The Neuroradiology Education and Research Foundation (the Foundation) was founded in 1996 with the goal of strengthening the field of neuroradiology by supporting (1) the continuing education of practicing neuroradiologists, (2) training of neuroradiology fellows, (3) development, application, and reimbursement of neuroradiologic studies, and (4) support of outcomes research and basic research to help reach goals 2 and 3. These goals have been and continue to be pursued by a number of different means. The education of practicing neuroradiologists is supported through the annual meeting of the ASNR and the accompanying yearly Foundation-supported symposium, the posting of state-of-the-art lectures about all aspects of neuroradiology on the ASNR Web site (eCME), and the annual meetings and activities of established and emerging societies. Training of fellows is supported by reduced fees for the AJNR, annual meeting, and symposium; the awarding of training grants and fellowships; and by providing funding for the personnel and information systems required for eCME. The development and application of new studies is supported by the yearly sponsorship of research awards and fellowships. Our ability to realize reimbursement for new techniques/procedures is aided by the support of outcomes research, the results of which are used by the ASNR Clinical Practice Committee (CPC) to promote fair reimbursement for practicing neuroradiologists.
As new techniques and applications of these techniques are constantly being developed in neuroradiology, the work of obtaining fair reimbursement for them is an ongoing struggle, one in which the ASNR and the Foundation are constantly involved. Reimbursement for new neuroimaging studies (indeed, for all new techniques) always lags behind the ability to perform them; many studies that are the mainstays of modern neuroradiology were not reimbursed for several years after they were introduced and some (tractography, perfusion imaging, functional MR imaging [fMRI], sometimes proton spectroscopy [MRS]) are still not reimbursed. Why not? Why is this reimbursement process so difficult? To better understand this and how the ASNR and Foundation are involved in the process, it will be necessary to digress for a few paragraphs to very briefly discuss the processes by which new procedures are evaluated and reimbursements are determined.
For a new procedure to be reimbursed by Medicare (and hence by most other insurers), it needs to clear 3 major hurdles: the Current Procedural Terminology (CPT) Editorial Panel; the Relative Value System Update Committee (RUC); and the Center for Medicare and Medicaid Services (CMS). Whenever a new technique or application is developed and the performing physician wants to be reimbursed for it by an insurer, an application must be submitted for a new code. The technique is presented to the CPT Editorial Panel, where evidence must confirm that the procedure is efficacious, that it is performed in many geographically diverse areas, and that no existing code is suitable. The efficacy of the procedure must be demonstrated by the use of evidence-based medicine based on data that are published in the literature. The CPT Editorial Panel looks at the quality and quantity of supporting literature and, if the data demonstrate an impact on clinical decision making or patient outcome, designates the procedure as category 1. Without this designation, there will be no reimbursement by Medicare. Much of the data that are supplied to the CPT Editorial Panel for neuroradiologic procedures comes from projects supported by the Foundation. For example, an important set of fMRI codes will be coming before the CPT panel in the fall. The proposal required a significant commitment of time and effort to craft an application acceptable to all parties. In recent years, projects have been supported to begin to acquire data regarding the efficacy of endovascular treatment of intracranial aneurysms, quantitative diffusion tensor imaging (DTI) tractography in white matter diseases, perfusion MR in carotid stenosis, embolization of intracranial tumors, DTI and fMRI in traumatic brain injury, and characterization of atherosclerotic carotid disease by CT positron-emission tomography and by multidetector row CT angiography (CTA), among others. In addition, the Neuroradiology Education and Research Foundation Outcomes Research grants fund studies to determine the quality of the data supporting these tests and what additional tests are necessary to support designation of procedures as category 1. One such analysis has already been performed for the use of MRS in brain tumors and proposals are currently being received for a study of MR and CT perfusion in cerebral ischemia.
Once a procedure has been designated as category 1, the next step is to determine the value of the test; this is determined by the RUC. Some of the factors taken into account are the skill level necessary, the intensity of the work, the stress, and the amount of time required (for pre-exam, intraexam, and postexam activities). Accurate determination of these factors requires polling of physicians who actually perform the test. Many neuroradiologists have received questionnaires from the CPC regarding the amount of effort and time spent on neuroradiologic tests and procedures. The purpose of these questionnaires is to acquire data to support a request for fair relative value units (RVUs) for new neuroradiologic exams. The results of these questionnaires, and documentation of an adequate number of responses, are crucial in determining the RVU—remember that your responses to these questionnaires are extremely important for getting proper reimbursement, so please take the time to fill these out! Armed with these data, members of the CPC meet with representatives from other specialties and organizations to come up with a consensus for the new procedure and then give an oral presentation at the RUC meeting. These decisions can be difficult, because the net spending has to be balanced; if value is assigned to a new procedure, the value of another procedure must be lowered. This requires a great deal of preparation and political skills by the CPC representative. When the meeting ends, the CPC representative leaves with a recommended value for the RVU.
The value recommended by the RUC, however, is only a recommendation. It is the CMS that has the final authority to assign an RVU value. During the summer after the RUC meeting, the CMS proposes an RVU value for the new procedure; this value is typically lower than the submitting group/society had requested. During the summer and fall comment period, the submitting group (in the case of neuroradiology, the CPC) has the opportunity to develop and present arguments as to why the value should be higher; again, this requires data from the membership and literature. The CMS needs to be persuaded before the new fee schedule is published in November for implementation in January. In addition, the CPC, working with other groups, must develop new ICD9 codes (disease or symptom-related codes) that correspond to the new procedure; if they do not, the CMS and regional carriers will do so and the list will likely be deficient.
It should be clear from this discussion that the Foundation, through its support of clinical research, outcomes research, informatics, and the CPC, is of critical importance in helping the practicing neuroradiologist to obtain adequate compensation. The Foundation strives to serve the field of neuroradiology in many ways; therefore, it needs to be positioned to deal with new challenges for our specialty as they arise. Among the many challenges currently facing neuroradiologists, the most acute is the rapidly increasing discrepancy between workload and workforce. To get an idea of the magnitude of this issue, an informal review of workload statistics during the past 5–10 years from 7 large practices (including 4 academic centers, 2 large private practices, and one large HMO) in different parts of the United States was conducted. The neuroimaging studies included CT and MR scans of the brain, spine, and head/neck. The average increase in number of studies among the 7 groups was 19% per year, with the largest increases being in one of the private practices (25%/year) and the HMO (30%/year). Significant increases were found in all categories of examinations, but the largest increases were in brain MR imaging and brain radiographic CT. In addition to the dramatic increase in the number of studies being performed, the complexity of the studies was also found to be increasing. Whereas 10–12 years ago, most CT studies included routine anatomic imaging in a single plane and MR studies included an average of 3 sequences (in 2 planes), current studies are longer and more complex. CT studies are often reformatted (see below) and MR studies average 5–6 sequences; one or more of the following sequences are included in >80% of studies: CTA, MR angiography (MRA) or venography, diffusion-weighted imaging (DWI) or DTI, diffusion tractography, MRS, CT or MR perfusion imaging, blood oxygen level–dependent imaging (fMRI), and multiplanar reformations (at several hospitals, the number of CT reformations has increased by a factor of 50 [5000%] during the past 10 years). All of these additional studies result in increased postprocessing time and an increased number of images that must be evaluated for each study, substantially increasing the time and effort required both for performing the exam and for proper evaluation of it. Although one might argue in rebuttal that many of these new exams replace exams (catheter diagnostic angiograms, myelography) that were more time consuming, the morbidity of the new studies is significantly lower and the resulting information so much more detailed that many more examinations are being ordered (sometimes for less-compelling indications). The sheer number of exams much more than compensates for the increasing speed of the techniques. In addition, the information supplied by these studies is often important for the evaluation of specific patients and all neuroradiologists want to be able to provide these studies and the information derived from them for their patients and referring clinicians.
Despite the rapid increase in the number and increasing complexity of neuroradiology studies being performed, the number of neuroradiologists being trained is increasing much more slowly. The size of the membership of the ASNR (the best measure of the number of North American neuroradiologists) increased by only 38% during the past 10 years; this is <30% of the increase in the number of studies. Another measure of the number of neuroradiologists being trained is the number of fellows in Accreditation Council for Graduate Medical Education-accredited neuroradiology fellowships. The numbers obtained by this method are almost identical to those obtained by looking at ASNR membership: the 124 new neuroradiology fellows starting accredited fellowships in 2005 will add 4% to the neuroradiology work force, even if these fellows train for only 1 year (and in the increasingly complex world of neuroradiology, 1 year hardly seems to be enough training). This increasing gap between the number of neuroradiologic procedures and the number of neuroradiologists creates significant problems in providing adequate care to patients, because it means that less-qualified people (those without sustained, dedicated training in neuroradiology) will be recommending, performing, and interpreting neuroradiologic studies. This will almost certainly lead to a decreased quality of diagnosis, decreased quality of care, more turf issues, and increased overall cost in the care of patients with neurologic disease. Payers now place greater emphasis on the quality of care, and pay for performance is becoming a reality. Therefore, more neuroradiologists must be trained. The question is how to accomplish this.
Neuroradiology fellows come from radiology residents, so an obvious first step is to increase the number of residents in radiology. This is not automatic or easy, because the number of residents authorized for a residency program is mandated by the Residency Review Committee and depends upon the academic caseload and environment of an institution. In addition, the program must figure out how to pay for the residency positions, because supplements from the government are limited. If enough residency positions are granted, one should remember that neurology residents with an interest in neuroradiology can become CAQ eligible by enrolling in a program of 2 years of neurology followed by 2 years of general radiology, and finishing with a 2-year neuroradiology fellowship. A similar process could be envisioned to develop more pediatric radiologists and radiologists in other subspecialties; this path could help to fill the void in radiology subspecialties. The problem with this approach is that such residents (for example, neurology residents) have to declare their intention when they apply for their residency. Thus, neurology residents who become disillusioned with their field do not have any route to neuroradiology other than applying to a radiology residency program and starting from the beginning. In light of the duration of medical training, it is not surprising that the number of physicians who add 2–3 extra years to their training by choosing this route is quite small. Another possibility would be to allow radiology residents to specialize earlier, for example by entering a fellowship after only 2 years. Such a 2–2 program would allow training of neuroradiology fellows (or pediatric radiology fellows, or musculoskeletal radiology, etc) in 4 years instead of 6. The 2-year fellowship allows the extensive subspecialty training necessary to bring added value to the subspecialty radiology practice. This is essentially what has happened in internal medicine and pediatrics, where the initial residencies are short, but nearly every physician specializes. Indeed, problems such as this confront all of medicine and are currently being addressed at many levels. Other specialties encourage their trainees to stay in an academic center for fellowship training by delaying board eligibility until 1–2 years after completion of their residency.
Whether more radiology residents are trained or not, more neuroradiology fellows must be trained. To do this requires recruiting more attending physicians in neuroradiology, which can be difficult when the salary structures of academic and private practices diverge. As a result, there is a need to make academic practices appealing in ways other than financial. In general, this means giving the academic physician sufficient time to pursue research interests; however, for the academic practice to be financially sustainable, academic time must be purchased with fellowship or grant money. Obviously, the practice cannot afford to pay a member who does not support his or her salary. The Foundation helps the young academician to purchase such time with fellowships and grants. These awards have given a boost to young academicians for many years. A recent poll of former winners of research awards from the ASNR and the Foundation showed that, of the 47 winners of awards who could be contacted, 41 are still in academic practice. This group includes 9 chiefs of neuroradiology sections, 3 department chairs, and one hospital vice president. All of those polled stated unequivocally that their award gave a much needed boost to their confidence and their careers. These leaders in neuroradiology have used the research time provided by their awards to train more neuroradiologists and to pursue development of new techniques and applications. As stated earlier, these techniques and applications eventually come to the neuroradiology reading room and allow us to give the added value of neuroradiology training to our patients and referring clinicians while at the same time leading to higher reimbursements for the practicing neuroradiologist.
Another avenue to increasing the strength of neuroradiology might be to convince radiology groups to wait an extra 2 years until trainees are fellowship trained before bringing them into a practice. Ultimately, this is to the benefit of the practice, as the young neuroradiologist, fresh from training at a top academic institution, will bring new, state-of-the-art techniques to the practice and thereby improve the quality of diagnosis and care. For neuroradiology to prosper, the quality of care given by a practicing neuroradiologist must have added value compared with that of practices without trained neuroradiologists. This added value can be maintained or increased by several means, including hiring only fellowship-trained neuroradiologists (preferably after 2 years of training), having practitioners attend the annual meeting of the ASNR and the Neuroradiology Education and Research Foundation Symposium, by reviewing the eCME lectures on the ASNR Web site, and by routinely reading the AJNR. Without the added value supplied by excellent, focused training and continuing education, it would not be possible to compete with the much larger number of other physicians who would like nothing more than to incorporate neuroradiology into their practices.
This editorial has tried to summarize the ways in which the Neuroradiology Education and Research Foundation and the ASNR are working to benefit neuroradiologists and neuroradiology. In many ways, it also answers a question that is often asked of the leaders of the Foundation and the ASNR: where does our money go? The answer is that it goes many places. It goes toward the development of new imaging techniques and therapies and documents the efficacy of these methods and outcomes for patients so that neuroradiologists can be fairly reimbursed for their work. The money also goes toward training new neuroradiologists who will keep up the high standards originally set by the pioneers of our specialty, who created the field of neuroradiology by showing that value is added by physicians with a high level of training in the demanding and complex field of neurodiagnosis and therapy. This continual evolution and improvement of methods and the accompanying high standards enable young neuroradiologists to take our specialty forward with a sense of pride and empowerment and with confidence in the future.
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