Orthopedics

Feature Article 

Orthopedic Surgeons Have Inadequate Knowledge of the Cost of Trauma-Related Imaging Studies

Blake Schultz, MD; Nathaniel Fogel, MD; Andrea Finlay, PhD; Cory Collinge, MD; Michael F. Githens, MD; Thomas Higgins, MD; Samir Mehta, MD; Robert V. O'Toole, MD; Hobie Summers, MD; Julius A. Bishop, MD; Michael J. Gardner, MD

Abstract

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1–19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454–e459.]

Abstract

Radiographic imaging is integral to the diagnosis and treatment of orthopedic injuries. Previous studies have shown that orthopedists consistently underestimate the price of implants, but their knowledge of imaging charges is unknown. This study evaluated whether orthopedic residents and faculty could accurately estimate charges of imaging modalities at their respective institutions. A survey with 10 common imaging studies was sent to 8 academic level I trauma centers. Participants estimated the total charge of each imaging modality. This was compared with the actual charge at their institution. Seven centers produced 162 responders: 74 faculty and 88 residents. The differences between the estimated cost and the billing charge were calculated and broken down by training level and imaging modality. Overall, imaging charges were underestimated by 31% (P<.001), with 19.4% of estimates being within 20% of actual charges (95% confidence interval, 19.1–19.9). There was no difference between training levels (P=.69). There was greater than 1000% variation in charges between institutions. Orthopedists across training levels underestimate hospital charges associated with common imaging studies, and there is a large variation in charges between centers. Awareness of charges is important because charges affect clinical decision making and are relevant to practicing both cost-conscious and clinically sound medicine. [Orthopedics. 2019; 42(5):e454–e459.]

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

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.

Statistical Analysis

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.

Results

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.

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.

Figure 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

Table 2:

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

Table 3:

Number of Participants Who Overestimated and Underestimated Cost at Each Institution

Discussion

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.

Conclusion

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.

References

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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 3-dimensional rendering

Mean Actual Billing Charge and Mean Estimated Charge for Each Imaging Modality

Imaging ModalityActual ChargeEstimated ChargeActual vs Estimated Mean % Differencea


MeanSDMeanSD
Radiograph 2 view hip$421$298$292$25361
Radiograph 2 view knee$472$322$265$23451
Radiograph 3 view ankle$519$366$300$26552
Computed tomography lower extremity without contrast$2057$1693$972$76255
Computed tomography pelvis without contrast$2477$1984$1164$87559
Computed tomography angiography low extremity with and without contrast$3584$3415$1912$153366
Computed tomography angiography pelvis with and without contrast$3670$3830$2113$165270
3-dimensional rendering$1346$1273$950$130899
Magnetic resonance imaging knee without contrast$2989$1669$1950$126068
Magnetic resonance angiography upper extremity with and without contrast$4146$3562$2589$1651111

Number of Participants Who Overestimated and Underestimated Cost at Each Institution

InstitutionNo. of Participants

Overestimated CostUnderestimated CostTotal
153136
28816
313114
424850
531013
6178
702525
Total32130162
Authors

The authors are from the Department of Orthopaedic Surgery (BS, NF, AF, JAB, MJG), Stanford University Hospital, Redwood City, California; the Department of Orthopaedics (CC), Vanderbilt University, Nashville, Tennessee; the Department of Orthopaedics (MFG), University of Washington, Seattle, Washington; the Department of Orthopaedics (TH), University of Utah, Salt Lake City, Utah; the Department of Orthopaedics (SM), University of Pennsylvania, Philadelphia, Pennsylvania; the Department of Orthopaedics (RVO), University of Maryland, Baltimore, Maryland; and the Department of Orthopaedics (HS), Loyola University Medical Center, Maywood, Illinois.

Drs Schultz, Fogel, Finlay, and Summers have no relevant financial relationships to disclose. Dr Collinge is a paid consultant for Biomet and Stryker and receives royalties from Advanced Orthopedic Solutions, Biomet, and Synthes. Dr Githens is on the speaker's bureau of Synthes. Dr Higgins is a paid consultant for DePuy Synthes and Imagen and holds stock in NT nPhase, OrthoGrid, and Summit Medical Ventures. Dr Mehta has received research support from DePuy Synthes and is on the speaker's bureau of DePuy Synthes, GE Healthcare, Nuvasive, and Smith & Nephew. Dr O'Toole is a paid consultant for Coorstek, Smith & Nephew, and Imagen; receives royalties from Coorstek; and holds stock in Imagen. Dr Bishop is a paid consultant for DePuy, Globus Medical, KCI, and Stryker; has received research support from Conventus; and receives royalties from Globus Medical and Innomed. Dr Gardner is a paid consultant for Stabiliz Ortho, Synthes, Conventus, Globus Medical, KCI, Osteocentric, and SI-BONE; has received research support from Smart Medical Devices and Medtronic; receives royalties from Synthes; and holds stock in Genesis Innovation Group and Imagen.

Correspondence should be addressed to: Blake Schultz, MD, Department of Orthopaedic Surgery, Stanford University Hospital, 450 Broadway St, Pavilion C, 4th Fl, M/C 6342, Redwood City, CA 94063 ( blakeschultzmd@gmail.com).

Received: July 10, 2018
Accepted: October 16, 2018
Posted Online: July 03, 2019

10.3928/01477447-20190627-04

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