Is it possible that the study that is emblematic of the specialty, and the one that still represents the lion’s share of procedures, if not images, is no longer tenable from an economic perspective?

The potential losses associated with screening mammography have been well documented, but until recently, the same scrutiny has not been accorded the humble radiograph, a study that can be obtained in just about any medical office in the nation. Yet the procedure accounts for an average 60% to 65% of all radiology department studies done in a hospital setting, and most freestanding centers are equipped to perform the procedure.

Mayo-Smith et al from the Department of Diagnostic Imaging at Brown Medical School, Rhode Island Hospital, took a close look at the cost of performing radiography in one of their freestanding settings and reported on the results at the recent meeting of the Radiological Society of North America: “Financial Impact of Performing Plain Radiographs in an Outpatient Setting: Revenue Loser or Loss Leader?” Modality cost accounting data for 4,295 plain radiographs were collected from one of the academic practice’s freestanding imaging centers for six consecutive months beginning January 2001. Site variable (film, jackets, linens, and other supplies) and fixed (technologist wages and benefits, equipment rental, service and space rental, and taxes) as well as overhead costs were collected. Total site examination volume was divided into the fixed and partitioned overhead costs and the variable costs for each examination to determine the true cost of each study. An average of 33 examinations were performed daily, and the average site cost (fixed and variable) was $28.50 per examination. Add to that the average overhead cost of $21.30 for an average total cost of $49.80 per examination. Average Medicare global reimbursement in Rhode Island at the time was $38.69 per procedure for a net average loss of $11.11 per examination, and that is before physician costs are included.

The exercise described above did not include physician reimbursement, so it must be presumed that reads were performed gratis. How much more would the study have cost the practice if the physician relative value units were factored in? How are hospitals faring? The researchers concluded that x-ray reimbursement is clearly inadequate, adding that increased efficiency is unlikely to make it a break-even proposition. They recommended that reimbursement be increased to cover costs.

If radiography has been served up as a sacrificial lamb in the interest of preserving reimbursement for the higher cost modalities, so be it. But perhaps it is time to take a closer look at the costs. Innovations in the digital world of radiography are enabling greater operational efficiencies and reportedlyin some instancesbetter clinical data with which to interpret these studies, resulting in a more expensive but critical buy for a digital radiology service. Should a digital chest radiograph performed with dual energy subtraction post processing be reimbursed at the same rate as a chest radiograph taken on a 20 year-old analog machine in an urgent care facility? What does your radiography service cost, and how much are you losing?

Surely Roentgen is turning in his grave.

Cheryl Proval

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