ORIGINAL ARTICLEThe Health Care Value TransparencyMovement.docx

ORIGINAL ARTICLE
The Health Care Value Transparency
Movement and Its Implications for
Radiology
Daniel J. Durand, MDa, Anand K. Narayan, MD, PhDb, Frank J.
Rybicki, MD, PhDc, Judy Burleson, MHSAd,
Paul Nagy, PhDb, Geraldine McGinty, MD, MBAe, Richard
Duszak Jr, MD f
Abstract
The US health care system is in the midst of disruptive changes
intended to expand access, improve outcomes, and lower costs.
As part of
this movement, a growing number of stakeholders have
advocated dramatically increasing consumer transparency into
the quality and
price of health care services. The authors review the general
movement toward American health care value transparency
within the
public, private, and nonprofit sectors, with an emphasis on
those initiatives most relevant to radiology. They conclude that
radiology,
along with other “ancillary services,” has been a major focus of
early efforts to enhance consumer price transparency. By
contrast,
radiology as a field remains in the “middle of the pack” with
regard to quality transparency. There is thus the danger that
radiology value
transparency in its current form will stimulate primarily price-
based competition, erode provider profit margins, and

disincentivize
quality. The authors conclude with suggested actions
radiologists can take to ensure that a more optimal balance is
struck between
quality transparency and price transparency, one that will
enable true value-based competition among radiologists rather
than
commoditization.
Key Words: Quality, value, transparency, pay for performance,
value-based contracting
J Am Coll Radiol 2015;12:51-58. Copyright � 2015 American
College of Radiology
Although there are many reasons the UShealth care systemfails
to deliver value on par with those of peer nations, few would
argue that “market failure”—the inefficient allocation of goods
and services by the free market—plays a significant role.
Beginning in March 2013 with Steven Brill’s [1] landmark
Time cover story, “Bitter Pill: Why Medical Bills Are Killing
Us,” and culminating later that spring with the first ever release
by CMS of Medicare pricing data on all US hospitals [2], this
view has been empirically validated by reports of price
variation
aEvolent Health, Arlington, Virginia.
bThe Russell H. Morgan Department of Radiology and
Radiological Sci-
ence, Johns Hopkins School of Medicine, Baltimore, Maryland.
cApplied Imaging Science Laboratory, Department of
Radiology, Brigham
and Women’s Hospital, Boston, Massachusetts.
dDepartment of Quality and Safety, American College of
Radiology,
Reston, Virginia.
eWeill Cornell Medical College, Cornell University, New York,
New York.

fDepartment of Radiology and Imaging Sciences, Emory
University School
of Medicine, Atlanta, Georgia.
Corresponding author and reprints: Daniel J. Durand, MD,
Evolent
Health, 800 N Glebe Road, Arlington, VA 22203; e-mail:
[email protected]
gmail.com.
ª 2015 American College of Radiology
1546-1440/14/$36.00 n
http://dx.doi.org/10.1016/j.jacr.2014.08.015
among hospitals at the local and national levels that appear
unrelated to any substantive difference in the quality of care
delivered. Within the market for medical imaging services, for
example, 500% variations in price in the same metropolitan
area have been cited as “commonplace” [3].
Given the broader societal movement toward information
transparency in health care, this recent wave of controversy
over price variation marks only the beginning of what is likely
to be a prolonged national dialogue. We review recent trends
toward health care transparency on both quality and price,
both from a general perspective and with an eye toward
radiology in particular. Our purpose is to acquaint the reader
with the major transparency initiatives currently active in the
United States throughout the public, private, and nonprofit
sectors and to review their potential impact on radiology.
THE PREVAILING THEORY: BRINGING
PERFECT VALUE TRANSPARENCY TO HEALTH
CARE CAN SAVE A FAILING MARKETPLACE
Before considering the nature of market failure in the
complex ecosystem of US health care, first consider how
price and quality are supposed to interact in an “ideal”
51

mailto:[email protected]
mailto:[email protected]
http://dx.doi.org/10.1016/j.jacr.2014.08.015
marketplace in which value is maximized. In this world,
value is defined in the simplest terms: some quantity of
“quality” per unit price. Rational buyers who desire goods
and services and who have access to perfect information on
price and quality collectively form a market. Most readers
are familiar with the classic price-setting relationship be-
tween supply and demand. In most industries, price is also
related to quality in that, generally speaking, higher quality
goods command higher prices at any time point [4]. When
quality is measured in the proper units, this relationship may
be positively and perhaps even linearly correlated with price.
Some authors have even referred to a “quality elasticity
function” that describes the degree to which value-conscious
consumers will pay more for progressively higher quality
goods (ie, the slope of a regression line that relates price to
quality) [5]. For example, a good with a price elasticity of
zero is a “perfect” commodity; quality is meaningless, and
price is purely a function of quantity supplied and quantity
demanded.
Such relationships among supply, demand, price, and
quality are not necessarily desirable when allocating essential
services such as health care. The predictable result would be
wide disparities in access and health outcomes based on
income levels. This concern over access to high-quality care
is the reason many governments, including that of the
United States, have taken a heavy hand in regulating health
care relative to other sectors of the economy. These regu-
lations complicate the price-quality relationship consider-
ably. For example, in many states, certificate-of-need

programs limit the supply of imaging providers, partly as a
means of reducing overall health care expenditure, which
increases the bargaining power of providers in general and
would be expected to increase unit prices across the board
for both high- and low-quality imaging services. At the same
time, econometric studies of Medicare populations have
generally found that quality per unit price (ie, increased
price elasticity of quality) is increased in more competitive
markets, which has been interpreted as meaning that when
providers cannot compete on price, they will compete more
aggressively on quality [6]. The preceding two examples are
not meant to be exhaustive but merely to illustrate the
myriad ways in which both state and federal regulatory
bodies can complicate the economic framework described
above.
Furthermore, empirical research has repeatedly demon-
strated that even in relatively unregulated and transparent
markets, price-quality relationships are not necessarily linear
and often do not conform well to trend lines [7]. Never-
theless, the scenarios depicted in Figure 1 are intended to
illustrate, at a high level, the theoretical implications of
different types of potential consumer behavior in reaction to
value transparency and their resultant implications for
52
market dynamics. For inasmuch as consumers (or their
proxies, such as a primary care practitioners or insurance
benefit managers) are increasingly motivated decision
makers who understand and have access to information on
both price and quality, this basic framework should apply.
A growing chorus of economists, entrepreneurs, and
policymakers believe that part of the answer to improving
value in US health care is to drastically increase transparency
on both price and quality [8]. This, in combination with
higher deductibles and other mechanisms of increasing pa-

tient cost consciousness, should gradually correct irrational
variations in price known to plague the system. This is also
the approach currently embraced by a large number of
health insurers and radiology benefits management organi-
zations with regard to imaging utilization management and
unit price reduction. By using claims-based analytic algo-
rithms, pricing firms can now compare prices with local
benchmarks to direct patients to specific sites of care using
either carrots (eg, incentivizing patients to choose higher
value providers) or sticks (eg, keeping high-priced and/or
low-value providers out of the network or using tools such as
varied copayments) [9].
Assuming that both measures of price and quality are
given ample weight by decision makers, one can immedi-
ately see the benefits of such a strategy (Figs. 1A and 1B).
The winners include high-quality providers, who can now
more reliably charge higher prices. Low-quality providers,
who now fetch lower prices for their work, are the losers.
Patients as a population receive more consistent value. But
the aggregate cost of the services obtained and the average
unit price will depend on the dynamics of the market, which
are impossible to predict in advance.
PRICE AND QUALITY DATA MAY INFLUENCE
PATIENT BEHAVIOR IN A DIFFERENTIAL
MANNER, LEADING TO SEVERAL POTENTIAL
MARKET OUTCOMES
One potentially important predictor of market behavior is
the relative importance consumers assign to price data versus
quality data, which itself depends on the nature of the data
provided. Before discussing this in depth, it is important to
note that the issue of relative importance or “weighting” is
not solely a function of the sheer volume of data available to
consumers. Rather, consumers’ decision making will likely
be influenced by several factors, including their levels of
access to transparency data, ability to understand it, trust in

its accuracy, and belief that the data are relevant to their own
choices of health care providers. For example, if quality data
are readily available but poorly understood or not trusted,
they will likely not be valued by consumers. Conversely,
relatively few data points on quality could be quite powerful
Journal of the American College of Radiology
Volume 12 n Number 1 n January 2015
Fig 1. Hypothetical graphs showing the relationships between
price and quality that could result from different types of
consumer
behavior. (A) The baseline scenario assumes an essentially
random association between quality and price that effectively
depicts
a dysfunctional market. (B) In this scenario, patients make
relatively balanced use of price and quality data, yielding a
positive
linear relationship between quality and price. (C) In this
scenario, patients assign more weight to price than quality,
resulting in a
relatively “flat” line with overall lower mean prices as unit
price reductions become the principal means of competition. (D)
In this
scenario, radiology services emerge as a “Veblen good,” leading
to a general increase in prices.
if they are readily accessible, well understood, and relevant,
and if they come from a reliable source. The same can be
said for measures of price, although with price, the issues of
understanding and relevance are unlikely to be limiting
factors, because patients generally know what a dollar is and
what it is worth to them.
If consumers pay more attention to price than to quality,
providers will be forced to compete primarily on price to

attract patients. Assuming supply remains constant and
provider cost structures do not change, this will result in a
reduction in unit prices (ie, “a race to the bottom”), eroding
provider profit margins. In this scenario (Fig. 1C), both
patients and payers win value in the short term. As a group,
providers lose, although there may be pockets of success
among exceptionally high-quality providers or those who are
able to achieve especially lean cost structures. In the most
extreme version of this scenario, patients make no use
whatsoever of quality data, and decisions are made purely on
Durand, Narayan, Rybicki n Health Care Value Transparency
and R
the basis of price as radiologic services are treated as pure
commodities. In the very short term, the biggest winner in
this scenario is payers, who will accrue most of the value lost
by radiologists. Patients with high deductibles and/or high
copayments would also net short-term gains in terms of cost
avoidance. Assuming healthy competition among payers,
this should translate into intermediate-term premium re-
ductions, which would transfer some of the value to em-
ployers or individuals purchasing insurance (eg, on the
federal exchanges). In the long term, however, patients and
payers would both lose to the extent that increasingly lower
quality imaging would likely adversely affect both health
outcomes and the efficiency of medical care delivery.
There is an alternative scenario in which transparency
could actually boost average prices—one in which providers
could capture more value than payers. For some goods and
services for which demand is positively correlated with price,
high prices increase demand because of the perception by
53
adiology

some consumers that higher prices mean higher quality.
These are properly referred to as Veblen goods (though they
are often mischaracterized in the press as “Giffen” goods)
[10]. Some economists have suggested that a subset of
health care services could behave this way. In Figure 1D, we
show a scenario of generally increased unit price—with
subsequent boosts to provider profit margins—that could
occur in situations in which high-priced providers are
paradoxically in higher demand on the basis of patient or
consumer perception. However, as we discuss later, such a
scenario seems unlikely for imaging.
CONSUMER TRANSPARENCY INTO
RADIOLOGY PRICES IS WELL DEVELOPED
RELATIVE TO OTHER SPECIALTIES AND
CONTINUES TO GROW RAPIDLY
A tide of health care price transparency initiatives has rolled
across the nation over the past decade, driven in part by
federal and state legislation [11]. At the time of this writing,
some 31 states, “red” and “blue” states alike, have enacted
legislation specifically related to the public disclosure of
health care pricing [12]. These laws use fairly diverse
mechanisms to promote the dissemination of such data.
New Hampshire’s HealthCost website represents one of the
oldest and most well-documented initiatives. Beginning in
2003, all insurance carriers operating in New Hampshire
were required to disclose claims information to the state.
Over time, these data were used to develop the New
Hampshire Comprehensive Health Information System.
Since 2007, the bundled cost of 30 common outpatient
health care services (primarily imaging and surgery), along
with childbirth as the lone inpatient procedure, have all
been posted online. Interestingly, a 2009 analysis by the
Center for Health System Change reported that the New
Hampshire program had failed to produce any significant
changes in price variation, with the authors citing a lack of

competition among providers and low penetration (<5%)
of high-deductible insurance plans among the state popu-
lation as two potential reasons for the lack of impact [13].
At the federal level, the Patient Protection and Affordable
Care Act contained two specific provisions that can be ex-
pected to increase price transparency. The first began last year
with the public disclosure of hospital pricing data, alluded to
previously. The second is that, beginning in 2014, health
plans listed on the federal exchanges are required to disclose a
wealth of information related to premium pricing and benefit
structure in plain English to their members. In addition, they
must also provide their members with estimated of out-of-
pocket costs for certain procedures [14].
Although far less widely cited in the academic literature
than these legislative initiatives [15], there is also a great deal
54
of private sector activity focused on providing health care
value transparency. Although the subcomponents of com-
plex medical care are notoriously difficult to price, discrete
services such as laboratory tests and imaging are more easily
handled by claims extraction algorithms [16], particularly
when performed at freestanding outpatient sites of service.
Accordingly, “outpatient ancillaries” have been a major
focus of early work to define, understand, and ultimately sell
such cost variation data to health care consumers and em-
ployers. Although there is a great deal of methodologic
variation in deriving such pricing data, the key point is that
consumers can compare prices among providers with
increasing ease, whereas it remains far more difficult for
them to compare quality. Table 1 shows salient examples of
the value and price transparency tools currently operating in
the US health care system.
Companies such as Truven Health Analytics and Cast-

light Health are marketing this kind of pricing data to large
employers and health plans on a national basis. Health in-
surers have long had insights into pricing data but have
typically been unable to share them because of specific
clauses in their provider contracts. In the new model, an
employer or health plan contracts with a price transparency
firm, allowing its members and employees access to a health
care consumer website that facilitates comparison shopping
among providers. Typically, these large employers are also
transitioning their employees to “consumer-directed” health
benefits (ie, lower cost options with higher copayments and
higher deductibles to curb excessive utilization). From all
appearances, the private sector believes firmly that this
model is the wave of the future: when Castlight Health went
public, the company was valued at more than 100 times its
annual revenue, making it the most optimistically priced
initial public offering in the American stock market in the
21st century.
Although it is true that firms like Castlight usually also
measure quality in some fashion (see the next section), it is
equally true that these firms have placed a heavy emphasis
on price variation in their public communications (eg, white
papers, press releases, marketing materials). For example,
Castlight Health’s website boasts an interactive imaging
price transparency map that shows regional price variations
for imaging services such as head CT, brain MRI, and
lumbar spine MRI [17]. There is, unfortunately, no inter-
active map for quality variation.
The case studies posted online by Castlight tell a similar
story. For example, Castlight’s publically disclosed case
example of its work with the firm Honeywell details the role
of price transparency in its strategy, stating that Castlight
highlighted the importance of consumer choice uti-

lizing maps, pricing data, and ratings to illustrate
Table 1. Prominent examples of tools and services offered by
companies in the medical imaging price and value transparency
marketplace
Approach Description Major Examples
Value-based steerage Patients are directly engaged to encourage
them
to use the lowest priced option with
comparable “quality”
Most major RBM organizations
Proprietary consumer
price or value
transparency portals
Online tools that match patients with
high-value local imaging providers, with pricing
often informed by claims analysis based on
commercial or CMS populations
Major payers (eg, BCBS, Aetna, Cigna,
UnitedHealthcare, WellPoint)
Castlight Health
Change Healthcare Corporation
Truven Healthcare Analytics, Inc
ClearCost Health
HealthSparq, Inc

Open-source consumer
price transparency portals
Browseable databases of local price ranges for
common health care procedures, including imaging
Health Care Blue Book
fairhealthconsumer.org
Value-oriented patient
referral networks
Primary care physicians engaged in risk sharing
arrangements (e.g., ACOs) send patients to the
highest quality and/or lowest cost provider to
optimize population health outcomes and
minimize total medical expense
Medicare shared savings programs
“Pioneer” Medicare ACOs
Commercial ACOs sponsored by
major payers
Provider-owned health plans
Note: ACO ¼ accountable care organization; BCBS ¼
BlueCross BlueShield; RBM ¼ radiology benefits management.
trade-offs in cost and quality. The two educational
themes that were reinforced consistently through the
use of maps in the engagement communications were:
“Price variance exists, even within network” and
“More expensive care is not always better care.” [18]
They did not mention which quality metrics were used to
discern between providers.

IMAGING QUALITY TRANSPARENCY REMAINS
RELATIVELY UNDERDEVELOPED
Although few would argue that there is variation in the level of
quality delivered by different radiologists or different radi-
ology groups, it is exceedingly difficult to measure, quantify,
and distribute information regarding this variation in a way
that would be meaningful to consumers or even referring
physicians. Nevertheless, there is increasing interest in quality
measures throughout medicine, on the basis of the growing
societal capability to mandate and implement automated
quality data collection across patient populations [19].
Beginning with attempts to define and measure outcomes
related to myocardial infarctions, numerous public agencies
and professional societies have expanded the scope of their
measurement efforts [20]. Many of these metrics have sub-
sequently undergone review by the National Quality Forum
(NQF), a publicly funded nonprofit organization [21]. For
example, in the past 6 years, the NQF has reviewed two
rounds of imaging efficiency metrics, several of which were
developed by CMS and ultimately incorporated into the CMS
Hospital Outpatient Quality Reporting program [22].
and R
Until recently, imaging quality metrics were perilously
underdeveloped relative to other specialties and were
designed and controlled largely by specialties outside radi-
ology. Consider that, at the moment, the ACR is the official
steward of just 1 NQF-endorsed metric (participation in the
ACR Dose Index Registry�), although it is soon to assume
stewardship of 4 additional NQF-endorsed metrics previ-
ously developed in conjunction with the Physician Con-
sortium for Performance Improvement of the AMA.
Furthermore, only 20 of 955 NQF-approved measures
(2.1%) explicitly deal with medical imaging [23], despite the
fact that imaging accounts for approximately 14% of health

care costs [24]. Finally, virtually all NQF-approved imaging
metrics deal with appropriateness (often more reflective of
ordering provider behavior rather than the quality of
radiologic service), and none at present focus on patient-
based outcomes.
At the same time, it is important to note that although
NQF endorsement is currently the de facto “gold standard”
for quality metric validation, organizations such as CMS
increasingly make use of measures that are not yet NQF
approved. For this reason, the statistical snapshot presented
earlier represents a dated picture that fails to capture late-
breaking progress within the radiology community with
regard to quality metrics that, although fully developed and
with potential impact, have not yet garnered NQF approval.
For example, the Qualified Clinical Data Registries
(QCDRs) referenced in the recent fiscal cliff legislation may
make use of non-NQF-approved metrics. Furthermore, the
ACR has applied to serve as a QCDR, offering to report
55
adiology
publicly on 20 measures across 5 of the existing ACR data
registries. The proposed ACR QDCR metrics focus mainly
on radiation dose optimization, mammographic quality
measures, turnaround time, and contrast extravasation. If
the ACR’s QCDR application is successful, it will represent
a significant victory within the radiology quality commu-
nity, which will signal that radiology as a field is moving to
the forefront of the quality movement. For the moment,
however, we remain at the trailing end of the movement
along with most other specialties.
It is also important to note that several of the afore-

mentioned NQF-approved imaging-related metrics are part
of the Physician Quality Reporting System (PQRS), a CMS
program designed to encourage the public reporting of data
[25]. Data reported through PQRS will be used to deter-
mine the value-based payment modifier, along with cost or
“resource use” measures, which will augment Medicare
payment for high-value performers and penalize low-value
performers. “Performance” in PQRS will be defined by a
complex value metric that CMS has yet to explicitly define
but will certainly have an aggregated quality measure in the
numerator and an aggregated cost measure in the denomi-
nator. However, it is important to recognize that only a
small percentage of PQRS metrics relate to imaging, and it is
possible for large provider groups (eg, large multispecialty
groups, integrated delivery networks) to participate in PQRS
without reporting any imaging-related metrics at all. Thus,
there is a concern that for larger groups within the PQRS
program, radiology quality metrics will be largely irrelevant,
as they will be lumped together with many other non-
radiology metrics—indeed, many large groups and inte-
grated delivery networks have already chosen not to report
imaging-related metrics at all. Furthermore, even PQRS
data collected from “pure” radiology groups are not yet
publicly reported in a fashion that consumers can easily
access and understand. Thus, PQRS data cannot currently
be used by patients to seek out high-quality radiologists.
Finally, many of the private sector firms mentioned in
Table 1 use their own independent metrics to assess quality.
Unfortunately, these metrics themselves tend to be hetero-
geneous and sometimes are not well defined or are even
intentionally undefined. Such metrics introduce the risk for
radiology value measures’ becoming proprietary and
completely ambiguous.
In summary, despite recent progress, radiology as a field

remains in the “middle of the pack” with regard to quality
metric development and significantly trails specialties at the
leading edge of the quality movement, such as cardiology,
primary care, orthopedics, and oncology. Radiology quality
metrics themselves can be loosely divided into 3 groups:
measures of imaging appropriateness, measures of radia-
tion safety, and measures of radiologist performance (eg,
56
turnaround time, diagnostic accuracy) and their subsequent
impact on patient outcomes [26]. The current strategy of
organized radiology is to begin to meet the need for quality
transparency by focusing mainly on evidence-based stan-
dards for imaging appropriateness and supporting greater
uptake through the use of clinical decision support and
order entry systems. Although the next generation of im-
aging metrics will likely be more process and performance
oriented, radiology quality metrics will probably always be
inherently less directly linked to health outcomes than those
developed by other specialists (eg, surgeons) who contribute
more directly to individual patient care.
THE COMBINATION OF RAPIDLY ADVANCING
PRICE TRANSPARENCY AND SLOWER
MOVING QUALITY TRANSPARENCY
HEIGHTENS THE THREAT OF
COMMODITIZATION
On the basis of the confluence of events we describe, it can
be expected that health care value transparency will stimu-
late primarily price-based competition between radiology
providers, a scenario analogous to Figure 1C.
There are several reasons this is thought to be the case.
First, because of changes related to the Patient Protection
and Affordable Care Act, patients in the United States will
have increasingly more “skin in the game” (eg, high de-
ductibles) and are likely to be increasingly sensitive to price.
Veblen good effects for radiology are unlikely, because

consumers tend to associate imaging quality with the tech-
nology itself rather than the skill or training of the radiol-
ogist (provided, of course, they are even aware that a
radiologist is a physician) [27].
Second, it has been well documented that patients have
little insight into what high-quality imaging services get
them in terms of health outcomes [28]. In other words, even
if provider-level data on quality are made accessible to the
public, US health care consumers need to become educated
in and convinced of the value of these data and must also
come to trust its source in order for it to meaningfully
inform their choices of providers. Unfortunately, this lack of
awareness of the value of high-quality radiology is not
limited to patients but is a common misconception among
our fellow physicians as well as health care policymakers. In
2012, a broad coalition of respected health care economists
and policy experts led by Ezekiel Emanuel openly referred to
radiology as a commodity in the pages of the New England
Journal of Medicine, writing that “Medicare should extend
competitive bidding to medical devices, laboratory tests,
radiologic diagnostic services, and all other commodities”
[29]. Interestingly, the same author group wholeheartedly
endorsed “requiring full transparency of [health care] prices”
as part of its recommendations.
RECOMMENDATIONS: ACTIONABLE STEPS TO
MOVE FROM SIMPLE PRICE TRANSPARENCY
TO TRUE VALUE TRANSPARENCY
It is precisely because radiologists are physicians first and
business people second that this scenario is distasteful.
Having spent years acquiring our skills and taken oaths to

provide the highest quality care possible to each patient, it is
demoralizing to consider that market forces may push us
toward commoditization and the delivery of lower quality
care. Fortunately, health care value transparency remains in
its infancy, and the markets alluded to above are probably
nowhere near equilibrium. Corrective courses of action
remain available.
It is our opinion that radiologists should not attempt to
fight the inevitable tide of price transparency. Once started,
such processes are unlikely to be reversed in a free society.
The tactics of consolidation and tacit collaboration among
groups to prevent price-based competition are likewise un-
attractive; they fail to leverage the opportunity that true
value transparency presents to patients, society at large, and
radiology as a field.
Instead, radiologists should embrace quality transparency
and seek “mastery of the numerator” in the value equation.
We can avoid commoditization by coming to consensus on
what quality means, communicating our shared vision to the
public, and actively engaging in healthy value-based compe-
tition among ourselves, rather than viewing quality reporting
as a mere compliance issue handed down from above. Ini-
tiatives such as the ACR’s Imaging 3.0� [30], for example,
provide a compelling platform for codeveloping a universal
quality framework that can help structure this dialogue going
forward. Therefore, we recommend the following set of ac-
tions to ensure that health care transparency truly rewards
high-value radiologic services:
1. Invest broadly in quality research and work toward
endorsing specific metrics that facilitate meaningful
quality comparisons among providers. This means
accepting the reality that performance is not equal among
radiologists.

2. Actively support professional societies (eg, the ACR) in
their ongoing efforts to provide systematic oversight of
quality metrics used by payers, radiology benefits man-
agement organizations, and other value transparency
firms—recall that the less this is about quality competi-
tion and the more it is about price competition, the more
value other market players (eg, payers) will grab from
radiologists.
3. Radiologists should actively participate in quality metrics
and registries. The registries maintained by the ACR will
continue to grow, and broad participation will help
ensure that the assessment of radiologists remains in
and R
control of radiologists. In addition, the establishment of
large databases will foster the transition toward more
accuracy- and performance-based metrics that are more
reflective of radiologists’ skills. Eventually, the ACR
registries may also offer a convenient means of direct
public reporting through CMS programs such as QCDR.
4. Radiology professional societies must invest in research to
demonstrate the high downstream costs (eg, total medical
expense) and/or poor outcomes associated with low-
quality imaging (eg, progression of undetected disease,
excessive follow-up imaging, unneeded surgery or bi-
opsies, unnecessary radiation exposure) and encourage
the publication of papers outside our own literature in
high-impact journals read by other specialists and poli-
cymakers (eg, Health Affairs, the New England Journal of
Medicine, JAMA).
a
TAKE-HOME POINTS

n Patients do not currently have access to data that
would allow them to choose one radiology provider
over another on the basis of quality, a point that is
generally true for all medical specialties apart from
those that spearheaded the quality movement over the
past two decades (eg, cardiology, primary care,
orthopedics).
n Radiology has been thrust to the forefront of the price
transparency movement, as both patients and refer-
ring physicians are increasingly being given radiology
pricing data by a variety of public, private, and
nonprofit entities and are further being encouraged to
“price-shop” for imaging services.
n On this basis, health care value transparency in its
current form will stimulate primarily price-based
competition among radiology providers, a scenario
that heightens the threat of commoditization.
n Potential actions to combat commoditization include
establishing unified systems for defining, measuring,
and reporting data on imaging quality as well as
promoting and supporting research relating higher
imaging quality to improved population health out-
comes and/or lower total medical expenses.
REFERENCES
1. Brill S. Bitter pill: why medical bills are killing us. Time.
Available at:
http://content.time.com/time/magazine/article/0,9171,2136864,0
0.
html. Accessed February 18, 2014.
2. Tocknell MD. CMS releases hospital pricing data. Available
at: http://

www.healthleadersmedia.com/content/hep-292001/CMS-
Releases-
Hospital-Pricing-Data. Accessed February 18, 2014.
3. Kliff S. How much does an MRI cost? In D.C., anywhere
from $400
to $1,861. The Washington Post. Available at: http://www.
57
diology
0.html
0.html
http://www.healthleadersmedia.com/content/hep-292001/CMS-
Releases-Hospital-Pricing-Data
http://www.washingtonpost.com/blogs/wonkblog/wp/2013/03/13
/how-much-does-an-mri-cost-in-d-c-anywhere-from-400-to-
1861/
washingtonpost.com/blogs/wonkblog/wp/2013/03/13/how-much-
does-
an-mri-cost-in-d-c-anywhere-from-400-to-1861/. Accessed
February
18, 2014.
4. Leibenstein H. Bandwagon, snob, and Veblen effects in the
theory of
consumers’ demand. Q J Econ 1950;64:183-207.
5. Narasimhan C, Sen S. Measuring quality perceptions.

Marketing Lett
1992;3:147-56.
6. Gaynor M. What do we know about competition and quality
in health
care markets? No. w12301. Cambridge, Massachusetts: National
Bu-
reau of Economic Research; 2006.
7. Shugan S. The price-quality relationship. Adv Consumer Res
1984;11:
627-32.
8. Cutler D, Dafny L. Designing transparency systems for
medical care
prices. N Engl J Med 2011;364:894-5.
9. Levin D, Rao V, Berlin J. Ensuring the Future of Radiology:
How to Respond to the Threats. J Am Coll Radiol 2013;10:
647-51.
10. Chao A, Schor J. Empirical tests of status consumption:
evidence from
women’s cosmetics. J Econ Psychol 1998;19:107-31.
11. Sinaiko A, Rosenthal M. Increased price transparency in
health care—
challenges and potential effects. N Engl J Med 2011;364:891-4.
12. National Conference of State Legislatures. Transparency
and disclosure
of health costs and provider payments: state actions. Available
at:
http://www.ncsl.org/research/health/transparency-and-
disclosure-health-
costs.aspx. Accessed February 18, 2014.

13. Tu H, Lauer J. Impact of health care price transparency on
price
variation: the New Hampshire experience. Issue Brief Cent Stud
Health Syst Change 2009;128:1-4.
14. The Commonwealth Fund. Health care price transparency:
can it
promote high-value care? Available at:
http://www.commonwealth
fund.org/Newsletters/Quality-Matters/2012/April-May/In-
Focus.aspx.
Accessed February 18, 2014.
15. Philips K, Labno A. A trend: private companies provide
health care
price data. Available at:
http://healthaffairs.org/blog/2014/01/08/a-
trend-private-companies-provide-health-care-price-data/.
Accessed
February 18, 2014.
16. Bossuyt X, Verweire K, Blanckaert N. Laboratory medicine:
challenges
and opportunities. Clin Chem 2007;53:1730-3.
58
17. Castlight Health. New analysis details most and least
expensive cities
for common medical services. Available at:
http://www.castlighthealth.
com/price-variation-map/. Accessed August 3, 2014.
18. Castlight Health. Introducing employee accountability with
health
care transparency. Available at:
http://www.castlighthealth.com/pdf/

Castlight-Honeywell-Case-Study.pdf. Accessed August 3, 2014.
19. Loeb J. The current state of performance measurement in
health care.
Int J Qual Health Care 2004;16(suppl):5-9.
20. Berenson RA, Pronovost PJ, Krumholz HM. Achieving the
potential
of health care performance measures. Available at:
http://www.rwjf.
org/en/research-publications/find-rwjf-
research/2013/05/achieving-the-
potential-of-health-care-performance-measures.html. Accessed
February
18, 2014.
21. Kizer K. The National Quality Forum enters the game. Int J
Qual
Health Care 2000;12:85-7.
22. Anumula N, Sanelli P. Hospital outpatient quality data
reporting
program. AJNR Am J Neuroradiol 2012;33:225-6.
23. American College of Radiology. PQRS measures relevant to
radiology.
Available at: http://www.acr.org/Quality-Safety/Quality-
Measurement/
PQRS/Measures. Accessed February 18, 2014.
24. Smith-Bindman R, Miglioretti D, Larson E. Rising use of
diagnostic
medical imaging in a large integrated health system. Health Aff
(Millwood) 2008;27:1491-502.
25. National Quality Forum. National voluntary consensus

standards
for outpatient imaging efficiency: a consensus report. Available
at:
http://www.qualityforum.org/Publications/2009/08/National_Vo
luntary_
Consensus_Standards_for_Outpatient_Imaging_Efficiency__A_
Consensus_
Report.aspx. Accessed February 18, 2014.
26. Shyu JY, Burleson J, Tallant C, Seidenwurm DJ, Rybicki FJ.
Perfor-
mance measures in radiology. J Am Coll Radiol 2014;11:456-
63.
27. Usman O. We need more supply-side regulation. Health Aff
(Mill-
wood) 2011;30:1615.
28. Miller P, Gunderman R, Lightburn J, Miller D. Enhancing
patients’
experiences in radiology: through patient-radiologist
interaction. Acad
Radiol 2013;20:778-81.
29. Emanuel E, Tanden N, Altman S, et al. A systemic approach
to
containing health care spending. N Engl J Med 2012;367:949-
54.
30. Ellenbogen P. Imaging 3.0: what is it? J Am Coll Radiol
2013;10:229.

1861/
1861/
http://refhub.elsevier.com/S1546-1440(14)00493-1/sref1
disclosure-health-costs.aspx
disclosure-health-costs.aspx
http://www.commonwealthfund.org/Newsletters/Quality-
Matters/2012/April-May/In-Focus.aspx
http://www.commonwealthfund.org/Newsletters/Quality-
Matters/2012/April-May/In-Focus.aspx
http://healthaffairs.org/blog/2014/01/08/a-trend-private-
companies-provide-health-care-price-data/
http://healthaffairs.org/blog/2014/01/08/a-trend-private-

companies-provide-health-care-price-data/
http://www.castlighthealth.com/price-variation-map/
http://www.castlighthealth.com/price-variation-map/
http://www.castlighthealth.com/pdf/Castlight-Honeywell-Case-
Study.pdf
http://www.castlighthealth.com/pdf/Castlight-Honeywell-Case-
Study.pdf
http://www.rwjf.org/en/research-publications/find-rwjf-
research/2013/05/achieving-the-potential-of-health-care-
performance-measures.html
http://www.acr.org/Quality-Safety/Quality-
Measurement/PQRS/Measures
http://www.acr.org/Quality-Safety/Quality-
Measurement/PQRS/Measures
luntary_Consensus_Standards_for_Outpatient_Imaging_Efficien
cy__A_Consensus_Report.aspx

http://refhub.elsevier.com/S1546-1440(14)00493-1/sref19The
Health Care Value Transparency Movement and Its Implications
for RadiologyThe Prevailing Theory: Bringing Perfect Value
Transparency to Health Care Can Save a Failing
MarketplacePrice and Quality Data May Influence Patient
Behavior in a Differential Manner, Leading to Several Potential
Market OutcomesConsumer Transparency Into Radiology Prices
Is Well Developed Relative to Other Specialties and Continues
to Grow RapidlyImaging Quality Transparency Remains
Relatively UnderdevelopedThe Combination of Rapidly
Advancing Price Transparency and Slower Moving Quality
Transparency Heightens the Threat of Comm
...Recommendations: Actionable Steps to Move From Simple
Price Transparency to True Value TransparencyTake-Home
PointsReferences

ORIGINAL ARTICLEThe Health Care Value TransparencyMovement.docx

Recommended

Recommended

More Related Content

Similar to ORIGINAL ARTICLEThe Health Care Value TransparencyMovement.docx

Similar to ORIGINAL ARTICLEThe Health Care Value TransparencyMovement.docx (20)

More from gerardkortney

More from gerardkortney (20)

Recently uploaded

Recently uploaded (20)

ORIGINAL ARTICLEThe Health Care Value TransparencyMovement.docx