Medicare cuts are speeding up the adoption of modern x-ray technology

The radiography field has been gradually replacing analog methods of detection in favor of digital technology over the past few decades, but these efforts are being accelerated by the US federal government’s latest attempts to cut healthcare costs.

The Consolidated Appropriations Act that passed in December 2015 includes an aggressive reduction in payment schedule for film and computed radiography (CR) exams. Facilities considering making an upgrade to their x-ray imaging technology from CR systems to direct, or digital, radiography (DR)—the most advanced radiography technology available today­­—now have further incentive to make the switch sooner.

The new law reduces Medicare reimbursements for the technical component of x-rays taken using screen film by 20% beginning in 2017. The cuts for CR will occur more gradually, starting with 7% for years 2018 through 2022. By 2023, the reduction in reimbursement for the technical component of CR exams will steepen to 10%. (The imaging facilities primarily affected by these reimbursement cuts will be outpatient, as the new law does not pertain to inpatient hospital stays.)

Long before DR came on the market, its predecessor CR gradually replaced the old analog method of film-screen cassettes by introducing imaging plates that are manually inserted into a computerized reader. Although larger hospitals have already started to make the conversion to the latest DR technology, CR systems are still commonly found in many facilities because they function reliably and replacing them involves cost.

While the law is not expected to have a large impact on analog technology because so few healthcare organizations are still using it, its effect on thousands of smaller imaging centers with CR systems installed could be more widespread. These imaging facilities face the choice to either convert their systems or experience reduced payments.

Advantages of DR

After the initial upfront investment in equipment, DR provides numerous advantages over CR, including better image quality, faster processing times, potentially lower radiation doses, and gains in productivity.

The most striking difference between CR and DR as imaging modalities is efficiency. Instead of previous x-ray methods that require the technologist to physically remove the film or cassette and carry it over to a processing area, DR technology captures the image directly onto a flat panel detector. DR images are available for review seconds after the image is taken.

“The technologists remain in the room while the image comes onto the monitor,” says Tracy Wilkinson, director of imaging services at WellStar North Fulton Hospital, who uses DR systems from Carestream Health, based in Rochester, NY. “They can ensure the image is what they want and move on to the next patient faster, cutting exam time per patient and decreasing processing time to a matter of seconds, depending on how many images the patient needs.”

Being able to retrieve and render captured images on the spot allows for a more productive radiology workflow. Wilkinson explains that DR reduces the processing time by anywhere from 90% to 95%. The quick turnaround increases workflow efficiency within the radiology department and results in time savings and as a result, cost savings. With fast and efficient DR technology, facilities can see more patients. Higher utilization of their assets also translates to a higher reimbursement rate.

There are other benefits to DR. Not only does the technology eliminate the need for costly film processing steps, but it carries the potential for radiation dose reduction. Imaging quality is also improved, with a wider dynamic range that makes it more forgiving for over- and under-exposure. Technologists can use DR system software to apply special image processing techniques that enhance overall display of the image, helping radiologists make better diagnostic decisions.

One of the downhill effects could be a more satisfying patient experience, a metric that many facilities would like to improve. “If a patient doesn’t have to wait a long time or if the imaging exam itself doesn’t take much time, I think it will improve patient satisfaction scores, too,” says George Curley, senior marketing manager at Agfa HealthCare, a manufacturer of DR technologies based in Mortsel, Belgium. “The technologist can spend more time with the patient rather than running plates.”

Planning for Upgrades

The benefits of DR are widely recognized by the medical imaging community, but adoption has been slow for some because of the challenge of finding cost-effective ways to upgrade or replace their existing technology.

“Most places aren’t cash-rich, and there are many priorities that compete for capital dollars, so replacing and upgrading x-ray equipment that still functions hasn’t been a pressing need until now,” Curley says.

Manufacturers of DR systems, such as Agfa and Carestream, are responding to these challenges by creating attractive programs and product packages that help facilities make the transition to digital affordable and with minimal interruptions in workflow.

“We can equip healthcare providers with a DR solution that will be right for them today and equip them to be ready for tomorrow,” says Sarah Verna, Carestream’s global marketing manager for x-ray solutions. “As their business grows and they need to add new capabilities or systems, we will work with them to map out that transition process.”

Because of budget cycles, most imaging facility administrators are currently in the planning stages of upgrades even if they don’t make the transition into DR until next year. One of the first considerations is the facility’s current space. What needs replacing and what could remain for a few more years? Will the whole room need to be replaced? Some facilities will have one or two rooms to upgrade, while others will have dozens.

For larger health delivery networks with multiple sites, putting together a strategic plan will help hospital administrators outline how to go forward, according to Curley. If those plans include construction, the room could be offline for several months. Organizational leaders may also need to consider changing the room’s configuration to better accommodate workflow.

Replacing the full x-ray room isn’t the only option, however. For some facilities, upgrading existing CR technology can allow them to make the shift to DR without major upfront costs.

A retrofit involves installing the DR panel into an existing x-ray room which simply takes the place of where the cassette is placed. The panels can be either wireless or tethered. “It gives you the benefits of digital without having to replace all the equipment,” Curley says.

For systems that need to be tethered, for example, Carestream offers more than 169 different cables that can interface with any system to get an imaging site up and running within a day, minimizing downtime. This timeframe holds true for x-ray rooms, as well as mobile units. The other option is to install wireless detectors, if appropriate for the imaging facility’s budget and needs.

From a staff workflow perspective, converting to a new DR system poses few training hurdles, Curley says, since many of the software platforms available are already familiar to technologists. Rather, the biggest challenge for most facilities is securing the capital funding to pay for the system, which manufacturers say they can offset by using customizable, vendor-neutral solutions. Agfa, for example, offers a program called Fast Forward DR that allows the company to provide a unique cost structure, such as monthly payments only marginally higher than those a hospital currently makes to maintain its prior CR technologies. The efficiencies gained by the new technology help the system pay for itself.

An offshoot of the Fast Forward initiative is a total cost of ownership program that includes the upgraded equipment, service for 60 months, and drop protection/drop coverage for the expensive panels. Every vendor also offers insurance programs that mitigate the cost of damage and preventive maintenance plans to give the customer peace of mind, according to Curley.

Finding the right solution for a facility to migrate to DR can take a lot of communication and planning. Verna encourages customers to reach out, ask questions, and work with vendors to voice their concerns. Not only can the manufacturer answer general questions about how the process works, but their specialists can also review the existing x-ray room’s layout. Retrofits often ensure a quick conversion, she says, because the DR detector replaces the CR cassette and the customer continues to use the existing x-ray system.

“We walk each customer through the process and provide the necessary information so they are confident in the decisions they are making when going from CR to DR,” Verna says.

Innovations in x-ray imaging technology have come a long way, and with more US hospitals adopting digital technology, the field will continue to benefit from improved image quality, reduced radiation dose to patients, and a more efficient workflow. Making the conversion to more efficient DR technology allows healthcare organizations to keep up with ever-changing healthcare regulations as well as maximize returns on their imaging investments.

Jane Kollmer is a contributing writer for 24×7. For more information, contact chief editor Jenny Lower at [email protected].

Photo credit: Carestream’s DRX Revolution mobile x-ray system