Radiology: Ancillary No More

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Radiologists must counteract practice developments that can result in trivializing their specialty's contributions to medicine

Under the 1989 Stark legislation, radiology services, both diagnostic and therapeutic, were classified by Medicare as ancillary. Medical imaging and radiation therapy were categorized as comparable to laboratory services, physical therapy, occupational therapy, speech/language pathology, durable medical equipment and supplies, nutritional therapy, prosthetics, home health services, and similar fields.

The word ancillary is derived from the Latin ancilla, which means maid. As an adjective, ancillary is defined as subordinate, auxiliary, or secondary. The context of the term’s use, within the Stark legislation, was the intent to address self-referral abuses within those services that were considered extensions of physician-office visits. These services included tests like chest radiographs, or even ultrasound exams in obstetrician/gynecologists’ offices. Such services, arguably, serve as extensions of the stethoscope in the new age of technology.

As we all know, modern radiology is by no means ancillary. Studies, particularly those acquired on high-tech equipment, are usually scheduled and performed at separate visits, and commonly at different locations than those of the originating office visits. These are not incidental exams, and they should no longer be classified as ancillary. The ACR currently is presenting this argument to CMS in an attempt to address the in-office exemption loophole on which most self-referral models rely for their justification.

Radiologists (and many referring physicians) realize that medical imaging is vital to evidence-based medical care. The booming rate of utilization for imaging tests is a testimony to the importance of radiology as a diagnostic imperative. For example, up to 75% of all emergency-department patients receive some sort of medical imaging.

The perception that radiology is something less than real medicine, however, somehow persists in many circles—including among some physicians, the public, and, unfortunately, politicians and regulators. On November 17, 2008, in the South Florida Sun-Sentinel, Ted Epperly, MD, president of the American Academy of Family Physicians, was quoted as saying, “America won’t be cared for properly by having a million radiologists and dermatologists. We’re producing the wrong doctor work force for America.” During the 2008 ACR branding campaign, it was determined that only about 50% of the public was aware that radiologists are doctors.

We also are contributing to this misperception. Our business models have emphasized increased productivity in order to make up for decreasing reimbursement. Some consequences of these new priorities include decreasing communication and contact with those we serve. The diffusion of PACS and teleradiology into our practices and hospitals has significantly reduced our direct interactions with referring physicians. Night-coverage services have led others to conclude that radiology can be commoditized. Put the CT data into a black box and an interpretation will appear.

Take a look at modern ECG machines. A computer-aided detection program types out the preliminary report before any physician touches the study. Automation is challenging the value proposition of some physicians’ professional services, including ours.

Added Value

The problem with this path is that it discounts the added value that we, as physicians, bring to the health care enterprise. Radiologists are the experts in image interpretation, but we do much more. We care for the patient, assume the responsibility for communication and follow-up, attend to contrast reactions, determine appropriateness, maintain protocols, monitor radiation safety, administer conscious sedation, and serve as medical directors for our hospitals and offices. Those reading this article could add many more responsibilities.

We also add value, in the business of medicine. We have established practice models that can handle large volumes of encounters. Radiology groups have developed organizational structures that have served to manage large numbers of physicians.

Radiologists must re-establish their roles as physicians integral to the health care enterprise. We are, first and foremost, physicians. We all went to medical school before we went into radiology. Our focus is on taking care of patients.

There are numerous opportunities, every day, for