Ten Questions to Ask in Comparing MRI Physics Services
The looming deadline of January 1, 2012, is prompting many MRI scan providers to apply for accreditation. According to section 135 of the Medicare Improvements for Patients and Providers Act, as of this date, any provider of advanced imaging services billing under Medicare Part B must be accredited to receive payment. Choosing the cheapest service might jeopardize not only your accreditation, but also the health of your MRI system. The annual MRI performance test required under the ACR® accreditation program is its annual physical, and the results provide not only a higher degree of confidence in the technical characteristics of your unit, but also function as an important check on the quality of service that your vendor provides. As you consider the physics services that you will need to support your accreditation process, these 10 questions can help you identify those with the competence and experience needed to facilitate the process (and to give you confidence that your system is performing well). They will also help you assess the true value of a quote by identifying support services that might or might not be included in the price. First, are you qualified, under ACR requirements, to perform annual MRI testing? Generally, this will require board certification for medical physicists or an advanced degree and a minimum of three years of experience in testing MRI for those qualifying as MRI scientists. Not all medical physicists have experience with MRI. You can also ask if the tester serves as an ACR reviewer, which shows an extra level of experience. Ask for the tester’s ACR number, and if he or she does not have one, ask why not. Second, how long does your testing take? To meet the criteria specified by the ACR for the annual exam, even the most efficient and competent MRI physics group will require at least two to four hours. If someone tells you that he or she can finish testing in less time, be very wary. Third, do you conduct testing outside normal scanning hours? The typical MRI scanner generates about $750 to $1,000 per hour in technical revenue, and MRI testing takes hours. If the physics group requires part of your scanning day for testing, that can cost thousands of dollars in lost patient time. Remember to add such costs when you are comparing quoted fees for services. Fourth, do you operate the MRI equipment without assistance? This question is very important. Those with limited experience cannot possibly offer you a competent test if they can’t run the MRI system. Would you trust your car to a mechanic who couldn’t drive it? Some argue that they can tell the technologist what exams to run, but why should you pay for a technologist to stay with the tester? Others might say that they oversee testing by your vendor’s service personnel, but how independent can such testing possibly be? Be extremely skeptical if a group needs any assistance during testing. If you still decide to employ it, require it to pay for the overtime cost of any assistance that it needs. Fifth, how many MRI units from my vendor and of my model have you tested in the past 12 months? Just as you would in researching the background of a surgeon for an open-heart procedure, you want someone who has experience with your equipment. Require at least two previous tests, unless you have a very new or unusual MRI model. Don’t be afraid to ask where the previous tests were done. Sixth, do your reports include all of the test criteria required by the ACR? Some groups try to save time and money by cutting corners. Ask for a copy of a representative report from the group. The ACR has established minimum test requirements in its published quality-control (QC) manual for MRI.¹ Check to see whether the testing and the report include all specialty coils used clinically (the report must include the model and serial number for each coil, as well as the transmit gain information from the test); homogeneity testing on the magnet; and luminance testing on the system monitor. Note that the ACR will reject reports not meeting its requirements. If this happens to you, you must get the testing group to return, complete testing, and resubmit the report. This can delay your accreditation significantly. Seventh, what fraction of MRI units pass your annual testing without any errors? Considering that you pay many thousands of dollars each year for a service contract, who is checking to see whether your vendor is doing a good job? If a physics group usually finds nothing wrong, it might not know how to look for problems that could exist. With experience based on more than 1,700 MRI tests, I have found something wrong in about 85% of cases. This has saved sites thousands of dollars in monitors, coils, gradient amps, and other components that needed to be replaced, but were not identified as faulty through vendors’ QC activities. Even more important, image quality suffers when the instrument is not performing optimally. If your system is not working as well as possible, you want to know. Eighth, do you provide QC training for our technologists as a part of your testing? The ACR requires sites to conduct weekly QC that must be checked annually by the physics group. Often, local technologists benefit from a short inservice session, conducted by the tester, that includes setup of the QC phantom, acquisition and interpretation of the data, and a discussion of how to fill out the required weekly paperwork. Does the physics group charge extra for such training? Ninth, what assistance with accreditation do you provide? As a part of the accreditation process, the ACR requires sites to submit five scans done on the ACR phantom. These are sent by the ACR to a reviewer for scoring. If the images do not pass a series of tests, the site is sent a notice of failure and must either appeal or resubmit new images (at an additional cost). A review prior to submission can help to identify problems that could result in failure and can save you time and money. Will the physics group conduct a review of your technical images, and does it charge extra for such service? Tenth, what help do you provide if I fail the technical portion of accreditation? Should you fail, the letter from the ACR will identify the tests that did not meet its criteria. Your physics group should review your submitted images and let you know whether it agrees with the ACR findings. If not, it should help you draft your appeal (this must be done within two weeks of notification of failure). Some groups offer a guarantee that you will pass accreditation. Be cautious of such claims, since they might constitute a direct conflict of interest. If the testing group has guaranteed passing, will it have a tendency to overlook possible problems? When comparing the costs and capabilities of different MRI physics services, remember to consider any additional costs for ancillary support that you will need. In-house training for your technologists, a review of your technical images, and support if you need to appeal a failure can add hundreds of dollars, if not included in the basic testing package. Finding faulty equipment also can save thousands of dollars. Competent and experienced MRI physics support should be worth far more than you pay for it. Robert A. Bell, PhD, is an independent MRI scientist based in Encinitas, California, and a senior reviewer for the ACR®; email@example.com.