Comparison of Advanced Imaging Resources, Radiology Workforce, and Payment Methodologies between the United States and Canada

SUMMARY: The purpose of this Practice Perspectives was to review the United States and Canadian approaches to health care access and payment for advanced imaging. The historical background, governmental role, workforce, coding, payment, radiologic challenges, cost, resource intensity, and overall outcomes in longevity are reviewed.

plan that covers all residents living in each jurisdiction for a minimum of 6 -8 months annually, depending on the province or territory. 6 The resident health card permits access to a full range of medical services, including diagnostic imaging at no or minimal out-of-pocket cost. Charging additional fees for medically necessary services is strictly forbidden by the Canada Health Act. Portability of health care services exists for Canadians who travel or work in other provinces, whereby their provincial health system compensates the delivering province at an agreed interprovincial rate. 7 Six of 10 Canadian provinces prohibit private insurance from covering services that are provided under the provincial health care plan, and 3 of the remaining 4 provinces allow private insurance coverage of these services but at a considerable disadvantage to physicians who decide to opt out from public payers. For example, it is illegal for a physician in Nova Scotia to charge fees that exceed the provincial public rate. Saskatchewan and New Brunswick physicians are not reimbursed if they opt-out of the provincial plan. Only Newfoundland and Labrador authorize private insurance coverage of medical services reimbursable by the public plan without any economic disincentives to opt-out of the provincial health plan. 8 Many Canadians have supplemental insurance for uncovered services, such as prescription drugs, ambulance services, vision, and dental care. 9 Unlike the United States, payment of Canadian physicians is generally restricted to specialty, as defined by the Royal College of Physicians and Surgeons of Canada and recorded by the provincial medical licensing authorities-that is, in Canada, only a radiologist can provide professional radiology services. 10,11 Professional fees of physicians are negotiated between the province and provincial medical association. [12][13][14][15][16][17][18] Canadian CT and MR imaging services are largely hospital-based performed in a hospital setting. Professional fees of Canadian radiologists vary between the Provinces and Territories of Canada as they are independently negotiated with the medical associations, Ministry of Health and providers. 19 More than 90% of CT and MR imaging services are delivered in publicly funded hospitals in Canada. CT and MR imaging fees in Canadian provinces are either tied to the provincial fee schedule or negotiated on a regional basis. The remaining CT and MR imaging services are provided at private imaging clinics. According to the Canadian Agency for Drugs and Technologies in Health 2017, there are approximately 561 CT and 366 MR imaging scanners in Canada. 20 Additionally, there are approximately 59 true private payer MR imaging and CT facilities across Canada, located in a subset of provinces in urban areas: British Columbia (BC) (n ϭ 17), Alberta (n ϭ 10), Quebec (n ϭ 31), and Nova Scotia (n ϭ 1). 21 In Ontario, there are approximately 184 CT scanners and 120 MR imaging scanners, all in hospitals. 20 United States. The United States has a multipayer system dependent on the private marketplace or government subsidy. Nongovernment plans include fee for service and prepaid plans. There are 6 government-based plans: Medicare, Medicaid, Children's Health Insurance Program, Tricare, Indian Health Service, and the Veterans Health Administration. Medicare plans are regionalized into 7 Medicare Administrative Contractors, which standardize covered benefits and rates. There are 274 different managed Medicaid plans, each with distinct coverage policies and reimbursement. 22 In 1965, President Lyndon B. Johnson signed the bill that led to Medicare and Medicaid. Medicare is federally funded by tax revenue benefiting largely the elderly (65 years or older) and individuals with disabilities. Medicaid is a federal and state cofunded program for those with limited financial resources. 23  In 2013, the radiology workforce in the United States was 8.14 radiologists per 100,000 with 25,730 radiologists serving a total United States population of 320.9 million. 28 In 2013, the Canadian per capita radiology workforce was 6.82 with 2396 radiologists, serving a Canadian population of 35.16 million. 29,30 The Canadian procedure codes, including imaging, are unique and individualized to each province with updates as needed. Canadian fee codes for CT and MR imaging are organized along body systems and contrast (without contrast, with contrast, and pre and post contrast). With the exceptions of cardiac CT and CT colonography, Canadian radiologists are paid on a fee-for-service basis. (Table 2).
In the United States, the imaging procedures are standardized by the 5-digit Current Procedural Terminology code, a methodology published and owned by the American Medical Association with standing meetings by the Current Procedural Terminology Editorial Panel 3 times a year. 31, 32 Medicare payments are based on a relative value unit formula weighted by the work of physicians, professional liability insurance, and practice expense with a geographic variation modifier as defined by the resource-based Relative Value Scale Update Committee, which also has standing meetings 3 times a year to evaluate updates and revisions, and, when approved by the United States Congress, with a conversion factor converting the relative value units into dollars. 33,34 Medicaid reimbursement and private insurance payments use the Medicare rates as a reference, but each plan individually determines the rate. 35

Radiology Services in Canada
CT and MR Imaging (Advanced Imaging) Wait Times. More CT and MR imaging scanners have been approved in the past decade, but an undersupply continues to exist in every province. The combination of an inadequate number of scanners and underfunding for the operation of these scanners has led to prolonged wait times for both modalities, but especially MR imaging. This issue is occurring with an increasing demand to meet longstanding indications as well as new clinical applications (eg, breast MR imaging and CT colonography) driven by a growing and aging population. The Fraser Institute survey, based on physician recollection and self-reported methodology for "medically necessary  elective treatment," reported average Canadian CT wait times ranging from 3 to 6 weeks in 2016 among the provinces and average MR imaging wait times from 4 to 24 weeks. 36 In Ontario (the most populous Canadian province with 38.5% of the population of the country), average wait times were 3 weeks for CT and 6 weeks for MR imaging. The Canadian Institute for Health Information, an agency of Health Canada that collects and reports "essential information on Canada's health systems and the health of Canadians," 37 reported a median CT wait time ranging from 6 to 34 days and MR imaging wait times from 33 to 84 days. Median CT wait times in Ontario were 6 days and 33 days for MR imaging. 38,39 Outpatients requiring nonurgent advanced imaging services in hospital radiology departments face significant backlogs; however, urgent and emergent priority procedures are completed within acceptable standards. 40 46 In Canada, the Aboriginal population has access difficulties; "medically necessary" services for Aboriginals are the direct responsibility of the provinces, though the federal government does provide some services for mental health, chronic conditions, and prescription drugs. 47 The confusing and bureaucratic "patchwork" of coverage and the often rural location of Aboriginals have led to challenging care for this community.
Professional Liability Insurance Cost. Professional liability insurance costs differ between Canada and the United States. California legislated a $250,000 cap on noneconomic damages and fostered the low professional liability insurance rate for radiology. State-filed malpractice premiums of diagnostic radiologists in California range from $5729 to $21,095, with an average of $10,934; low-risk physicians receive a discount up to 50% on state-filed rates. 48 Greater than 90% of Canadian physicians are members of the Canadian Medical Protective Association, a mutual legal defense association that aims to decrease medical-legal risk for its members and improve the safety of health care. In BC, the annual fees (premiums) for diagnostic radiologists are near the median with other Canadian physicians, CaD$5280 in 2016 (ϳ$3830 US dollars). 49 The actual fees paid may be less because each provincial medical association negotiates with the provincial government to subsidize a portion of the fees paid. In BC, the government rebated nearly half of the annual fee, CaD$2597 (ϳ$1884 US dollars), to radiologists. In the United States, the malpractice claim rate of radiologists is approximately 7%, 50 compared with a Canadian malpractice claim rate of 1.9% in 2013 per the Canadian Medical Protective Association report of 46 claims against radiologists. 51 Nearly all 2396 radiologists in Canada were covered by the Canadian Medical Protective Association.

Advanced Imaging Equipment Funding and Use
Funding of Radiology Equipment. In Canada, each provincial ministry of health funds most hospital operating budgets, either  directly or indirectly through Regional Health Authorities. Hospital imaging equipment purchases involve some combination of an approval of the health authority, ministry of health capital equipment funding, or funds raised through the charitable foundation of the hospital. The ministry/health authority controls operating budgets and approval of capital purchases. In the United States, except for the Veterans Administration and large government-owned hospitals, manufacturers and providers negotiate imaging equipment costs directly with the hospitals and facilities. 52 Advanced Imaging Use and Units. The variation in the volume of advanced imaging procedures in Canada and the United States is marked (Tables 3 and 4

CONCLUSIONS
The American and Canadian systems both strive to provide health care to their citizens. The system in United States uses standardized coding within a dual system of government and private payer health insurance. The Canadian universal coverage is largely funded from tax revenue collected by the federal legalization payments and provincial government but is independently administered by provinces and territories using different coding and payment policies. The Canadian health system, including advanced imaging, is highly regulated and accounts for the per capita expenditure for health care in Canada being more than half that of the United States. As the United States struggles with increasing health care expenditures, Canada is struggling with the demand for greater access. The United States population is 10 times that of Canada, with health care costs nearly twice as high per beneficiary. The explanation of less expensive care and longer outpatient procedure wait times is complex, though perhaps due to a less adverse malpractice climate in Canada compared with the United States. Delivery in a nonprofit Canadian Government-controlled system may be an oversimplification; perhaps differing populations, poverty rates, and medical conditions served despite similar culture and origins may account for the apparent discordance of health care cost and access.