Ever since we learned that the Consolidated Appropriations Act of 2016 would reduce reimbursement rates starting next year, people have been asking why this change?  Most people understand the 20% reduction for film studies…it’s another strong encouragement for all medical history to be available via electronic media, but why is the government cutting payment for CR studies eventually by 10%?  Why the decimation of CR over DR?

I haven’t gotten a good answer.  The only answer I’ve seen is to encourage adoption of the latest technology.

However, I don’t see that this reasoning applies to CR.  There is both an economic and patient care argument against this.

Once you have read this post, please let me know if I’ve missed anything and I’ll pass your comments on to others. There are a lot of us who don’t understand.

The Economic or “Workflow” Argument: The move to DR will significantly improve workflow.

Generally this boils down to the time it takes to process an image.  Let’s, for argument’s sake, say that both DR and CR have the same data input requirements and patient set-up time.  Since the modality worklist feature can be added to both digital technologies, data input is still the same for CR and DR with or without MWL.  What the workflow argument amounts to is processing time.  So let’s be generous and say DR is 10 seconds and CR is 90 seconds.  If you assume that in an 8 hour shift one will work a maximum of 7 ½ hours, then a facility would have process to 338 images a day to save one full time employee.  Numbers of this size are found in only the very busiest imaging centers or hospitals.

These numbers assume that the tech is working full out doing nothing but processing images.  But there is a lot more involved in taking images, including machine setting, patient positioning, setting the collimator, etc.  When one CR plate is processing, the tech is doing other work and when using DR the tech still has to do some or all of these functions between images.   This means that our assumption of an 80 second advantage for DR is just not realistic.  The 338 images/day number is most likely much higher.

Only institutions that do hundreds of images a day can make a solid justification that workflow justifies DR. One has to find the extra money somewhere to pay for DR over CR and the workflow argument does not seem to be a slam dunk.  If anyone has seen a study proving reductions of FTE’s using DR vs. CR, please share it.

The Patient Care Argument:  DR technology is superior to CR technology when considering patient care issues.

IanMcLeanHere I’ll take a back seat to a professional who I respect.  Meet Dr. Ian Mclean, DC, DACR, and Director of Radiology for the three campuses of Palmer Chiropractic College.  He manages three clinics, an outside reading service and the teaching of radiology to hundreds of students each year.  He was an early adopter of digital technology, having the schools purchase then best of breed equipment including CR’s and DR panels.  He has seen images from a wide variety of CR and DR manufacturers.

Here’s his statement: “The issue not discussed is the wide variation in imaging quality with DR systems both in terms of patient dose and image quality. DR includes not only traditional TFT panels but also CCD based technology, which is not equivalent. Direct flat panel detectors generally provide excellent image quality and are the preferred device for most radiology departments that can absorb the relatively higher cost. While CCD panels have a relatively low cost, the necessary dose tends to be higher and image quality is not optimal.”

“There are also a large number of CR units available that also provide excellent quality images at a lower dose than many DR panels.  The discussion should be focused around quality and dose benchmarks rather than one digital technology over another.”

Underlying Dr. Mclean’s statement is the point that the government’s  reimbursement decision could have the unintended consequence of hindering technology development.  What’s to say that CR workflows can’t be improved or another technology can’t challenge DR?

Another point that I’ve discussed with Dr. Mclean and others is that this reimbursement decision may limit access to imaging.   In effect, this decision forces providers to move away from CR and adopt a more expensive technology.  For those who have recently purchased CR, it forces on them a new and harsher financial justification for this CR decision.  It is very easy to see that practices could simply walk away from their imaging departments, forcing patients to go to more remote, larger centers and less immediate care.

So why was this reimbursement change made?  Do you know?  If so, please share.

Was it simply “new is better”?  Was it workflow (miscalculation)? Was it one manufacturing group making a larger impression on regulators than another? Or was it just a mistake that should be corrected?

I think most of us agree that moving to a full digital imaging environment is best in the long run.  We “old guys” may think fondly about the “film days”.  We will laugh when our grandchildren cannot tell us what “x-ray film” is just as we have chuckled when our kids asked what an “LP” is. But some changes are good and I think most of us believe that, all things considered, digital imaging is better.

However, if the goal is to move practices to “digital,” then CR should remain an equal to DR. It is more affordable than DR, especially when one considers the large number of quality used systems that are coming on the market as larger providers move to DR,  These systems could be purchased by small practices that are still film-based or using CCD DR or earlier generation CR.

Let’s go digital, but let’s do it in a way that is affordable, that encourages maximum quality and minimal dose, and that provides a level playing field for all manufacturers and equipment providers.

What do you think?  Please let me know.

Daniel Giesberg – giesberg@amdtechnologies.com – 1.310.471.8900 ext 300