The Evolving Role of Radiologists within the Health Care System
Introduction
Over the past 2 decades, a series of changes in medicine, technology, and national health care funding have significantly changed the role radiologists play in the health care system. Recently, the effects of these changes have become more conspicuous in the wake of increasing legislative scrutiny of diagnostic imaging and the ever increasing impact of information technology on all aspects of health care. The traditional image of radiologists as physicians whose role is to sit in dark rooms interpreting films and generating reports has become outdated, if not obsolete.
Although containing rising health care costs has long been an area of significant concern for the entire medical community, recent congressional action has significantly increased the attention focused on diagnostic imaging. On February 1, 2006, the US House of Representatives passed the Deficit Reduction Act of 2005, a budget-cutting bill with provisions to significantly reduce Medicare reimbursement for imaging services [1]. Although the Congressional Budget Office [2] has estimated that the imaging provisions will save $2.8 billion over 5 years, the American College of Radiology's (ACR) preliminary analysis indicates that these cuts could result in a $6 billion financial impact on radiologists over 5 years [1].
Two major provisions of the Deficit Reduction Act will affect radiologist reimbursement. Both provisions address the technical component of reimbursement without affecting the professional component [3]. The first provision, effective January 1, 2007, reduces the technical component of reimbursement for nonhospital outpatient settings to the lesser of the Hospital Outpatient Prospective Payment System payment or the Medicare fee schedule payment. Previously, the technical fee schedule for in-office imaging was higher than that for the hospital setting to offset the costs of physician ownership of the equipment and the involvement of staff members in the services [4]. This provision does not affect outpatient imaging performed in the hospital setting. The second provision, also effective January 1, 2007, reduces technical-fee reimbursement for certain diagnostic imaging procedures on contiguous body parts by 25% in 2007 for non–hospital-based imaging [3]. This recent series of events underscores the need for the radiology community to remain politically active to ensure the future of diagnostic imaging as an integral and viable component of the health care system.
This series of budget cuts was almost certainly influenced by the rapidly increasing costs of diagnostic imaging within the federal health care budget. According to a recent article by Kirby [5], imaging costs are considerably outstripping the growth of other sectors, accounting for nearly $100 billion annually, according to Medicaid and US Government Accounting Office data. Comparative analysis shows a threefold discrepancy in the growth of medical imaging compared with other medical services from 1999 to 2002 and a further increase by 16% in 2005. Medicare costs have increased by 30%, with imaging costs increasing by 50% 5, 6. Although a significant portion of this increase can be attributed to imaging performed by nonradiologists, there are several opportunities for radiologists to help prevent inappropriate utilization or overutilization of diagnostic imaging.
Advances in imaging and information technology have increased the importance of radiologists not only by increasing the utilization of diagnostic imaging but also by moving radiologists into a more central role in integrated patient care.
The increased utilization of diagnostic imaging significantly affects the use of funds, the systems operations of a health care system, patient safety, and a system's information infrastructure. Consequently, radiologists are assuming increasing responsibilities with respect to gatekeeping, quality-of-care improvement, patient safety, and information management.
In addition, advances in radiology are yielding more and better techniques for cancer screening. Therefore, radiologists are presented with new opportunities to expand their role as public health providers.
Although image generation and interpretation remain central to the practice of radiology, radiologists' role in the integrated health care system has expanded to provide significantly more value to the health care system.
Section snippets
The Radiologist as Gatekeeper
Although the term gatekeeper has traditionally been applied to primary care physicians, radiologists can also have a role in ensuring that medical resources are utilized efficiently and appropriately. A gatekeeper can be defined as a person who is positioned between an organization and the individuals who wish to use the resources within that organization [7]. Although a primary care physician may be a patient's first contact in the medical system, a radiologist often becomes involved in the
Radiologists as Political Advocates
Radiologists can also help contain increasing health care costs by influencing the policy decisions of private payers and the government. The ACR is actively involved with both private payers and the government. For example, in 2004, UnitedHealthcare consulted with the ACR to implement imaging protocols for more than 190 conditions [15]. The government relations department of the ACR has staff members who attend numerous fund-raisers throughout the year to speak with members of Congress who
Radiologists as Public Health Providers
Generally considered the domain of the primary care provider, public health encompasses a range of topics, including immunizations, cancer screening, and other key health care services for reducing morbidity and mortality in the population. Although radiologists are certainly involved in public health and preventative medicine (eg, breast and colon cancer screening), it is not immediately obvious that radiologists' practice can be used as a vehicle to encourage increased adherence to cancer
Radiologists as Safety Officers
The increased utilization of computerized tomography has been a major factor in the renewed interest in radiation safety. Increases in both the availability of multidetector row CT scanners and the number of clinical indications for computed tomography has caused explosive growth in its utilization [26]. Subsequently, much of the recent emphasis in the radiation safety literature has focused on reducing patient dose from CT scans 26, 27, 28. In the past decade, there has been increased emphasis
Radiologists and Continuous Quality Improvement
The CQI literature emphasizes systems orientation and patient safety but also seeks to apply lessons from operations research and industrial management to multiple other aspects of health care [29]. Continuous quality improvement methods have been widely adopted by administrators but are a relatively new concept within the radiology literature [29]. Although a full discussion of CQI is beyond the scope of this paper, we will attempt to familiarize the reader with some of the basic concepts. If
Radiologists as Information Technologists
It was not long ago that the vast majority of radiologists read film, dictated reports to human transcriptionists, and sent their reports on paper to referring clinicians. Many such practices still exist today, but the role of information technology in the practice of radiology is rapidly changing.
Although digital imaging (ie, ultrasound, computed tomography, and MRI) has been part of radiologic practice for decades, picture archiving and communications systems (PACS) are a relatively recent
Conclusions
The traditional view of radiologists in dark rooms in front of view boxes and adding value to the health care system solely by interpreting images is rapidly becoming outdated. Although advances in imaging technology, especially CT and MRI, have expanded radiologists' diagnostic capabilities, the value of radiologists has also expanded outside of image interpretation. Advances in information technology have the potential to make the role of radiologists more central in the overall systems
References (42)
Self-dealing in medical imaging: call for action
J Am Coll Radiol
(2007)- et al.
Turf wars in radiology: the overutilization of imaging resulting from self-referral
J Am Coll Radiol
(2004) - et al.
Turf wars in radiology: other causes of overutilization and what can be done about it
J Am Coll Radiol
(2004) Health promotion in primary care: problems and potential
Prev Med
(1986)- et al.
Value added radiology: using existing radiology services to improve cancer screening
Acad Radiol
(2005) Continuous quality improvement for radiologists
Acad Radiol
(2004)- et al.
Illustrating the root-cause analysis process: creation of a safety net with a semiautomated process for the notification of critical findings in diagnostic imaging
J Am Coll Radiol
(2005) Defining quality in radiology
J Am Coll Radiol
(2007)Budget bill targets diagnostic imaging services
2007 reimbursement guide: what you need to know
Deficit Reduction Act of 2005 enacts sweeping Medicare and Medicaid changes. Law Watch
Current issues: self referral. ACR Web site
Primary care gatekeeping and referrals: effective filter or failed experiment?
BMJ
Physicians utilization and charges for outpatient diagnostic imaging in a Medicare population
JAMA
Nationwide trends in rates of utilization of noninvasive diagnostic imaging among the Medicare population between 1993 and 1999
Radiology
Practice patterns of radiologists and nonradiologists in utilization of noninvasive diagnostic imaging among the Medicare population 1993-1999
Radiology
Leasing imaging facilities to referring physicians: fee shifting or fee splitting
Radiology
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