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The objective of our study was to assess temporal changes in the utilization of musculoskeletal extremity imaging in Medicare beneficiaries over a recent 20-year period (1994-2013).Medicare Physician Supplier Procedure Summary Master Files from 1994 through 2013 were used to study changing utilization and utilization rates of the four most common musculoskeletal imaging modalities: radiography, MRI, CT, and ultrasound.Utilization rates (per 1000 beneficiaries) for all four musculoskeletal extremity imaging modalities increased over time: 43% (from 441.7 to 633.6) for radiography, 615% (5.4-38.6) for MRI, 758% (1.2-10.3) for CT, and 500% (1.8-10.8) for ultrasound. Radiologists were the most common billing specialty group for all modalities throughout the 20-year period, maintaining dominant market shares for MRI and CT (84% and 96% in 2013). In recent years, the second most common billing group was orthopedic surgery for radiography, MRI, and CT and podiatry for ultrasound. The physician office was the most common site of service for radiography, MRI, and ultrasound, whereas the hospital outpatient and inpatient settings were the most common sites for CT.In the Medicare population, the most common musculoskeletal extremity imaging modalities increased substantially in utilization over the 2-decade period from 1994 through 2013. Throughout that time, radiology remained the most common billing specialty, and the physician office and hospital outpatient settings remained the most common sites of service. These insights may have implications for radiology practice leaders in making decisions regarding capital infrastructure, workforce, and training investments to ensure the provision of optimal imaging services for extremity musculoskeletal care.

Rapidly rising health care costs coupled with variability in pricing and patient service have led to intense public scrutiny and pressure for health care providers to demonstrate value. Recent changes in legislation and payment models have intensified a shift from volume-based to value-based care, transferring risk from payers to providers. The American College of Radiology's Imaging 3.0 initiative encourages radiologists to become leaders in this changing health care landscape, helping to redefine value relative to health outcomes that matter to patients. Finding value and areas for improvement can prove difficult. However, through the imaging value chain, a plethora of opportunities are easily identifiable. It will be critical for musculoskeletal radiologists to leverage information technology and develop meaningful metrics to assess and demonstrate imaging's contribution to improved patient outcomes and reduction in costs, and to advocate for appropriate reimbursement.

Purpose The aim of this study was to assess the changing use of emergency department (ED) cervical spine imaging in the Medicare population. Methods Using national aggregate Medicare claims data from 1994 through 2012, all cervical spine radiographic, CT, and MR examinations performed in the ED setting were identified. Shifts in modalities and providers and changes in utilization rates were studied. Results Between 1994 and 2004, ED cervical spine radiography volumes in the Medicare fee-for-service population increased from 203,645 to 306,442 (+50.5%) and then declined to 152,755 (−50.2%) by 2012. CT volumes increased every year, overall by +8,864% from 1994 through 2012 (from 6,360 to 570,121). MR grew by +1,381%, but volumes overall were small (from 944 to 13,979). With these changes, CT overtook radiography as the dominant ED cervical spine imaging modality in 2007. Per 1,000 Medicare beneficiaries, utilization rates of radiography, CT, and MR changed by −27%, +8,682%, and +1,351% from 1994 through 2012 (from 6.3 to 4.6, from 0.2 to 17.3, and from 0.0 to 0.4). For all years, compared with other specialists, radiologists remained by far the dominant providers of radiography, CT, and MR (+91.7%, +93.4%, and +96.0% in 1994 and +96.9%, +99.3%, and +99.0% in 2012) in the ED setting. Conclusions Between 1994 and 2012, the overall utilization rate of cervical spine imaging for Medicare beneficiaries in the ED setting more than tripled. With a small decline in radiography (–27%) but a dramatic increase in CT (+8,864%), CT is now by far the dominant modality for imaging the cervical spine in the ED. Radiologists remain overwhelmingly the dominant providers of these interpretive services.

Although most musculoskeletal MRI examinations are interpreted by radiologists, some nonradiologists provide interpretations as well. We aimed to study day of week (weekday vs weekend), site of service, and patient complexity differences between radiologists and nonradiologists interpreting lower extremity MRI examinations on Medicare beneficiaries.Using fee-for-service carrier claims for a 5% sample of Medicare beneficiaries nationally from 2012 through 2014, we identified all lower extremity joint MRI examinations. Services were classified by physician specialty, day of week, and site of service. Charlson comorbidity index (CCI) values were calculated for all patients. Chi-square statistical testing was performed.Of all 125,800 billed lower extremity joint MRI examinations, 118,295 (94.0%) were performed on weekdays and 7505 (6.0%) on weekends. Of the weekday examinations, radiologists interpreted 85,991 (83.3%) and nonradiologists 17,260 (16.7%). Of the weekend examinations, radiologists interpreted 6212 (92.8%) and nonradiologists 485 (7.2%). Of examinations performed in inpatient hospital and emergency department settings, radiologists interpreted 6499 (99.2%) and nonradiologists 51 (0.8%). Of the examinations on the most clinically complex patients (CCI ≥ 3), radiologists interpreted 4228 (90.2%) and nonradiologists 461 (9.8%). All interspecialty differences were statistically significant (p0.001).In the Medicare population, radiologists interpret most lower extremity joint MRI examinations. Compared with nonradiologists, radiologists disproportionately provide services on weekends, in the highest acuity settings, and on the most clinically complex patients. To promote patient access and minimize disparities, future pay-for-performance metrics should consider temporal, acuity, and complexity parameters.

BACKGROUND AND PURPOSE: Although most neuroimaging examinations are interpreted by radiologists, many nonradiologists provide interpretation services. We studied day of the week, site of service, and patient complexity differences for common Medicare MR neuroimaging examinations interpreted by radiologists versus nonradiologists. MATERIALS AND METHODS: Using carrier claims files for a 5% sample of Medicare beneficiaries from 2012 to 2014, we identified all claims for brain and lumbar spine MR imaging examinations. Services were categorized by physician specialty, day of the week, and the site of service. Patient complexity was calculated using Charlson Comorbidity Indices. The χ(2) was performed to test statistical significance. RESULTS: A provider specialty could be identified for 568,423 brain and lumbar spine MR imaging examinations. Of weekday examinations, radiologists interpreted 475,288 (92.3%), and nonradiologists, 39,510 (7.7%). Of weekend examinations, radiologists interpreted 52,028 (97.0%) and nonradiologists 1597 (3.0%). Radiologists interpreted 145,904 (98.7%) examinations in the inpatient hospital and emergency department settings versus 1882 (1.3%) by nonradiologists. Of all examinations, 44,547 of those interpreted by radiologists (8.4%) were on the most clinically complex patients versus 2139 (5.2%) for nonradiologists. All interspecialty differences for day of the week, the site of service, and patient complexity were statistically significant (P < .001). CONCLUSIONS: Although radiologists interpret most common MR neuroimaging examinations for Medicare beneficiaries, in contrast to nonradiologists, they disproportionately render those services on weekends, in higher acuity sites, and on more complex patients. To optimize access and minimize disparities in necessary neuroimaging, quality metrics should consider such service characteristics.

The purpose of this study is to identify the specialty characteristics of providers referring musculoskeletal (MSK) extremity imaging examinations to radiologists, so as to better understand the drivers of MSK imaging utilization and potentially improve the appropriateness of such imaging examinations.Data on provider referral for MSK extremity imaging services were extracted from the 2014 Medicare Referring Provider Utilization for Procedures public use file, which aggregates data on diagnostic procedures according to referring provider identities and service codes. MSK extremity imaging services were identified using Neiman Institute Types of Service codes. The referring provider specialty was identified from cross-linked Medicare provider characteristics files.For 4,275,647 MSK extremity imaging examinations ordered, the most common specialties of the referring providers were orthopedic surgery (37.6% of ordered examinations), internal medicine (20.2%), family practice (14.8%), emergency medicine (7.9%), and rheumatology (5.7%). Orthopedic surgery was the referring specialty that most commonly ordered MSK extremity CT (33,465 ordered examinations; for all other specialties,2000 examinations), MRI (325,485 examinations; for all other specialities,20,000 examinations), and radiography (1,249,748 examinations; for all other specialities,850,000 examinations), whereas internal medicine was the referring specialty that most commonly ordered MSK extremity ultrasound examinations (8052 ordered examinations; for all other specialties,6000 examinations). Among the select specialties most relevant to MSK imaging, the most frequent referrers after orthopedic surgeons were rheumatologists, for radiography (236,057 ordered examinations) and ultrasound (2034 examinations), and podiatrists, for CT (1201 examinations) and MRI (19,159 examinations). The most commonly ordered individual MSK extremity imaging services were knee radiography, with 190,354 examinations ordered by orthopedic surgeons; hand radiography, with 66,167 examinations ordered by rheumatologists; foot radiography, with 137,042 examinations ordered by podiatrists; shoulder radiography, with 11,299 examinations ordered by sports medicine specialists; and hip radiography, with 9838 examinations ordered by physiatrists.Referral patterns for MSK imaging vary considerably by provider specialty. Referral pattern insights may guide targeted efforts by radiologists to ensure the appropriateness of such examinations.