GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
April 9, 2015
American
College of
Radiology
Analysis of the AMA 2007/2008 Physician Practice
Information Survey
Review of the Final Report, April 2010
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Organization of the Report:
April 9, 2015
American
College of
Radiology
2
1.
Background
2.
Results by main objectives:
A.
Determine the effect that weighting the PPIS data by population based
proportions of office-based versus hospital-based radiologists would
have on the reported PPIS results.
B. 1) Determine the ACR’s total direct costs in the Supplemental Practice
Expense (SPE) survey and compare these to those obtained in the
PPIS.
2) Determine if the results lend support to the belief that CMS is not
paying for all the costs of Radiology as identified in previous studies.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Organization of the Report:
2.
April 9, 2015
American
College of
Radiology
Results by main objectives (cont.):
C. Assist the ACR in understanding how the physician hours for
delivering direct patient care, as calculated in the recent PPIS data,
compares to prior SMS data.
D. Examine the responses to the PPIS’s equipment utilization questions
by those practices reporting medical equipment in use in 2006 that
cost more than $500,000 to acquire.
E.
The ACR would like GfK Kynetec to provide guidance on the best
methods for blending the new PPIS data and the SPE for Radiology
survey data.
3.
Summary
4.
Recommendations
3
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Background:
American
College of
Radiology
4
The AMA’s 2007/2008 Physician Practice Information Survey (PPIS) was a
comprehensive survey whose results directly affect physician practice expense
per hour (PE/HR) calculations for patient care services for Radiology,
Interventional Radiology and Nuclear Medicine.
The results from this PPIS were compared with the results obtained by the
Supplemental Practice Expenses (SPE) of Radiologists survey conducted on
behalf of the ACR in 2003/2004 and other current information sources.
The medical societies sponsoring this post hoc research and sharing the
results include:
The American College of Radiology
The Society of Interventional Radiology
The Society of Nuclear Medicine
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Background (cont.)
April 9, 2015
American
College of
Radiology
5
There are several aspects of the PPIS survey that have drawn criticism from the
medical specialties negatively affected by the proposed PE/HR calculations based
on the PPIS results. These include:
•
Small sample sizes
•
Failure to meet precision
•
Inclusion of employee and sub-contractor physicians in the survey
•
Length of the survey
However, none of these are considered “lethal” and the AMA, The Lewin Group
and CMS can defend these limitations.
Therefore, GfK Kynetec’s analyses has attempted to find other “weaknesses” or
biases in the data to warrant further review and subsequent actions.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Background (cont.)
April 9, 2015
American
College of
Radiology
6
The most vulnerable weaknesses and the best opportunities for developing a serious
challenge to the PPIS results include:
1. The results are not sufficiently representative of the population of radiology,
based on comparisons to alternative sources of information.
2. The AMA’s attempt to make the results more representative by weighting the
data, using AMA Membership and Size of Practice, does not make data more
representative.
3. The data is most representative of lower cost practices, many of whom do not
report expenses in all 3 direct PE/HR costs.
4. Reweighting the data by alternative measures to the AMA’s Size of Practice
variable will help make the data more representative and increases the average
PE/HR for radiology.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Results by Objective:
American
College of
Radiology
7
Objective A - Determine the effect that weighting the PPIS data
by population based proportions of office-based versus hospitalbased radiologists would have on the reported PPIS results.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
April 9, 2015
American
College of
Radiology
8

The 2003/04 SPE collected 171 useable surveys; The PPIS collected 105
useable surveys (61% of the SPE sample).

If one very large practice is withheld, the average size of practice for the PPIS
is 15. The 2007 Survey of Radiologists * (n = 601) reported an average of 20
radiologists per practice. The PPIS did not interview enough larger practices.

Only one of the practice size categories in the SPE survey has a lower PE/HR
than the comparable practice size category from the PPIS survey, that for 1119 radiologists.
* See Slide 11
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A Determine the effect of weighting the PPIS data by
American
College of
Radiology
population based proportions
9
SPE
Size of Practice
PPIS
Participants
SPE PE/HR Lewin
Participants
PPIS PE/HR AMA
Used in
Weighted
Used in
Weighted
Calculation
Calculation
1-5 Radiologists
42 (25%)
$224.78
33 (31%)
$123.87
6–10 Radiologists
41 (24%)
$206.02
20 (19%)
$69.82
45 (26%)
$112.58
22 (21%)
$181.39
43 (25%)
$163.13
30 (29%)
$133.46
171 (100%)
$159.41
105 (100%)
$129.77
11–19
Radiologists
20+ Radiologists
Total

The information suggests that the data gathered by the PPIS represents a
somewhat different segment of the Radiology population than that
obtained in the SPE survey.

The $69.82 level further suggests that the PPIS survey contains a number
of smaller practices that do not incur all of the direct costs expenses that
would be associated with an independent office-based practice.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
April 9, 2015
American
College of
Radiology
10
a)
ACR Survey Data:

An alternative weighting variable examined was Office-Based versus HospitalBased practices. The underlying assumption is that office-based practices will
have higher expenses than those that are hospital-based, because they do
not receive any assistance for covering direct expenses.

One source for estimating the appropriate population proportions for officebased versus hospital-based radiology practices comes from the information
contained in the “2007 Survey of Radiologists: Practice Characteristics,
Ownership and Affiliation with Imaging Centers.”
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
April 9, 2015
American
College of
Radiology
11

The 2007 Survey of Radiologists asked whether or not the respondents “have
an ownership interest or equity partnership in any radiology office or imaging
center facility or other entity that owns diagnostic imaging equipment used to
perform tests outside the hospital setting?”

56% of the respondents answered “yes,” while 44% answered “no.”

The presence of medical equipment, and the purchase and maintenance
expenses that owning this equipment would entail, should be an essential
element defining an office-based practice.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
12
PPIS useable
surveys
Those
reporting No
equipment
expenses
NM
16
IR
Percent of
respondents
ACR physicians
not owning
equipment
Difference
10
62.50%
44%
18.50%
33
21
63.64%
44%
19.64%
Rad.
56
33
58.93%
44%
14.93%
total
105
64
60.95%
44%
16.95%
Specialty

The high percentage of physicians in the PPIS who report having no medical
equipment expenses is at odds with the results of the 2007 ACR survey.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
 Recommendation: PPIS practices with no medical equipment expenses should
be weighted down to 44% of the total, while those practices in the sample that
have medical equipment expenses should be weight up to 56%.
Nuclear
Radiology
PPIS weighted
$134.84
$52.01
$101.55
$129.77
Equipment
weight applied
$147.82
$58.78
$110.98
$142.47
Medicine
Int. Radiology
3 specialties
PE/HR
combined
 Weighting by office-based versus hospital-based (i.e., presence or absence
of medical equipment expenses) elevates the PE/HR for the three
combined specialties by $12.70 per/hour.
13
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology

The PPIS may be tapping into a different portion of radiology practices than
those surveyed by the ACR SPE and 2007 Survey of Radiologists.

It is difficult to determine whether the PPIS is over-represented by practices
with minimal direct expenses, as the fraction of the population these types of
practices actually represent is unknown.

However, to examine the impact of expanding the definition of what constitutes
a true “office-based” practice, bearing all of the direct expenses, a set of
potential scenarios was tested.

These scenarios examined the 105 PPIS practices using three qualifying
thresholds for direct expenses. The criteria was that a true, office-based
practice cannot have:
1.
2.
3.
Zero expenses in any of the 3 direct expense categories
Any direct expenses less than $2.00 per hour
Any direct expenses less than $5.00 per hour
14
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
Results
15
Scenario 1
Any Direct
Expenses =
$0.00?
PE/HR
ACR
recommended
proportions
New
Proportion/Old
Proportion
N
New Weight
Yes
81
$106.65
0.7
.70/.74
0.9524
No
24
$193.89
0.3
.30/.26
1.1321
Combined
Sample
105
$129.77
PPIS
New
PE/HR
$132.81
Scenario 2
Any Direct
Expenses less
than $2.00?
PE/HR
ACR
recommended
proportions
New
Proportion/Old
Proportion
N
New Weight
Yes
88
$102.06
0.7
.70/.80
0.8710
No
Combined
Sample
17
$243.15
0.3
.30/.20
1.5278
105
$129.77
PPIS
New
PE/HR
$144.39
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
Results
16
Scenario 3
Any Direct
Expenses =
$0.00?
PE/HR
ACR
recommended
proportions
New
Proportion/Old
Proportion
N
New Weight
Yes
96
$110.39
0.7
.70/.89
0.7883
No
9
$283.31
0.3
.30/.11
2.6786
Combined
Sample
105
$129.77
PPIS
New
PE/HR
$162.28

The PE/HR increases from $133 for anything above zero to $162 if officebased practices incur at least $5.00 per/hour in all 3 direct expense
categories.

If defining true, office-based practices requires meeting relatively modest
direct expense criteria, the sample of 105 PPIS practices significantly underrepresent the proportion of “office-based” practices in the population.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
17
b) CMS Claims Data:

Another source for estimating the appropriate population proportions for
Radiology comes from Medicare claims submission data. The Medicare
distribution of imaging claims for radiologists in 2007 indicates that 51% of
the claims for Radiology are for the Professional component (PC) only.
Medicare 2007 PSPS Allowed charges – Radiology
PC only
Global
TC
Total
50.7%
47.2%
2.2%
100.0%
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
18

The TC and Global claims are most likely coming from private offices or
imaging centers. When combined, the ratios provide some evidence that
almost half of the Medicare claims come from practices that own some
amount of medical equipment, such as diagnostic imaging equipment.

This finding provides additional credibility to the 2007 ACR Survey of
Radiologists assertion that 56% of radiology practices have equipment
expenses.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
19
c) AMA Physician Masterfile Data:


The AMA variable that looked most promising as a source for providing proper
proportions between office-based and hospital-based radiology practices is
Major Professional Activity (MPA). MPA has two main categories: OfficeBased and Hospital-Based.
MPA
Office
Hospital
3 specialties combined
95.24%
4.76%
Nuclear Medicine
100%
Interventional Radiology
96.97%
3.03%
Radiology
92.86%
7.14%
However, as it is highly unlikely that 93% of radiologists belong to true
private office-based practices, the AMA database shows some evidence of
misinformation.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
April 9, 2015
American
College of
Radiology
20

Responses to the self-classification question in the PPIS contradict these
proportions. Across the 3 specialties, nearly 70% of the PPIS respondents
report that they work primarily in a teaching (23%) or non-teaching (46%)
hospital setting.

Further investigation reveals that only 20% of the 100 practices in the PPIS,
which are classified as office-based, reported expenses in all three direct
expense categories. This data suggests that the overwhelming majority of
the practices in the PPIS are likely mixed practices with elements of both
office and hospital settings.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
American
College of
Radiology
population based proportions
21
Costs in all 3 direct
expense categories
Yes
No
Total

Major Professional Activity
Office
Hospital
Total
21
0
21
20%
0%
20%
79
5
84
75%
5%
80%
100
5
105
Accumulated evidence within the ACR suggests that at least 30%
of the radiology practices are truly “office-based,” and should incur
modest to substantial costs in all 3 direct expense categories.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
April 9, 2015
American
College of
Radiology
d) Other Appropriate Weighting Factors:

One variable investigated in the analysis is the self-classification question in
the PPIS (Q4) that asked the physician to choose “the primary setting in
which you provide most of your patient care services.”

The self-classifications of the 105 physicians in the PPIS were compared to
those of 601 physicians representing the three radiology specialties who
responded to a similar question in the 2007 ACR Survey of Radiologists.

While the answer choices between the two surveys were not identical, there
is enough over-lap to provide the basis for an analysis of the correspondence
between the practice types or settings of the 2 surveys.
22
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
 The PPIS practice setting choices included:
Physician's office, solo practice
Physician's office, single specialty group practice
Multi-specialty group practice or clinic
Hospital, teaching
Hospital, non-teaching
 The 2007 Survey of Radiologists practice setting choices included:
Solo Practice
Private - Radiology, Nuclear Medicine, Interventional Radiology
Private – Multispecialty
Primarily Academic
Other (i.e., government, hospital employee, other)
23
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions

American
College of
Radiology
The classifications selected and their weighted proportions from the two
surveys are presented below:
Primary
Practice
Setting
PPIS
PPIS
Classification
Categories with Elements of Direct Correspondence
Primary
Practice
Setting
2007 Survey
2007 ACR
Difference
Recommendation
of
Survey
Radiologists Classification
%
Solo Practice
3.24%
4.90%
Solo Practice
-1.66%
Weight PPIS up
4.9
Multispecialty
Group
6.97%
20.00%
Private
Multispecialty
-13.03%
Weight PPIS up
20.0
Teaching
Hospital
22.54%
18.50%
Primarily
Academic
4.04%
Weight PPIS down
18.5
Sub Total
32.75%
43.40%
-10.65%
24
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions

American
College of
Radiology
The remaining categories and their weighted proportions are presented below.
The residual from all those that do match can be used to aggregate the settings
for which there is no clear correspondence.
Categories without Elements of Direct Correspondence
Primary Practice
Setting
PPIS
Classification
PPIS
2007 Survey
of
Radiologists
4.40%
Single Spec.
Group
21.36%
0
Non Teaching
Hospital
45.89%
52.20%
Sub Total
67.25%
56.60%
Grand Total
100.00%
100.00%
Primary Practice
Setting
2007 ACR
Survey
Classification
Other
Difference
Recommendation
%
Weight PPIS down
56.6
-4.40%
21.36
Private Rad.,
NM, IR
-6.31
+10.65%
100
25
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
 The PPIS practices with classifications corresponding to the 2007 ACR survey
were weighted to the proportions of the 2007 ACR Survey of Radiologists. The
sum of these three practice settings (Solo Practice, Multispecialty Group, and
Teaching Hospital) were weighted to represent 43.4% of the total.
Nuclear
Radiology
PPIS weighted
$134.84
$52.01
$101.55
$129.77
Re-proportioned
practice setting
weight applied
$145.16
$46.37
$102.78
$139.12
Medicine
Int. Radiology
3 specialties
PE/HR
combined
 Reweighting the PE/HR by the proportions of practice setting reported in
the 2007 ACR survey raised the combined specialties by $9.35 per/hour.
26
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
American
College of
Radiology
 Since reweighting by office versus non-office (based on equipment expenses)
and practice setting both resulted in increases in the PE/HR amounts, we
examined the potential result if both factors were used to reweight the PPIS
results simultaneously.

Nuclear
Radiology
Both alternative
weights applied
$150.33
$33.28
$102.42
$143.11
Reweights, but
with no PPIS
weights
$151.69
$46.66
$102.43
$144.88
Medicine
Int. Radiology
3 specialties
PE/HR
combined
The impact of reweighting the PE/HR by the proportions of office /nonoffice and practice setting raises the amount for all 3 specialties by $13
- $15 per/hour over the AMA weighted level.
27
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: A - Determine the effect of weighting the PPIS data by
population based proportions
April 9, 2015
American
College of
Radiology

Across these analyses, the limitations of weighting have their most visible
impact when applied to Nuclear Medicine, whose original sample size consists
of 16 respondents with useable data.

This observation begs the question, “Should the PPIS data for Nuclear
Medicine even be accepted as the basis for determining the correct PE/HR for
this medical specialty?”

A sample size of 16 is considered very small by any statistical standards. The
margin of error is +/- 24.5%, at the 95% confidence level.

Because the data lacks adequate representation, GfK Kynetec recommends
that the PPIS data for Nuclear Medicine be rejected. Instead, the PE/HR for
this medical specialty should be based upon the data for the two remaining
radiology specialties, Radiology and Interventional Radiology.
28
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Results by Objective:
American
College of
Radiology
29
Objective B –
1. Determine the ACR’s total direct costs in the Supplemental
Practice Expense (SPE) survey and compare these to those
obtained in the PPIS.
2. Determine if the results lend support to the belief that CMS
is not paying for all the costs of Radiology as identified in
previous studies.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: B1 - Determine the ACR’s total direct costs in SPE
survey and compare these to those obtained in the PPIS
April 9, 2015
American
College of
Radiology

The portion of the PE/HR expenses that are attributable to direct costs were
tracked over 3 reporting periods.

These include:

The 2003/04 SPE

The amount negotiated with CMS reported in the 2007 rule

The 2007/08 PPIS.
30
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
American
College of
Radiology
Objective: B1- Determine the ACR’s total direct costs in SPE
survey and compare these to those obtained in the PPIS

While all categories of direct expenses have fallen, the biggest drop in
reimbursable expenses involves medical equipment. The per hour expense
has decreased by $10.16 from 2003, and by $24.82 from 2007.
Direct
Expenses
$ amount
% of Total
Expenses
2008
2003-04
2007
2008
SPE
CMS
PPIS
$5
$61.81
$86.31
$37.08
$57.19
39%
42%
29%
35%
All direct =>
Direct Expense Categories
Clinical Labor
$26.57
$32.62
$17.46
$23.47
Med. Supplies
$10.28
$14.15
$5.78
$11.72
Med. Equip.
$24.96
$39.62
$13.84
$22.00
Total
$61.81
$86.39
$37.08
$57.19
31
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: B1- Determine the ACR’s total direct costs in SPE
survey and compare these to those obtained in the PPIS
April 9, 2015
American
College of
Radiology

Using the earlier assumption that a true-office based practice would incur at
least $5.00 PE/HR in each of the 3 direct expense categories, an additional
column was added to the preceding table. This column displays the results if
the data is reweighted to reflect a 30% office-based population proportion.

As that column shows, the expenses are much more closely aligned with the
results obtain in the 2003-04 SPE and do not show any of the steep declines
in expenses reported in the PPIS.

When totaled, the direct expense categories in this column represent 35% of
the total PE/HR, which also aligns much more closely with prior survey data
than the PPIS.
32
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
American
College of
Radiology
Objective: B1- Determine the ACR’s total direct costs in SPE
survey and compare these to those obtained in the PPIS

Indirect expenses reported by the PPIS have dropped since 2003, with only
office related expenses showing any inflation over the five year span. The
decrease in clinical and clerical labor costs shown by the PPIS are counter
intuitive in light of the increasing costs of medical care in the US over time.
2008
All direct =>
Indirect
Expenses
2003-04
2007
2008
$ amount
SPE
CMS
PPIS
$97.61
$118.48
$92.68
$105.08
61%
58%
71%
65%
% of Total
Expenses
$5
Indirect Expense Categories
Clerical Labor
$34.63
$42.29
$33.99
$37.16
Office
$21.94
$28.95
$29.68
$41.89
Other Expenses.
$41.04
$47.24
$29.01
$26.04
Total
$97.61
$118.48
$92.68
$105.08
33
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: B2- Determine if the results support the belief that
CMS is not paying for all the costs of Radiology
April 9, 2015
American
College of
Radiology

As with direct expenses, an additional column has been added to the table,
representing office-based practices incurring at least $5.00 PE/HR in all 3
direct expense categories. This column shows increases in clerical labor and
office related expenses, but a drop in the “Other” expense category.

When totaled, the 3 indirect expenses show an overall increase in indirect
expenses since 2003, and a drop in the proportional contribution of the
indirect expenses to the total PE/HR (65%). This level is more consistent
with the earlier surveys.

The PPIS results indicate that both direct and indirect costs for radiology are
deceasing over time. This assertion is counter to a substantial amount of
evidence that cost of delivering medical services in the US is running far
ahead of general economic inflation.
34
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Results by Objective:
American
College of
Radiology
35
Objective C - Assist the ACR in understanding how the physician
hours for delivering direct patient care, as calculated in the recent
PPIS data, compares to prior SMS data.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
American
College of
Radiology
Objective: C - Assist the ACR in understanding how the PPIS
physician direct patient care hours compares to prior SMS data

Information on the direct patient cares hours provided by radiologists was
compiled from the SMS survey conducted in 1997, the 2003/04 SPE survey,
the 2007 ACR Survey of Radiologists and the 2007/08 PPIS.
Annual Average Direct Patient Care Hours Per Physician
Study
1997 SMS
2003/04 SPE
2007 ACR
2007/08 PPIS
Average
Ave. Hours
2274
1950
2200
2109
2133

The general trend has been for radiologists’ annual hours of direct patient care
to decrease over time. The SPE survey has the lowest average annual hours.

The SPE enjoyed good participation by very large radiology practices. Those
practices with 20 or more radiologists reported the lowest number of annual
direct patient care hours (1,774 hours per/physician) of the four size of
practice categories used in the study.
36
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Results by Objective:
April 9, 2015
American
College of
Radiology
37
Objective D - Examine the responses to the PPIS’s equipment
utilization questions by those practices reporting medical equipment
in use in 2006 that cost more than $500,000 to acquire.
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: D – Examine responses to the PPIS’s questions regarding
the use of medical equipment in 2006 that cost $500,000 + to acquire
April 9, 2015
American
College of
Radiology
38

Only respondents who provided valid responses to both (1) questions
regarding ownership of equipment in 2006 that cost at least $500,000 (Q82a)
and (2) the total number of weekly hours the practice was open for patient
care (Q69) were included in the analysis.

The following table presents the type of equipment owned by the practice in
Q82b (A-F), the number of hours that that the equipment was in use on a
weekly basis, and the average hours in which the practice was open to serve
patients during a typical week.
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
American
College of
Radiology
Objective: D – Examine responses to the PPIS’s questions regarding
the use of medical equipment in 2006 that cost $500,000 + to acquire
39
PPIS Q82b
(A-F)
3 Specialties combined
Equipment
Hrs.
Equip.
In use
p/wk
Hrs.
Practice
open
p/wk
Use
rate
Hrs.
Equip.
In use
p/wk
Hrs.
Practice
open
p/wk
Use
rate
Hrs.
Equip.
In use
p/wk
Hrs.
Practice
open
p/wk
Use
rate
Hrs.
Equip
in use
p/wk
Hrs.
Practice
open
p/wk
Use
rate
A.
Angiography
Room
28.6
128.1
22.3%
23.1
128.5
18.0%
33.5
114.3
29.3%
36.0
168.0
21.4%
B. Computer
Tomography
52.3
112.6
46.5
%
54.4
121.4
44.8%
44.5
94.7
47.0
%
59.7
117.8
50.7
%
C. IMRT
20.0
168.0
11.9%
-
-
-
-
-
-
20.0
168.0
11.9%
D. Gamma
Camera Sys.
39.6
113.1
35.0%
34.6
119.0
29.1%
40.0
117.0
34.2%
46.2
103.6
44.6%
E. MRI
49.1
116.8
42.0
%
52.5
121.6
43.2%
44.2
100.8
43.9
%
42.3
127.0
33.3%
F. Other
Equipment
39.3
109.4
35.9%
43.1
113.1
38.1%
37.3
119.0
31.3%
34.2
95.2
35.9%
Radiology
Interventional Radiology
Nuclear Medicine
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: D – Examine responses to the PPIS’s questions regarding
the use of medical equipment in 2006 that cost $500,000 + to acquire
April 9, 2015
American
College of
Radiology

The average weekly utilization rates reported are nearly all below 50% per
week. However, this is partly the result of the ratio between hours of
equipment use and the hours that the practice is open to provide patient
services.

The average number of hours that these practices are open to serve patients
is very high and indicates that a substantial number of the practices are
hospital based (open 24/7 – i.e., at or near 168 hours per week).

Across the three specialties, utilization rate is highest for computer
tomography (46.5%) and MRI (42%).

The following table presents the percentage of the valid responses for each
type of equipment as a proportion of total surveys submitted of the PPIS.
40
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Objective: D – Examine responses to the PPIS’s questions regarding
the use of medical equipment in 2006 that cost $500,000 + to acquire
% of valid
Responses
3 Specialties
combined
Radiology
Interventional
Radiology
American
College of
Radiology
41
Nuclear Medicine
Valid
Resp.
% of total
respondents
Valid
Resp.
% of total
respondents
Valid
Resp.
% of total
respondents
Valid
Resp.
% of total
respondents
A. Angiography
Room
16
4.6%
8
5.0%
6
5.1%
2
2.4%
B. Computer
Tomography
49
14.1%
25
16.6%
15
12.8%
9
10.8%
1
0.3%
0
0.0%
0
0.0%
1
1.2%
D. Gamma Camera
Sys.
25
7.2%
12
7.9%
4
3.4%
9
10.8%
E. MRI
49
14.1%
30
19.9%
13
11.1%
6
7.2%
F. Other Equipment
18
5.2%
9
6.0%
4
3.4%
5
6.0%
Equipment
C. IMRT
Total submitting
surveys
348
151
117
83
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Objective: D – Examine responses to the PPIS’s questions regarding
the use of medical equipment in 2006 that cost $500,000 + to acquire
April 9, 2015
American
College of
Radiology

The number of respondents reporting on hours of equipment use is generally
low, particularly when the three specialties are taken separately.

GfK Kynetec recommends that caution be exercised when using the PPIS
results to aid in decision-making regarding equipment utilization. If results
from the PPIS study are to be used, data from the 3 specialties need to be
taken together in order to provide any measure of reliability.

The data is dominated by hospital-based practices, as the average number of
weekly hours the practices are open to serve patients exceeds 100 hours per
week.

The data does not support decisions to increase the utilization rate for the
types of equipment considered in the PPIS to any level above the current
50% utilization rate.
42
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Summary:
April 9, 2015
American
College of
Radiology
 The PPIS is not as representative of Radiology as the earlier SPE survey. Why?

Smaller sample size

Questionnaire length and difficulty level

The PPIS sample represents practices with fewer expenses than those that actually
exist in the population of radiologists

The inclusion of employee and other “non-owner” physicians in the PPIS may have
lowered reported costs.
An employee physician may accurately report no expense for one or more of the
direct or indirect expense categories, because he/she may not bear that expense as
a “non-owner.” But since the respondent serves as a “proxy’ for all of the
radiologists in the practice, these zero expenses are assigned to both owners and
non-owners.

Physicians from hospital-based practices may not be fully aware of the portions of
the practice expenses borne by the hospital, the practice or in some shared
arrangement.
43
GfK Kynetec
Summary:

April 9, 2015
Analysis of the 2007/2008 AMA PPIS
American
College of
Radiology
Weighting the data by AMA Membership and Practice Size fails to
adequately address a number of deviations from the population of
radiology, such as equipment ownership and practice setting.
 There are too many teaching and non-teaching hospital practices represented
in the PPIS results, which may have caused physicians outside of private
practice to have greater influence on the PE/HR than their numbers justify.
 In the PPIS, 67% of the radiologists came from hospital settings, including
28% from teaching hospitals. This was nearly three times as many as the
average ratio for all 42 medical specialties participating in the PPIS (26%).

Too many practices in the PPIS fail to cover all of the expense categories
that are used to set the PE/HR rates.
44
GfK Kynetec
April 9, 2015
Analysis of the 2007/2008 AMA PPIS
Summary:
American
College of
Radiology

Over 60% of the practices in the PPIS report zero costs in at least one
or more of the 3 direct expense categories.

There are too few private, office-based radiology groups represented
(likely only about 10%) for weighting by Practice Size and AMA
Membership to help distribute PE/HR costs properly.

An attempt should be made to reweight the results to produce a more
accurate representation of the population of radiologists.
45
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Recommendations:
The ACR would like GfK Kynetec to provide
guidance on the best methods for blending the PPIS and SPE survey data
April 9, 2015
American
College of
Radiology

Nuclear Medicine has too few cases to adequately represent this medical
profession. The results should be set aside and Nuclear Medicine should
be blended into the results obtained for Radiology and Interventional
Radiology.

The results for the two remaining specialties need to be weighted by the
additional variables of office versus hospital-based (i.e., equipment
expenses), and a practice setting distribution conforming more to the
2007 Survey of Radiologists.

When a minimal cost per hour in each direct expense category is used
to help define true office-based practices ($5.00 PE/HR), and the
proportion that these radiology practices represent in the PPIS is set to
30%, the total PE/HR increases to $162.
46
GfK Kynetec
Analysis of the 2007/2008 AMA PPIS
Recommendations:
The ACR would like GfK Kynetec to provide
guidance on the best methods for blending the PPIS and SPE survey data
April 9, 2015
American
College of
Radiology

The $162 PE/HR level of expense should serve as the starting point for
blending the survey results from the PPIS with other sources of
information that address the PE/HR for radiology.

Since the 6 main expense categories appear to be under-reported in the
PPIS sample, the SPE survey results, updated to the 2007 level accepted
by CMS ($204 PE/HR), should be blended with the combined Radiology
and Interventional Radiology PPIS results.

Blending with the updated SPE records would provide sufficient response
from the full spectrum of radiology practices to adequately compensate
for the expenses incurred in delivering radiology service to Medicare
eligible patients.
47
GfK Kynetec
Example Project Title, Job Number
Through knowledge, confidence
Brian J. Hagan, M.A.
Executive Vice-President
Tel 1-314-786-1945
brian.hagan@gfk.com
April 9, 2015