quality and price, the algorithms behind these measures were unclear, and they were presented with a paucity of information supporting the provided scores for individual practices. Accordingly, these measures may not reliably evaluate the value of radiology practices. ACR accreditation was the most commonly reported quality measure that relates to clinical care. ACR accreditation is a rigorous process that is specific to individual modalities and entails review of the licensing and certification of a center's radiologists, technologists, and physicists; submission of phantom and clinical images; as well as documentation of the continuing experience and continuing medical education of the radiologists and of a quality assurance program [15]. A centers' satisfaction of this comprehensive review provides useful information that patients and referring physicians may take into consideration. Nonetheless, some high-quality centers may not seek accreditation given the associated upfront and recurring costs that increase with the centers' number of scanners as well as the potential cost to purchase a phantom. In addition, information regarding the specific modality receiving accreditation was either unclear or missing from the transparency Web sites. Finally, even receipt of ACR accreditation does not provide patients with robust information regarding the diagnostic performance of the radiologist who will be interpreting their scan. Transparency Web sites are just one mechanism encouraging an emphasis on customer service and patient satisfaction. Of particular importance, as a result of provisions in the Patient Protection and Affordance Care Act, patient satisfaction, as measured by the HCAHPS survey, has become a key factor in determining hospital reimbursements based on Medicare's Value-Based Purchasing system [16]. Other stakeholders are also increasingly using patient satisfaction as a metric for profiling and comparing providers [17,18]. These trends have resulted in a pronounced emphasis by providers (hospitals in particular) on initiatives specifically designed to improve patient satisfaction, including the investment of time, personnel, and other resources [19–21]. Indeed, some individual practices and payers have begun to provide information regarding service quality, including patient satisfaction scores, directly to patients. Therefore, while the preponderance of patient satisfaction and other service measures among the quality measures available on the transparency Web sites may be contributing to providers' growing focus on patient satisfaction, the transparency Web sites certainly are not the only, or even primary, cause of the trend. We unequivocally agree that patient satisfaction is an important measure in radiology and healthcare in general, indeed having been associated with clinical outcomes [22,23]. Nonetheless, it is also important that radiologists do not focus on this particular measure to the point of neglecting their ultimate mission of rendering an accurate diagnosis that contributes to patient care.
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The paucity of information on the transparency Web sites relating to the clinical performance of centers' radiologists, including an absence of information relating to accuracy or other aspects of diagnostic performance, is of particular note. Patients may lack an awareness of the critical role and impact of the individual radiologist interpreting their scan and likewise lack an appreciation for the added value of having a skilled radiologist render a high-quality interpretation [24]. In comparison, from the patients' perspective, direct service-related factors will have the most immediate impact on their experience [25]. In addition, the actual equipment with which the patient is scanned, rather than the interpreting radiologist whom the patient does not meet, may appear on the surface to be the dominant component of clinical quality [3]. While we do not question the importance of modern high-quality equipment, the performance of the interpreting radiologist cannot be understated. In this regard, the nature of the content on the transparency Web sites may serve to further encourage such incomplete, if not inaccurate, public perceptions. The ACR's current Imaging 3.0 initiative helps to address this gap through efforts to improve radiologists' visibility and exposure to patients, including efforts to promote patients' understanding of the clinical role and value of radiologists [26,27]. The lack of meaningful clinical quality information on the transparency Web sites may misleadingly suggest to patients that radiology practices generally offer a similar level of clinical quality. However, this imbalance cannot be fully attributed to the sites' developers, as robust and relevant clinical quality metrics for radiology practices do not currently exist in a publicly available forum for the sites to utilize, even if desired. This reality highlights the need for radiologists to take measures to address this gap, as it is only once such metrics are developed and made accessible that such meaningful data may be incorporated into the transparency Web sites. Indeed, Durand et al. have recently proposed a number of actions that radiologists may take in response to the dominance of price information in the ongoing transparency movement [3]. These actions entail radiologists embracing the transparency effort by working as a specialty to identify meaningful quality metrics and to craft the necessary infrastructure to measure and report these in a consistent fashion [3]. That is, radiologists are called upon to directly oversee and take responsibility for the development of those facets of their practices by which they will be compared [3]. Just as mortality, complication, and readmission rates are becoming increasingly standardized and accepted as measures of a surgeon's performance, it is hoped that an appropriate package of relevant and measurable clinical outcomes can be developed for radiologists. It is anticipated that direct active participation by radiologists would facilitate this process and promote the emergence of measures that are more reflective of diagnostic accuracy along with other aspects of radiologists' clinical performance, as is currently lacking on the transparency Web sites. A number of limitations of this study warrant mention. First, our analysis includes only a small number of Web sites. However, this small number reflects the reality of the number of such sites available at the time of our Web searches. In this regard, our observations provide a snapshot of the transparency Web sites that exist at a single point in time. It is anticipated that additional comparison Web sites will be developed and that additional metrics or other content will be incorporated into existing Web sites that may offer a more balanced perspective of radiology practices than we currently report. In addition, we have not demonstrated the role of the transparency Web sites in influencing the behavior of patients or of radiology practices but have solely inferred that such associations exist to some extent. In addition, we have not explored associations between the information provided by the transparency Web sites and the Web sites' source or included providers. For instance, one Web site with numerous quality measures was generated by the federal government and only provides information for hospital outpatient departments participating in Medicare, while one private Web site requires radiology centers to pay a fee in order to be listed. Finally, we have not confirmed the accuracy of the information provided by the Web sites. Whether or not the information is accurate, the
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provided information reflects the reality of that which is currently available and presumably being used by patients in making decisions.
5. Conclusion Among eight transparency Web sites providing information comparing individual radiology centers within specific geographic regions across the country, the most commonly reported information was the price of imaging examinations at individual centers (six of eight Web sites). Provided information regarding the patient experience most commonly related to hours of operation, although also incorporated a broad range of factors related to various aspects of parking, transportation, accessibility, and waiting area amenities. The emergence of Web sites promoting transparency is encouraging, although the preponderance of price (and to a lesser extent service quality) information, with minimal clinical quality information, risks competition among radiology practices based largely on price at the expense of quality; accordingly, radiologists are called upon to oversee the development and dissemination of more robust and meaningful quality metrics that promote actual value-based competition.
References [1] Cutler D, Dafny L. Designing transparency systems for medical care prices. N Engl J Med 2011;364(10):894–5. [2] Sinaiko AD, Rosenthal MB. Increased price transparency in health care–challenges and potential effects. N Engl J Med 2011;364(10):891–4. [3] Durand DJ, Narayan AK, Rybicki FJ, Burleson J, Nagy P, McGinty G, et al. The health care value transparency movement and its implications for radiology. J Am Coll Radiol 2015;12(1):51–8. [4] Collins SR, Rasmussen PW, Doty MM, Beutel S. Too high a price: out-of-pocket health care costs in the United States. Findings from the Commonwealth Fund Health Care Affordability Tracking Survey. September-October 2014. Issue Brief (Commonw Fund) 2014;29:1–11. [5] Dolan PL. High-deductible impact. Balancing rising out-of-pocket costs and outcomes. Med Econ 2014;91(9):17–20. [6] Tu HT, Lauer JR. Impact of health care price transparency on price variation: the New Hampshire experience. Issue Brief 2009(128):1–4. [7] Gaynor M. What do we know about competition and quality in health care markets? No. w12301. Cambridge, Massachusetts: National Bureau of Economic Research; 2006.
[8] Whaley C, Schneider Chafen J, Pinkard S, Kellerman G, Bravata D, Kocher R, et al. Association between availability of health service prices and payments for these services. JAMA 2014;312(16):1670–6. [9] Dahlke AR, Chung JW, Holl JL, Ko CY, Rajaram R, Modla L, et al. Evaluation of initial participation in public reporting of American College of Surgeons NSQIP surgical outcomes on Medicare's Hospital Compare website. J Am Coll Surg 2014;218(3): 374–80 [80 e1-5]. [10] Bossuyt X, Verweire K, Blanckaert N. Laboratory medicine: challenges and opportunities. Clin Chem 2007;53(10):1730–3. [11] Loeb JM. The current state of performance measurement in health care. Int J Qual Health Care 2004;16(Suppl. 1):i5–9. [12] Berenson RA, Pronovost PJ, Krumholz HM. Achieving the potential of health care performance measures. http://www.rwjf.org/en/research-publications/find-rwjf-research/2013/05/achieving-thepotential-of-health-care-performance-measures. html. [Accessed on August 2, 2015]. [13] Levin DC, Rao VM, Berlin J. Ensuring the future of radiology: how to respond to the threats. J Am Coll Radiol 2013;10(9):647–51. [14] Center for Medicare & Medicaid Services. Hospital outpatient quality reporting program. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/HospitalOutpatientQualityReportingProgram.html. [Accessed on: November 8, 2015]. [15] American College of Radiology. Accreditation. http://www.acr.org/quality-safety/accreditation. [Accessed on: August 4, 2015]. [16] Dempsey C, Reilly B, Buhlman N. Improving the patient experience: real-world strategies for engaging nurses. J Nurs Adm 2014;44(3):142–51. [17] Lang EV, Yuh WT, Ajam A, Kelly R, Macadam L, Potts R, et al. Understanding patient satisfaction ratings for radiology services. AJR Am J Roentgenol 2013;201(6):1190–5 [quiz 6]. [18] Carlos RC, Buist DS, Wernli KJ, Swan JS. Patient-centered outcomes in imaging: quantifying value. J Am Coll Radiol 2012;9(10):725–8. [19] Fustino NJ, Kochanski JJ. Improving patient satisfaction in a midsize pediatric hematology-oncology outpatient clinic. J Oncol Pract 2015;11(5):416–20. [20] Petitgout JM. Implementation and evaluation of a unit-based discharge coordinator to improve the patient discharge experience. J Pediatr Health Care 2015; 29(6):509–17. [21] Lasserre C. Fostering a culture of service excellence. J Med Pract Manage 2010;26(3): 166–9. [22] Glickman SW, Boulding W, Manary M, Staelin R, Roe MT, Wolosin RJ, et al. Patient satisfaction and its relationship with clinical quality and inpatient mortality in acute myocardial infarction. Circ Cardiovasc Qual Outcomes 2010;3(2):188–95. [23] Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. Am J Manag Care 2011;17(1):41–8. [24] Miller P, Gunderman R, Lightburn J, Miller D. Enhancing patients' experiences in radiology: through patient-radiologist interaction. Acad Radiol 2013;20(6):778–81. [25] Rosenkrantz AB, Pysarenko K. The service encounter in radiology: acing the "moments of truth" to achieve patient-centered care. Acad Radiol 2015;22(2):259–64. [26] McGinty GB, Allen B, Geis JR, Wald C. IT infrastructure in the era of imaging 3.0. J Am Coll Radiol 2014;11(12 Pt B):1197–204. [27] Ellenbogen P. Imaging 3.0: what is it? J Am Coll Radiol 2013;10:229.
Contents lists available at ScienceDirect
Clinical Imaging journal homepage: http://www.clinicalimaging.org
Original Article
Public transparency Web sites for radiology practices: prevalence of price, clinical quality, and service quality information☆ Andrew B. Rosenkrantz ⁎, Ankur M. Doshi Department of Radiology, NYU Langone Medical Center, New York, NY 10016 USA
a r t i c l e
i n f o
Article history: Received 5 October 2015 Received in revised form 10 November 2015 Accepted 18 November 2015 Keywords: Radiology practice Price Quality Value Transparency
a b s t r a c t Purpose: To assess information regarding radiology practices on public transparency Web sites. Methods: Eight Web sites comparing radiology centers' price and quality were identified. Web site content was assessed. Results: Six of eight Web sites reported examination prices. Other reported information included hours of operation (4/8), patient satisfaction (2/8), American College of Radiology (ACR) accreditation (3/8), on-site radiologists (2/8), as well as parking, accessibility, waiting area amenities, same/next-day reports, mammography follow-up rates, examination appropriateness, radiation dose, fellowship-trained radiologists, and advanced technologies (1/8 each). Conclusion: Transparency Web sites had a preponderance of price (and to a lesser extent service quality) information, risking fostering price-based competition at the expense of clinical quality. © 2016 Elsevier Inc. All rights reserved.
1. Introduction Recent efforts to promote greater value in healthcare have fostered a surge of interest in transparency initiatives [1,2]. An ability to directly compare providers in terms of both quality and price is anticipated to influence informed decision making by patients regarding where to seek their care [3]. Such rational decision making by patients is encouraged by the increasing out-of-pocket costs that patients are facing for their healthcare, in part related to generally higher deductibles [4,5]. This behavior by patients, bolstered by the greater availability of information on which to base decisions, is expected to, in turn, drive providers in a competitive fashion to raise their offered value by improving quality, lowering costs, or both [6,7]. A primary mechanism for achieving transparency has been the development of Web sites that provide publicly available data regarding practices' price and quality [8,9]. Such Web sites offer an easy and straightforward way for costaware patients to become aware of regional benchmarks and perform “comparison shopping” among practices [3]. Concern has been raised regarding the current status of the transparency movement as relevant to radiology practices [3]. Specifically, there is the potential for imbalance between the level of mature,
☆ Conflicts of interest: All authors: No disclosures related to the work under consideration or outside of the submitted work. ⁎ Corresponding author. Department of Radiology, Center for Biomedical Imaging, NYU School of Medicine, NYU Langone Medical Center, 660 First Avenue, 3rd Floor, New York, NY 10016. E-mail addresses: [email protected] (A.B. Rosenkrantz), [email protected] (A.M. Doshi). http://dx.doi.org/10.1016/j.clinimag.2015.11.020 0899-7071/© 2016 Elsevier Inc. All rights reserved.
comprehensive information regarding price and quality. Price information for individual imaging examination encounters in outpatient centers is readily extracted and summarized using automated processes [3,10]. On the other hand, methods for measuring and disseminating the quality of radiology practices remain immature in comparison with the quality information available for some other disciplines [3]. With some exceptions, currently applied schemes for assessing quality tend to rely on surrogate measures that do not directly relate to radiologists' diagnostic performance and are commonly poorly defined, applied inconsistently among practices, and unrelated to patient outcomes [11,12]. This disparity between price and quality information risks competition among radiology practices largely based on price, such that quality ultimately suffers as further investment by practices in quality becomes disincentivized [7]. In this framework, radiology practice becomes a commodity [13], with a push by centers to drive their prices as low as possible in order to gain market share. Despite such concern, a systematic evaluation of the content of comparison Web sites as relevant to radiology practices remains lacking. Such an assessment could provide insights that guide radiology practices, as well as the specialty as a whole, in taking future actions to help achieve better overall value transparency. Therefore, we performed this study in order to assess the price and quality information regarding radiology practices that is available on public transparency Web sites.
2. Materials and methods This study did not involve human subjects research and therefore did not require institutional review board approval. Two radiologists
532
A.B. Rosenkrantz, A.M. Doshi / Clinical Imaging 40 (2016) 531–534
Table 1 Web sites included in study analysis on basis of providing price or quality information for individual imaging examinations at specific imaging centers in various geographic regions in the United States Web site
Ownership
Price data
Quality/Service data
Providers may pay for enhanced listing features
www.okcopay.com www.affordascan.com www.clearhealthcosts.com www.newchoicehealth.com www.medicare.gov/hospitalcompare www.pokitdok.com/marketplace www.saveonmedical.com www.yelp.com
Private Private Private Private Federal government Private Private Private
⁎ ⁎ ⁎ ⁎
⁎ ⁎
⁎
⁎ ⁎
⁎ ⁎
⁎
⁎ ⁎
⁎ ⁎
⁎ Three additional Web sites providing suggested fair or average price or quality information for individual imaging examinations in various geographic regions in the United States, although not at the level of specific imaging centers, were not included: www.castlighthealth.com/price-variation-map, www.healthcarebluebook.com, www.nerdwallet.com.
independently performed Internet searches using Google, Bing, and Yahoo to identify transparency Web sites that provide either price or quality information for individual imaging examinations at specific radiology centers in various geographic regions across the United States. Searches generally comprised a term related to radiologic imaging (i.e., radiology, radiology center, or a particular imaging examinations such as MRI or knee MRI) in combination with a term related to price or quality that patients may potentially search (i.e., price, cost, best, top, cheap, compare, quality, best quality, highest rated, where to get). Approximately, the first 100 search results resulting from individual searches were assessed for individual Web sites potentially meeting our study's inclusion criteria. Transparency Web sites referenced by news articles identified by the initial Web searches were also included. Web sites providing information for individual imaging examinations in various geographic regions, but not at the level of specific imaging centers, were recorded but not included for more detailed evaluation. The two radiologists in consensus recorded the features of individual radiology practices provided by the Web sites. Content pertaining to the frequency of potentially unindicated “combination” computed tomography (CT) scans (i.e., combination CT scans of the brain and sinus or combination pre- and postcontrast CT scans of the chest), reflecting metrics incorporated in Medicare's Hospital Outpatient Quality Reporting Program [14], was inferred to provide information relating to CT dose. Features listed by a Web site as a search option, but that returned no centers when selected, were not counted. Recorded features were grouped by a number of broad categories: price, patient satisfaction, other aspects of the patient experience, radiologists' performance, and other aspects of quality. The radiologists also recorded additional content related to individual radiology practices that was identified on the Web sites, although not fitting within these categories. The number of Web sites providing information regarding individual practice features was computed, and the most commonly provided information was tabulated. 3. Results A total of eight Web sites providing information comparing individual radiology centers, stratified by individual geographic regions across Table 2 Features of radiology practices reported by at least two of the included transparency Web sites Number of reporting Web sites
Radiology practice feature
6/8 4/8
Price of imaging examination Hours of operation (i.e., early morning, evening, and weekend hours) ACR accreditation Internally developed value score Capability for patient reviews in free-response form Radiologists on-site
3/8 2/8
the country, were identified (Table 1). The most commonly included information was the price of specified imaging examinations at individual imaging centers (six of eight Web sites). Provided information relating to patient satisfaction included the capability to enter reviews in free response form (2/8) and numeric patient satisfaction scores (1/8); one additional Web site provided patient satisfaction scores for the overall facility via Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) results, although not specifically for imaging services. Provided information regarding other aspects of the patient experience included hours of operation (4/8), WiFi availability (1/8), Spanish language availability (1/8), free parking (1/8), parking within 100 feet (1/8), wheelchair accessibility (1/8), provision of transportation (1/8), refreshments in the lobby (1/8), television in the lobby (1/8), and availability of images online or on DVD (1/8). Provided information regarding radiologists' performance included same- or next-day reports (1/8) and screening mammography follow-up rates (1/8). Provided information regarding other aspects of quality included American College of Radiology (ACR) accreditation (3/8), on-site radiologist (2/8), fellowship-trained radiologists (1/8), examination volume (1/8), imaging appropriateness (1/8), inferred radiation dose (1/8), availability of advanced imaging technology such as digital mammography (1/8), and physician portal (1/8). None of the Web sites provided information regarding radiologists' diagnostic accuracy. Three of eight Web sites provided an internally developed composite score reflecting a combination of price and quality factors (i.e., a “docometer” score provided by one site), although precise explanations were not given regarding how these hybrid scores were derived. Three of eight Web sites provided direct links for scheduling an appointment at specific imaging centers. Table 2 summarizes the most commonly available information across these various categories. An additional three Web sites, not included in these eight, provided suggested fair or average prices for individual imaging examinations within specific geographic regions, although it did not provide information comparing price or quality between individual imaging centers within specific geographic regions. 4. Discussion In this study, we assessed transparency Web sites providing public information regarding radiology practices. The most consistently provided information related to the prices of imaging examinations, which was reported by the majority of Web sites. Information relating to quality or service was provided by a minority of Web sites and most commonly related to patient satisfaction, scheduling, and ACR accreditation. A broad range of other aspects of the patient experience, for instance relating to parking or the waiting area, was also occasionally reported. Other, more clinically oriented, aspects of quality were less commonly reported, rarely related to radiologists' performance, and never related to diagnostic accuracy or clinical outcomes. These observations validate existing concerns regarding the imbalance between publicly available price and quality information for radiology centers.
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Radiologists should be aware (if not already) of this dichotomy and recognize the resulting threat to radiologic quality in the current reality in which patients increasingly make informed decisions within a competitive healthcare marketplace. In addition, radiologists must recognize the need to take and support actions to provide patients with more complete and representative information on which to base decisions. We acknowledge that it is natural for comparison Web sites to provide that content which is most readily obtained. For instance, patient reviews, practices' hours of operations, and ACR accreditation status represent information that can be collected, organized, and presented in a straightforward fashion. Nonetheless, a proliferation of Web sites providing similar sets of incomplete metrics may establish a suboptimal norm in terms of the level of meaningful information that consumers come to expect. Such provided information is likely to drive, to some extent, the behaviors of patients, and thus of providers as well, thereby leading to a focus on these particular measures and a potential shift away from other important aspects of quality and service. Rather, patients would be better served if the developers of transparency Web sites, as well as of the metrics on which such Web sites are based, attempt to collect and distribute more revealing information. While several of the Web sites did provide composite measures of quality and price, the algorithms behind these measures were unclear, and they were presented with a paucity of information supporting the provided scores for individual practices. Accordingly, these measures may not reliably evaluate the value of radiology practices. ACR accreditation was the most commonly reported quality measure that relates to clinical care. ACR accreditation is a rigorous process that is specific to individual modalities and entails review of the licensing and certification of a center's radiologists, technologists, and physicists; submission of phantom and clinical images; as well as documentation of the continuing experience and continuing medical education of the radiologists and of a quality assurance program [15]. A centers' satisfaction of this comprehensive review provides useful information that patients and referring physicians may take into consideration. Nonetheless, some high-quality centers may not seek accreditation given the associated upfront and recurring costs that increase with the centers' number of scanners as well as the potential cost to purchase a phantom. In addition, information regarding the specific modality receiving accreditation was either unclear or missing from the transparency Web sites. Finally, even receipt of ACR accreditation does not provide patients with robust information regarding the diagnostic performance of the radiologist who will be interpreting their scan. Transparency Web sites are just one mechanism encouraging an emphasis on customer service and patient satisfaction. Of particular importance, as a result of provisions in the Patient Protection and Affordance Care Act, patient satisfaction, as measured by the HCAHPS survey, has become a key factor in determining hospital reimbursements based on Medicare's Value-Based Purchasing system [16]. Other stakeholders are also increasingly using patient satisfaction as a metric for profiling and comparing providers [17,18]. These trends have resulted in a pronounced emphasis by providers (hospitals in particular) on initiatives specifically designed to improve patient satisfaction, including the investment of time, personnel, and other resources [19–21]. Indeed, some individual practices and payers have begun to provide information regarding service quality, including patient satisfaction scores, directly to patients. Therefore, while the preponderance of patient satisfaction and other service measures among the quality measures available on the transparency Web sites may be contributing to providers' growing focus on patient satisfaction, the transparency Web sites certainly are not the only, or even primary, cause of the trend. We unequivocally agree that patient satisfaction is an important measure in radiology and healthcare in general, indeed having been associated with clinical outcomes [22,23]. Nonetheless, it is also important that radiologists do not focus on this particular measure to the point of neglecting their ultimate mission of rendering an accurate diagnosis that contributes to patient care.
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The paucity of information on the transparency Web sites relating to the clinical performance of centers' radiologists, including an absence of information relating to accuracy or other aspects of diagnostic performance, is of particular note. Patients may lack an awareness of the critical role and impact of the individual radiologist interpreting their scan and likewise lack an appreciation for the added value of having a skilled radiologist render a high-quality interpretation [24]. In comparison, from the patients' perspective, direct service-related factors will have the most immediate impact on their experience [25]. In addition, the actual equipment with which the patient is scanned, rather than the interpreting radiologist whom the patient does not meet, may appear on the surface to be the dominant component of clinical quality [3]. While we do not question the importance of modern high-quality equipment, the performance of the interpreting radiologist cannot be understated. In this regard, the nature of the content on the transparency Web sites may serve to further encourage such incomplete, if not inaccurate, public perceptions. The ACR's current Imaging 3.0 initiative helps to address this gap through efforts to improve radiologists' visibility and exposure to patients, including efforts to promote patients' understanding of the clinical role and value of radiologists [26,27]. The lack of meaningful clinical quality information on the transparency Web sites may misleadingly suggest to patients that radiology practices generally offer a similar level of clinical quality. However, this imbalance cannot be fully attributed to the sites' developers, as robust and relevant clinical quality metrics for radiology practices do not currently exist in a publicly available forum for the sites to utilize, even if desired. This reality highlights the need for radiologists to take measures to address this gap, as it is only once such metrics are developed and made accessible that such meaningful data may be incorporated into the transparency Web sites. Indeed, Durand et al. have recently proposed a number of actions that radiologists may take in response to the dominance of price information in the ongoing transparency movement [3]. These actions entail radiologists embracing the transparency effort by working as a specialty to identify meaningful quality metrics and to craft the necessary infrastructure to measure and report these in a consistent fashion [3]. That is, radiologists are called upon to directly oversee and take responsibility for the development of those facets of their practices by which they will be compared [3]. Just as mortality, complication, and readmission rates are becoming increasingly standardized and accepted as measures of a surgeon's performance, it is hoped that an appropriate package of relevant and measurable clinical outcomes can be developed for radiologists. It is anticipated that direct active participation by radiologists would facilitate this process and promote the emergence of measures that are more reflective of diagnostic accuracy along with other aspects of radiologists' clinical performance, as is currently lacking on the transparency Web sites. A number of limitations of this study warrant mention. First, our analysis includes only a small number of Web sites. However, this small number reflects the reality of the number of such sites available at the time of our Web searches. In this regard, our observations provide a snapshot of the transparency Web sites that exist at a single point in time. It is anticipated that additional comparison Web sites will be developed and that additional metrics or other content will be incorporated into existing Web sites that may offer a more balanced perspective of radiology practices than we currently report. In addition, we have not demonstrated the role of the transparency Web sites in influencing the behavior of patients or of radiology practices but have solely inferred that such associations exist to some extent. In addition, we have not explored associations between the information provided by the transparency Web sites and the Web sites' source or included providers. For instance, one Web site with numerous quality measures was generated by the federal government and only provides information for hospital outpatient departments participating in Medicare, while one private Web site requires radiology centers to pay a fee in order to be listed. Finally, we have not confirmed the accuracy of the information provided by the Web sites. Whether or not the information is accurate, the
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provided information reflects the reality of that which is currently available and presumably being used by patients in making decisions.
5. Conclusion Among eight transparency Web sites providing information comparing individual radiology centers within specific geographic regions across the country, the most commonly reported information was the price of imaging examinations at individual centers (six of eight Web sites). Provided information regarding the patient experience most commonly related to hours of operation, although also incorporated a broad range of factors related to various aspects of parking, transportation, accessibility, and waiting area amenities. The emergence of Web sites promoting transparency is encouraging, although the preponderance of price (and to a lesser extent service quality) information, with minimal clinical quality information, risks competition among radiology practices based largely on price at the expense of quality; accordingly, radiologists are called upon to oversee the development and dissemination of more robust and meaningful quality metrics that promote actual value-based competition.
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