Radiographic imaging plays an integral role in the diagnosis and management of orthopedic trauma injuries, but it is also a major component of health care spending. Driven by a dramatic increase in the use of magnetic resonance imaging (MRI) and computed tomography (CT), Medicare reimbursement for musculoskeletal imaging is projected to be $3.6 billion by 2020.1 Given the rapid growth in US health care spending and the increasing emphasis on practicing cost-conscious medicine, it is important for orthopedic surgeons to understand the total charges associated with the radiographic studies that they order.
Previous research has indicated that health care providers generally have a poor understanding of the charges associated with common components of patient care, including pharmaceuticals, laboratory studies, and surgical implants.2–5 Several previous studies have surveyed radiologists and other medical specialists about imaging charges specifically, but cost awareness of imaging studies among orthopedic surgeons is unknown.6,7
Although cost should not be the sole driving force behind medical decision making, understanding general charges to the health care system, and possibly the patient, is important to effectively manage health care resources.8,9 Understanding charges can be difficult, as reimbursement varies widely across insurance plans and is often substantially different from the actual billing charge generated by the hospital.10,11 However, previous studies across other medical specialties have shown that displaying either the average Medicare reimbursement rates or the actual billing charges has the same effect on physician ordering behavior—fewer tests are usually ordered, leading to decreased health care cost without compromising clinical care.12–17 If physicians know the charges associated with imaging, they can better determine whether the additional information likely to be obtained is worth the extra resources. Understanding both general charges and reimbursements will be particularly important in the transition to bundled payments and is also relevant when patients' insurance does not cover the full cost of their care or they pay out of pocket.
This study sought to determine whether orthopedic surgery residents, fellows, and faculty could accurately estimate the hospital charges of common orthopedic imaging modalities at their institutions. The authors hypothesized that all groups would underestimate charges, but that faculty would have a better knowledge of charges than trainees and that there would be no difference between estimates for various imaging modalities, including radiographs, MRI, and CT scans.
Materials and Methods
This was a cross-sectional observational study. Ten modalities commonly used for musculoskeletal imaging, including radiographs, MRI, and CT scans, were incorporated into an online survey (Table 1).
The 10 Imaging Modalities Listed in the Survey
Participants were asked to estimate the total charge for each imaging study, which included both professional and facility fees, at their institution. They also noted their training level (faculty, fellow, or resident) and institution, but were otherwise anonymous. Participants' estimates were compared with the actual charges at their specific institutions, which were obtained from the radiology department or the billing center.
The survey was distributed using SurveyMonkey to 8 academic medical centers in different regions of the United States in June 2017. One center declined to participate. A total of 170 participants, including 74 faculty, 88 residents, and 8 fellows, from 7 centers completed the survey. Due to the low number of responses from fellows, they were excluded from the final analysis. There was a mean of 23 respondents from each institution (SD, 15). The response rate was 51% (44.5% of faculty vs 55.6% of residents). This was higher than what has been the average for similar web-based physician surveys.18 The demographics of the participants were limited to maintain anonymity. As with all surveys, there may have been a responder bias. However, because all of those surveyed were faculty or residents at large academic centers, the authors assume that there was no substantial difference in responders vs nonresponders.
The percent difference between the estimated and the actual charge was calculated by dividing the estimated billing charge by the actual billing charge and multiplying the result by 100%. This percent difference was calculated separately for each imaging study for each participant. The difference between residents and faculty was examined using a t test. To facilitate comparison with previous studies of estimated implant and medical costs, the percentage of estimates within 20% of the actual charge was also calculated.2–4 For example, if the actual charge was $100, any estimate between $80 and $120 was considered accurate.
Imaging studies were grouped as radiographs, CT scans, and MRI. Average percent differences between these types of imaging studies were examined using an analysis of variance test. An analysis of variance test with post hoc contrast tests was used to estimate differences between the 7 centers. Participants were characterized as underestimating costs if their average estimated cost was lower than the actual cost and as overestimating costs if their average estimated cost was higher than the actual cost for their institution.
Statistical analysis was conducted using R (R Core Team, Vienna, Austria) and RStudio (Rstudio Team, Boston, Massachusetts) software.
Overall, actual billing charges were underestimated by 31% (P<.001; 95% confidence interval, 59–79). Further, 19.4% of estimates were within 20% of actual charges (95% confidence interval, 19.1–19.9). By level of training, 21.2% of resident estimates (95% confidence interval, 21.5–21.9) and 17.1% of faculty estimates (95% confidence interval, 16.2–18) were within 20% of actual charges.
There was no significant difference in estimation between faculty and residents (P=.69). Overall, faculty underestimated charges by 33.5% (95% confidence interval, 53–80) and residents underestimated charges by 29.5% (95% confidence interval, 56–85). This is further detailed in Figure 1.
Average percent estimate of actual billing charge broken down by training level and imaging modality. *Magnetic resonance imaging (MRI) estimates were closer to actual values than estimates for radiographs (XR) (P=.002). Abbreviation: CT, computed tomography.
There was a difference in overall estimation accuracy between imaging modalities, with MRI charges being estimated more accurately than radiograph charges. The average percent difference between estimated and actual billing charges for radiographs was 53.5% (95% confidence interval, 48–60), meaning charges were underestimated by 46.5%. For CT scans, the average percent difference was 69.5% (95% confidence interval, 58–81). For MRI, the average percent difference was 89.4% (95% confidence interval, 71–108). The analysis of variance test indicated a significant difference by type of imaging study (F=6.50, P=.002). Post hoc tests indicated that the mean percent difference for radiographs was significantly different from the mean percent difference for MRI (P<.005). There were no significant differences between CT scans and MRI, or between radiographs and CT scans (Figure 1).
There was a large variation in billing charges between institutions. For example, the total charge ranged from $182 to $1239 for an ankle series and from $657 to $11,926 for CT angiography of the pelvis (Figure 2, Table 2).
Range of billing charges at different institutions by imaging modality. Abbreviations: 3D, 3-dimensional; CT, computed tomography; CTA, computed tomography angiography; LE, lower extremity; MR, magnetic resonance; MRA, magnetic resonance angiography; PEL, pelvis; UE, upper extremity; XR, radiograph.
Mean Actual Billing Charge and Mean Estimated Charge for Each Imaging Modality
In comparison, estimations of total charges from survey participants at different institutions were relatively similar. Of the 21 permutations comparing different survey sites directly with each other (eg, estimations from site A vs site B), there were only 2 combinations for which the average estimated charges were statistically different from each other (P>.05).
Of the 162 faculty and residents, 130 participants underestimated charges overall and 32 participants overestimated charges overall (Table 3). Of the 7 academic centers included, participants from 2 institutions collectively overestimated costs, while participants from the remaining 5 institutions collectively underestimated costs.
Number of Participants Who Overestimated and Underestimated Cost at Each Institution
This study indicates that orthopedic surgeons across all levels of training underestimate hospital charges for common orthopedic imaging studies. It is well-known that health care providers across specialties generally have a poor understanding of medical expenses incurred by both hospitals and patients.2–5,19 Previous systematic reviews of cost awareness across medicine, including diagnostic tests, medical consumables, pharmaceuticals, and health care visits, have shown 31% to 33% accuracy in estimates, defined by an estimate within 20% of the actual costs.3,4 A similar study investigating resident and faculty awareness of the price of orthopedic implants showed 21% accuracy.2 The current study showed a similar lack of awareness of the charges associated with orthopedic trauma imaging, with only 19.4% of estimates within 20% of actual charges.
One would expect some incremental increase in cost awareness as a physician gains experience in practice and becomes more involved in the business of health care; however, the current study did not find any statistically significant difference between residents and faculty.19,20 This speaks to the lack of transparency in health care pricing.
Interestingly, the charge of MRI was more accurately estimated than that of radiographs across level of training, despite radiographs being far more frequently ordered. This implies that ordering a test more frequently does not necessarily mean that the health care provider will have a better idea about the charges for that test.
As previously mentioned, it is important to note the difference between charge and ultimate reimbursement. Hospitals generally create their own chargemaster that sets charges billed to insurers. They are then reimbursed, often at a substantially lower rate, based on regional and contracting variations.10,21,22 The orthopedic trauma and arthroplasty literature suggests that, on average, hospitals charge more than 3.5 times the amount they are reimbursed by Medicare.10,11 However, not everyone has the negotiating power of insurance companies. The most vulnerable patients, including uninsured patients, are commonly asked to pay the full charges. Similarly, out-of-network patients and casualty and workers' compensation insurers are asked to pay a large percentage, if not all, of the hospital charges.23 High charges have also been associated with increasing insurance premiums and a general rise in health care spending.24
As previously mentioned, despite the difference in charge and reimbursement, charge data are still relevant and charge awareness can affect ordering behavior.14,17
In the era of health care economic reform and bundled payments, being cognizant of charges for common diagnostic studies is increasingly important, and physicians have a duty to scrutinize the clinical utility of all studies they order.25,26 Previous studies across specialties have shown that posting reimbursement and billing charges changes ordering behavior, thereby decreasing costs without impacting clinical care.13,14,17,27–29 In orthopedics, posting the price hospitals pay for implants has been shown to affect implant selection.2,30 Although no study has investigated the effect of posting orthopedic imaging charges, the current authors hypothesize that doing so may have the same effect on imaging ordering behavior as it did on implant selection. Again, the billing charges should not be the main factor in a physician's decision to order a test. However, general knowledge of charges is important and may motivate future research into the clinical relevance of specific tests.
One area where cost awareness could have an impact is in the setting of a routine trauma workup in the emergency department. Understanding the charges associated with imaging may emphasize to providers the importance of a focused and thoughtful radiographic evaluation instead of the traditional pan scan. Additionally, in the postoperative period, recent literature suggests that early imaging after routine fracture treatment has no impact on clinical outcomes and may represent an unnecessary use of resources while also increasing radiation exposure.31–37 Understanding the large financial burden associated with routine early postoperative radiographs motivated the authors to examine their clinical utility. Now, limiting unnecessary early postoperative radiographs may provide alignment of both health care costs and sound clinical practice.
An unexpected finding of this study was the large variation in charges among academic centers of similar size, with up to 18 times the billing charge at one institution compared with another for identical images. Factors such as geography, patient demographics, and negotiating power of the health care system influence the chargemaster, but there is also a large component of variation that is not well explained by observable patient or hospital characteristics, making it more difficult for health care professionals to provide cost-conscious medical treatment.38–42 Despite the variation in billing charges, there was little variation in the estimated charges between survey respondents at different institutions. This means that participants had the same general expectations of imaging charges across the country but little awareness of the relative expensiveness of their institution.
One limitation of this study was that it surveyed only academic centers. It would be interesting to extend the survey to private practice surgeons and community hospitals. They have different financial incentives and more transparency regarding the business aspect of orthopedic surgery. It would also be interesting to see how accurately orthopedists could estimate average Medicare reimbursement rates for the imaging studies and whether this was more accurate than their awareness of actual hospital charges. As with any web-based survey, there was the potential for response bias. However, the sample was large enough and had a sufficient response rate to limit these concerns. The number of institutions surveyed also limited the ability to make any general statements about charge variation across geographic regions.
Orthopedic surgeons across all levels of training underestimate hospital charges associated with common orthopedic trauma imaging studies, and there is a large variation in charges between centers. Cost-conscious medicine is an important component of health care economics. Charge awareness is known to affect physician ordering, decreasing costs without impacting clinical care. These findings highlight the importance of better educating surgeons about the charges associated with these modalities and analyzing the clinical utility of these modalities. This study opens the door for future research into the effect that posting imaging charges has on physician ordering behavior.
- Parker L, Nazarian LN, Carrino JA, et al. Musculoskeletal imaging: Medicare use, costs, and potential for cost substitution. J Am Coll Radiol. 2008;5(3):182–188. doi:10.1016/j.jacr.2007.07.016 [CrossRef]
- Okike K, O'Toole RV, Pollak AN, et al. Survey finds few orthopedic surgeons know the costs of the devices they implant. Health Aff (Millwood). 2014;33(1):103–109. doi:10.1377/hlthaff.2013.0453 [CrossRef]
- Allan GM, Lexchin J. Physician awareness of diagnostic and nondrug therapeutic costs: a systematic review. Int J Technol Assess Health Care. 2008;24(2):158–165. doi:10.1017/S0266462308080227 [CrossRef]
- Allan GM, Lexchin J, Wiebe N. Physician awareness of drug cost: a systematic review. PLoS Med. 2007;4(9):e283. doi:10.1371/journal.pmed.0040283 [CrossRef]
- Streit JJ, Youssef A, Coale RM, Carpenter JE, Marcus RE. Orthopaedic surgeons frequently underestimate the cost of orthopaedic implants. Clin Orthop Relat Res. 2013;471(6):1744–1749. doi:10.1007/s11999-012-2757-x [CrossRef]
- Vijayasarathi A, Hawkins CM, Hughes DR, Mullins ME, Duszak R Jr, . How much do common imaging studies cost? A nationwide survey of radiology trainees. AJR Am J Roentgenol. 2015;205(5):929–935. doi:10.2214/AJR.14.14167 [CrossRef]
- Vijayasarathi A, Duszak R Jr, Gelbard RB, Mullins ME. Knowledge of the costs of diagnostic imaging: a survey of physician trainees at a large academic medical center. J Am Coll Radiol. 2016;13(11):1304–1310. doi:10.1016/j.jacr.2016.05.009 [CrossRef]
- Long T, Bongiovanni T, Dashevsky M, et al. Impact of laboratory cost display on resident attitudes and knowledge about costs. Postgrad Med J. 2016;92(1092):592–596. doi:10.1136/postgradmedj-2015-133851 [CrossRef]
- Agrawal S, Taitsman J, Cassel C. Educating physicians about responsible management of finite resources. JAMA. 2013;309(11):1115–1116. doi:10.1001/jama.2013.1013 [CrossRef]
- Dodd AC, Lakomkin N, Bulka C, Thakore R, Collinge CA, Sethi MK. Geographic variations in orthopedic trauma billing and reimbursements for hip and pelvis fractures in the Medicare population. J Orthop. 2016;13(4):264–267. doi:10.1016/j.jor.2016.06.015 [CrossRef]
- Thakore RV, Greenberg SE, Bulka CM, Ehrenfeld JM, Obremskey WT, Sethi MK. Geographic variations in hospital charges and Medicare payments for major joint arthroplasty. J Arthroplasty. 2015;30(5):728–732. doi:10.1016/j.arth.2014.12.011 [CrossRef]
- Cummings KM, Frisof KB, Long MJ, Hrynkiewich G. The effects of price information on physicians' test-ordering behavior: ordering of diagnostic tests. Med Care. 1982;20(3):293–301. doi:10.1097/00005650-198203000-00006 [CrossRef]
- Goetz C, Rotman SR, Hartoularos G, Bishop TF. The effect of charge display on cost of care and physician practice behaviors: a systematic review. J Gen Intern Med. 2015;30(6):835–842. doi:10.1007/s11606-015-3226-5 [CrossRef]
- Hampers LC, Cha S, Gutglass DJ, Krug SE, Binns HJ. The effect of price information on test-ordering behavior and patient outcomes in a pediatric emergency department. Pediatrics. 1999;103(4, pt 2):877–882.
- Long MJ, Cummings KM, Frisof KB. The role of perceived price in physicians' demand for diagnostic tests. Med Care. 1983;21(2):243–250. doi:10.1097/00005650-198302000-00011 [CrossRef]
- Sedrak MS, Myers JS, Small DS, et al. Effect of a price transparency intervention in the electronic health record on clinician ordering of inpatient laboratory tests: the PRICE randomized clinical trial. JAMA Intern Med. 2017;177(7):939–945. doi:10.1001/jamainternmed.2017.1144 [CrossRef]
- Tierney WM, Miller ME, McDonald CJ. The effect on test ordering of informing physicians of the charges for outpatient diagnostic tests. N Engl J Med. 1990;322(21):1499–1504. doi:10.1056/NEJM199005243222105 [CrossRef]
- Cunningham CT, Quan H, Hemmelgarn B, et al. Exploring physician specialist response rates to web-based surveys. BMC Med Res Methodol. 2015;15:32. doi:10.1186/s12874-015-0016-z [CrossRef]
- Weinberger SE. Providing high-value, cost-conscious care: a critical seventh general competency for physicians. Ann Intern Med. 2011;155(6):386–388. doi:10.7326/0003-4819-155-6-201109200-00007 [CrossRef]
- Oppong R, Mistry H, Frew E. Health economics education in undergraduate medical training: introducing the health economics education (HEe) website. BMC Med Educ. 2013;13:126. doi:10.1186/1472-6920-13-126 [CrossRef]
- Kronick R, Gilmer TP. Medicare and Medicaid spending variations are strongly linked within hospital regions but not at overall state level. Health Aff (Millwood). 2012;31(5):948–955. doi:10.1377/hlthaff.2009.1065 [CrossRef]
- Li Y, Lu X, Wolf BR, Callaghan JJ, Cram P. Variation of Medicare payments for total knee arthroplasty. J Arthroplasty. 2013;28(9):1513–1520. doi:10.1016/j.arth.2013.06.001 [CrossRef]
- Bai G, Anderson GF. Extreme markup: the fifty US hospitals with the highest charge-to-cost ratios. Health Aff (Millwood). 2015;34(6):922–928. doi:10.1377/hlthaff.2014.1414 [CrossRef]
- Bai G, Anderson GF. US hospitals are still using chargemaster markups to maximize revenues. Health Aff (Millwood).2016;35(9):1658–1664. doi:10.1377/hlthaff.2016.0093 [CrossRef]
- Hackbarth G, Reischauer R, Mutti A. Collective accountability for medical care: toward bundled Medicare payments. N Engl J Med. 2008;359(1):3–5. doi:10.1056/NEJMp0803749 [CrossRef]
- Miller DC, Gust C, Dimick JB, Birkmeyer N, Skinner J, Birkmeyer JD. Large variations in Medicare payments for surgery highlight savings potential from bundled payment programs. Health Aff (Millwood). 2011;30(11):2107–2115. doi:10.1377/hlthaff.2011.0783 [CrossRef]
- Bates DW, Kuperman GJ, Jha A, et al. Does the computerized display of charges affect in-patient ancillary test utilization?Arch Intern Med. 1997;157(21):2501–2508. doi:10.1001/archinte.1997.00440420135015 [CrossRef]
- Miyakis S, Karamanof G, Liontos M, Mountokalakis TD. Factors contributing to inappropriate ordering of tests in an academic medical department and the effect of an educational feedback strategy. Postgrad Med J. 2006;82(974):823–829. doi:10.1136/pgmj.2006.049551 [CrossRef]
- Seguin P, Bleichner JP, Grolier J, Guillou YM, Mallédant Y. Effects of price information on test ordering in an intensive care unit. Intensive Care Med. 2002;28(3):332–335. doi:10.1007/s00134-002-1213-x [CrossRef]
- Okike K, Pollak R, O'Toole RV, Pollak AN. “Red-Yellow-Green”: effect of an initiative to guide surgeon choice of orthopaedic implants. J Bone Joint Surg Am. 2017;99(7):e33. doi:10.2106/JBJS.16.00271 [CrossRef]
- Marchand LS, Working ZM, Rane AA, et al. Serial radiographs do not change the clinical course of nonoperative stable OTA/AO 44-B1 ankle fractures. J Orthop Trauma. 2017;31(5):264–269. doi:10.1097/BOT.0000000000000785 [CrossRef]
- Nagar M, Forrest N, Maceachern CF. Utility of follow-up radiographs in conservatively managed acute fifth metatarsal fractures. Foot (Edinb). 2014;24(1):17–20. doi:10.1016/j.foot.2014.01.001 [CrossRef]
- Pannell WC, Alluri RK, Sivasundaram L, Heckmann N, Ghiassi A. Utility of postoperative imaging in radial shaft fractures. Hand (N Y). 2016;11(2):184–187. doi:10.1177/1558944715627629 [CrossRef]
- Stone JD, Vaccaro LM, Brabender RC, Hess AV. Utility and cost analysis of radiographs taken 2 weeks following plate fixation of distal radius fractures. J Hand Surg Am. 2015;40(6):1106–1109. doi:10.1016/j.jhsa.2015.02.013 [CrossRef]
- Tufescu T. Working toward reducing postoperative fracture radiographs: a survey of Canadian surgeons. Can J Surg. 2016;59(1):26–28. doi:10.1503/cjs.005715 [CrossRef]
- Tufescu T. The cost of screening radiographs after stable fracture fixation. Can J Surg. 2017;60(1):53–56.
- Westerterp M, Emous M, Vermeulen MC, Erenberg JP, van Geloven AA. No additional value of routine check X-rays after internal fixation of hip fractures. Eur J Trauma Emerg Surg. 2013;39(2):163–165. doi:10.1007/s00068-012-0244-4 [CrossRef]
- Arora V, Moriates C, Shah N. The challenge of understanding health care costs and charges. AMA J Ethics. 2015;17(11):1046–1052. doi:10.1001/journalofethics.2015.17.11.stas1-1511 [CrossRef]
- Reinhardt UE. The pricing of U.S. hospital services: chaos behind a veil of secrecy. Health Aff (Millwood). 2006;25(1):57–69. doi:10.1377/hlthaff.25.1.57 [CrossRef]
- Hsia RY, Akosa Antwi Y, Weber E. Analysis of variation in charges and prices paid for vaginal and caesarean section births: a cross-sectional study. BMJ Open. 2014;4(1):e004017. doi:10.1136/bmjopen-2013-004017 [CrossRef]
- Hsia RY, Akosa Antwi Y, Weber E, Brownell Nath J. A cross-sectional analysis of variation in charges and prices across California for percutaneous coronary intervention. PLoS One. 2014;9(8):e103829. doi:10.1371/journal.pone.0103829 [CrossRef]
- Hsia RY, Akosa Antwi Y, Nath JB. Variation in charges for 10 common blood tests in California hospitals: a cross-sectional analysis. BMJ Open. 2014;4(8):e005482. doi:10.1136/bmjopen-2014-005482 [CrossRef]
The 10 Imaging Modalities Listed in the Survey
|Radiograph 2 view hip
Radiograph 2 view knee
Radiograph 3 view ankle
Magnetic resonance imaging knee without contrast
Magnetic resonance angiography upper extremity with and without contrast
Computed tomography lower extremity without contrast
Computed tomography pelvis without contrast
Computed tomography angiography lower extremity with and without contrast
Computed tomography angiography pelvis with and without contrast
Mean Actual Billing Charge and Mean Estimated Charge for Each Imaging Modality
|Imaging Modality||Actual Charge||Estimated Charge||Actual vs Estimated Mean % Differencea|
|Radiograph 2 view hip||$421||$298||$292||$253||61|
|Radiograph 2 view knee||$472||$322||$265||$234||51|
|Radiograph 3 view ankle||$519||$366||$300||$265||52|
|Computed tomography lower extremity without contrast||$2057||$1693||$972||$762||55|
|Computed tomography pelvis without contrast||$2477||$1984||$1164||$875||59|
|Computed tomography angiography low extremity with and without contrast||$3584||$3415||$1912||$1533||66|
|Computed tomography angiography pelvis with and without contrast||$3670||$3830||$2113||$1652||70|
|Magnetic resonance imaging knee without contrast||$2989||$1669||$1950||$1260||68|
|Magnetic resonance angiography upper extremity with and without contrast||$4146||$3562||$2589||$1651||111|
Number of Participants Who Overestimated and Underestimated Cost at Each Institution
|Institution||No. of Participants|
|Overestimated Cost||Underestimated Cost||Total|