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Analysis of the AMA 2007/2008 Physician Practice Information Survey

Analysis of the AMA 2007/2008 Physician Practice Information Survey. Review of the Final Report, April 2010. Organization of the Report:. 1. Background Results by main objectives:

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Analysis of the AMA 2007/2008 Physician Practice Information Survey

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  1. Analysis of the AMA 2007/2008 Physician Practice Information Survey Review of the Final Report, April 2010

  2. Organization of the Report: • 1. Background • Results by main objectives: • 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.

  3. Organization of the Report: • 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

  4. Background: • 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 surveyconducted 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

  5. Background (cont.) • 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.

  6. Background (cont.) • 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.

  7. Results by Objective: • Objective 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.

  8. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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 11-19 radiologists. * See Slide 11

  9. Objective: A Determine the effect of weighting the PPIS data by population based proportions • 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.

  10. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • ACR Survey Data: • An alternative weighting variable examined was Office-Based versus Hospital-Based 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 office-based versus hospital-based radiology practices comes from the information contained in the “2007 Survey of Radiologists: Practice Characteristics, Ownership and Affiliation with Imaging Centers.”

  11. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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.

  12. Objective: A - Determine the effect of weighting the PPIS data by population based proportions 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.

  13. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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%. • 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.

  14. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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: • 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

  15. Objective: A - Determine the effect of weighting the PPIS data by population based proportions Results Scenario 1 Scenario 2

  16. Objective: A - Determine the effect of weighting the PPIS data by population based proportions Results Scenario 3 • The PE/HR increases from $133 for anything above zero to $162 if office-based 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 under-represent the proportion of “office-based” practices in the population.

  17. Objective: A - Determine the effect of weighting the PPIS data by population based proportions 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

  18. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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.

  19. Objective: A - Determine the effect of weighting the PPIS data by population based proportions 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: Office-Based and Hospital-Based. • 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.

  20. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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.

  21. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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.

  22. Objective: A - Determine the effect of weighting the PPIS data by population based proportions 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.

  23. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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)

  24. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • The classifications selected and their weighted proportions from the two surveys are presented below:

  25. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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.

  26. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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. • 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.

  27. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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. • The impact of reweighting the PE/HR by the proportions of office /non-office and practice setting raises the amount for all 3 specialties by $13 - $15 per/hour over the AMA weighted level.

  28. Objective: A - Determine the effect of weighting the PPIS data by population based proportions • 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.

  29. Results by Objective: • 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.

  30. Objective: B1 - Determine the ACR’s total direct costs in SPE survey and compare these to those obtained in the PPIS • 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.

  31. 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.

  32. Objective: B1- Determine the ACR’s total direct costs in SPE survey and compare these to those obtained in the PPIS • 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.

  33. 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.

  34. Objective: B2- Determine if the results support the belief that CMS is not paying for all the costs 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.

  35. Results by Objective: • 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.  

  36. 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. • 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.

  37. Results by Objective: • 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.

  38. Objective: D – Examine responses to the PPIS’s questions regarding the use of medical equipment in 2006 that cost $500,000 + to acquire • 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.

  39. Objective: D – Examine responses to the PPIS’s questions regarding the use of medical equipment in 2006 that cost $500,000 + to acquire

  40. Objective: D – Examine responses to the PPIS’s questions regarding the use of medical equipment in 2006 that cost $500,000 + to acquire • 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.

  41. Objective: D – Examine responses to the PPIS’s questions regarding the use of medical equipment in 2006 that cost $500,000 + to acquire

  42. Objective: D – Examine responses to the PPIS’s questions regarding the use of medical equipment in 2006 that cost $500,000 + to acquire • 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.

  43. Summary: • 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.

  44. Summary: • 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.

  45. Summary: • 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.

  46. Recommendations: The ACR would like GfK Kynetec to provide guidance on the best methods for blending the PPIS and SPE survey data • 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.

  47. Recommendations: The ACR would like GfK Kynetec to provide guidance on the best methods for blending the PPIS and SPE survey data • 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.

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