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Out-of-network (OON) balance billing, commonly known as surprise billing but better described as a surprise gap in health insurance coverage, occurs when an individual with private health insurance (vs a public insurer such as Medicare) is administered unanticipated care from a physician who is not in their health plan's network. Such unexpected OON care may result in substantial out-of-pocket costs for patients. Although ending surprise billing is patient centric, patient protective, and noncontroversial, passing federal legislation was challenging given its ability to disrupt insurer-physician good-faith negotiations and thus impact in-network rates. Like past proposals, the recently passed No Surprises Act takes patients out of the middle of insurer-physician OON reimbursement disputes, limiting patients' expense to standard in-network cost-sharing amounts. The new law, based on arbitration, attempts to protect good-faith negotiations between physicians and insurance companies and encourages network contracting. Radiology practices, even those that are fully in network or that never practiced surprise billing, could nonetheless be affected. Ongoing rulemaking processes will have meaningful roles in determining how the law is made operational. Physician and stakeholder advocacy has been and will continue to be crucial to the ongoing evolution of this process. © RSNA, 2021.

Pediatric radiology is an immensely rewarding career choice. Eight pediatric radiologists, enthusiastic for their profession, were asked six questions about their career choice. Their responses illustrate the common virtues of pediatric radiology and also demonstrate the diverse paths and activities that pediatric radiologists take and pursue.

Radiology is participating in the recent consolidation trend. Larger practices can invest in the infrastructure and teams to help improve the clinical value of the services they deliver. An example of national practice is provided that leverages its scale to promote clinical best practices aimed at reducing variability in the recommendations radiologists make for common imaging findings. This is accomplished by promoting the culture of learning and collaboration. In some initiatives, developing a machine learning tool to facilitate the application of clinical algorithms at the point of dictation facilitates the adoption of the recommendations. Regular feedback on practice and individual performance promotes improvement in performance and personal satisfaction of the clinicians. Cost savings through the reduction of unnecessary imaging studies or invasive procedures as well as improved outcomes through evidence-based follow-up have been achieved. In some cases, reductions in the rupture rate of abdominal aortic aneurysms have been realized through clinical follow-up programs. Embracing a culture of continuous learning through peer learning can lay the foundation for sharing clinical best practices. Having access to the benefits of scale in the form of investment in data, analytics, project management, and machine learning tools can facilitate the process of creating clinical value for our patients.

The purpose of this article is to outline practical steps that a department can take to transition to a peer learning model.The 2015 Institute of Medicine report on improving diagnosis emphasized that organizations and industries that embrace error as an opportunity to learn tend to outperform those that do not. To meet this charge, radiology must transition from a peer review to a peer learning approach.

A major outcome of the current health care reform process is the move away from unrestricted fee-for-service payment models toward those that are based on the delivery of better patient value and outcomes. The authors' purpose, therefore, is to critically evaluate and define those components of the overall imaging enterprise that deliver meaningful value to both patients and referrers and to determine how these components might be measured and quantified. These metrics might then be used to lobby providers and payers for sustainable payment solutions for radiologists and radiology services. The authors evaluated radiology operations and services using the framework of the imaging value chain, which divides radiology service into a number of discrete value-added activities, which ultimately deliver the primary product, most often the actionable report for diagnostic imaging or an effective outcome for interventional radiology. These value activities include scheduling and imaging appropriateness and stewardship, patient preparation, protocol design, modality operations, reporting, report communication, and clinical follow-up (eg, mammography reminder letters). Two further categories are hospital or health care organization citizenship and examination outcome. Each is discussed in turn, with specific activities highlighted.

Radiology in the United States of America is evolving from a fee-for-service to a value-based, "pay-for-performance" system. Such a system requires objective measures, termed metrics, to grade performance. Current grading systems in health care, not designed with the unique nature of radiology in mind, often emphasize patient outcomes; this can be a challenge for measuring and grading performance in radiology, which is often several steps removed from patient outcome. At the present, while there are hundreds of individual radiology-specific metrics, there is no widely accepted overall standard for quality or value in diagnostic radiology services. This article analyzes the current system of radiology metrics and suggests a new direction for performance-based reimbursement in diagnostic radiology, focusing on a limited number of reasonably measurable outcomes-related factors that are specific to radiology.

Delivering a presentation that is educational, memorable, and even inspiring is the aspiration of all speakers. Unfortunately, public speaking is an anxiety-producing experience for many. This is especially true when delivering a talk to physician colleagues. Like so many daunting activities, success is achievable if you are willing to invest the time and energy to prepare. We believe that adherence to the principles outlined in this article, including a focus on content, delivery and design, will help you to succeed.

As a result of macroeconomic forces necessitating fundamental changes in health care delivery systems, value has become a popular term in the medical industry. Much has been written recently about the idea of value as it relates to health care services in general and the practice of radiology in particular. Of course, cost, value, and cost-effectiveness are not new topics of conversation in radiology. Not only is value one of the most frequently used and complex words in management, entire classes in business school are taught around the concept of understanding and maximizing value. But what is value, and when speaking of value creation strategies, what is it exactly that is meant? For the leader of a radiology department, either private or academic, value creation is a core function. This article provides a deeper examination of what value is, what drives value creation, and how practices and departments can evaluate their own value creation efficiencies. An equation, referred to as the Total Value Equation, is presented as a framework to assess value creation activities and strategies.

Recent political and economic factors have contributed to a meaningful change in the way that quality in health care, and by extension value, are viewed. While quality is often evaluated on the basis of subjective criteria, pay-for-performance programs that link reimbursement to various measures of quality require use of objective and quantifiable measures. This evolution to value-based payment was accelerated by the 2015 passage of the Medicare Access and CHIP (Children's Health Insurance Program) Reauthorization Act (MACRA). While many of the drivers of these changes are rooted in federal policy and programs such as Medicare and aimed at adult patients, the practice of pediatrics and pediatric radiology will be increasingly impacted. This article addresses issues related to the use of quantitative measures to evaluate the quality of services provided by the pediatric radiology department or sub-specialty section, particularly as seen from the viewpoint of a payer that may be considering ways to link payment to performance. The paper concludes by suggesting a metric categorization strategy to frame future work on the subject.

Whether a doctor, professional baseball manager, or a politician, having successful negotiation skills is a critical part of being a leader. Building upon prior journal articles on negotiation strategy, the author presents the concept of the multiple equivalent simultaneous offer (MESO). The concept of a MESO is straightforward: as opposed to making a single offer, make multiple offers with several variables. Each offer alters the different variables, such that the end result of each offer is equivalent from the perspective of the party making the offer. Research has found several advantages to the use of MESOs. For example, using MESOs, an offer was more likely to be accepted, and the counterparty was more likely to be satisfied with the negotiated deal. Additional benefits have been documented as well, underscoring why a prepared radiology business leader should understand the theory and practice of MESO.

Synapses were analyzed in the middle molecular layer (MML) and inner molecular layer (IML) of the rat dentate gyrus following the induction of long-term potentiation (LTP) by high-frequency stimulation of the medial perforant path carried out on each of 4 consecutive days. Potentiated animals were sacrificed 1 hour after the fourth high frequency stimulation. Stimulated but not potentiated and implanted but not stimulated animals served as controls. Using the stereological disector technique, unbiased estimates of the number of synapses per postsynaptic neuron were differentially obtained for various subtypes of axospinous junctions: For atypical (giant) nonperforated synapses with a continuous postsynaptic density (PSD), and for perforated ones distinguished by (1) a fenestrated PSD and focal spine partition, (2) a horseshoe-shaped PSD and sectional spine partition, (3) a segmented PSD and complete spine partition(s), and (4) a fenestrated, (5) horseshoe-shaped, or (6) segmented PSD without a spine partition. The major finding of this study is that the induction of LTP in the rat dentate gyrus is followed by a significant and marked increase in the number of only those perforated axospinous synapses that have multiple, completely partitioned transmission zones. No other synaptic subtype exhibits such a change as a result of LTP induction. Moreover, this structural alteration is limited to the terminal synaptic field of activated axons (MML) and does not involve an immediately adjacent one (IML) that was not directly activated by potentiating stimulation. The observed highly selective modification of synaptic connectivity involving only one particular synaptic subtype in the potentiated synaptic field may represent a structural substrate of the long-lasting enhancement of synaptic responses that characterizes LTP.

In my first week of business school, an MBA program for executives, the professor asked people to raise their hands if they considered the industries they were in to be both highly competitive and increasingly challenging. The group of students in the classroom was quite diverse. Represented were the oil and gas industry, investment banking, construction, and even a private intelligence agency, among many others. Every single person in the class raised their hand. It may have been the only time our class had complete agreement. So, with the understanding that everyone thinks their own industry is particularly competitive, I nonetheless contend that radiology is facing unique and unprecedented challenges. The future viability of any radiology practice will depend in very large measure on how its members recognize and respond to these novel challenges. Previously, the greatest threat to any private radiology group was displacement by a competing group, typically from the same city. Today, practices remain threatened from local groups but now also face the aditional threat of displacement by ational teleradiology outsourcing rms. Of additional concern is enanced competition from local roups that themselves were dislaced by teleradiology outsourcing rms. Furthermore, many groups re disappearing as radiologists are ecoming direct employees of the ospitals. This competitive landcape exists during a time of major pheaval in the health care environent as well as in an environment f state and federal budget shortalls. So, at the same time as a comletely new way to staff radiology epartments has emerged, thanks o technological advances, there is

Supravital staining by thiazins of segments of small intestine and mesentery of young dogs was studied with reference to specificity for nervous tissue. Attempts to secure a purer form of methylene blue by alumina adsorption and alcohol elution of the commercial, medicinal dye yielded a product which appeared to be structurally different from the original dye. The treated dye had absorption maxima from 620 to 655 mμ in contrast with 665 for the untreated. Small nerve bundles were stained by the treated dye after 2 to 4 hours of immersion, but staining was always incomplete. Staining by untreated methylene blue was compared with that by the leucobase, thionol, methylene green, toluidine blue, new methylene blue and the azures. It was concluded that the specificity for nerve fibers resides mainly in the =N(CH3)2Cl radical, although some specificity appears to be effected by the methyl groups on the trivalent nitrogen, since azure A (dimethyl) and azure C (mono-methyl) stained weakly, but thionin did not. Me...

The preparation by McGee (6) of extracts of bull testes that stimulated growth of the comb of castrated cocks and the subsequent advances in the purification of these extracts by Gallagher and Koch (1, 2) are now well known. Similarly, through the publications of Moore and his associates (7, 8, 9), it has been demonstrated that these extracts prevent the onset of castration changes in the mammal, or repair them if administered subsequent to castration damage [Vatno (14), Heller (4)]. Several mammalian test methods have been utilized, all of which have dealt with the accessory organs of reproduction. Since it is necessary to know that these preparations are effective in preventing all changes known to follow castration before arriving at the conclusion that they contain the complete hormone, I have made a study of the spontaneous activity in the rat in relation to its hormone state to learn whether voluntary activity can be successfully used as a hormone indicator.

A patient is described with complete heart block and a ventricular septal defect, both secondary to a stab wound of the chest. The escape rhythm was characterized by a wide QRS interval with a configuration suggesting right bundle branch block. His bundle (H) recordings revealed “split” H potentials with a P-H1 interval of 100 msec and an H2-V interval of 40 msec. Recording of left bundle branch (LB) potentials showed the left bundle branch spike to occur in the H2-V interval with an H2-LB interval of 15 msec and an LB-V interval of 25 msec. Atrial pacing produced prolongation of P-H1, administration of atropine and isoproterenol produced shortening. Wenckebach periods proximal to H1 were noted at an atrial paced rate of 190/min. During the study, the QRS pattern unexpectedly shifted from right to left bundle branch block, with H2 potentials still preceding each QRS interval. The most likely explanation for this was the occurrence of longitudinal dissociation in the distal His bundle allowing preferential distribution of the cardiac impulse to one or the other ventricle. However, the possibility of varying bundle branch block, or shifting of the pacemaker from the His bundle to the bundle branches could not be absolutely excluded. In summary, His bundle recording suggested a site of block in the His bundle. Observations are made on the nature of “split” H potentials and evidence for the occurrence of longitudinal dissociation in the His bundle is presented.

A study of the effects of osmotic pressure, pH, the presence of dextrose, acetate, pyruvate or lactate, and agents affecting cell permeability during supravital staining by methylene blue was made by means of an immersion technic. Mesentery and intestine of dogs and cats were used. Penetration of the dye was limited to the mesentery and more superficial layers of intestine. Conditions which facilitated the characteristic differentiation of of nerve fibers were: continuous oxygenation of the staining solution, pH about 5.6 stabilized by phosphate buffer, and the presence of small amounts of acetate and lactate. Young animals' tissue stained better than old. Methylene blue was a much more effective staining agent than less completely methylated thionins.