ACR in 2014: 5 Hot Topics

CHICAGO - What are the five major areas of concern for radiologists in 2014? Representatives from the ACR detailed at RSNA 2013 several hot topics for the organization, as well as the ACR’s efforts to meet and guide its members through the challenges ahead.

Quality and safety

For the ACR, quality and safety efforts have focused on two main areas in 2013, said Paul Ellenbogen, MD, chair of the ACR Board of Chancellors. And the goal is roughly the same: helping providers and referring physicians better understand how to use imaging modalities.

In 2011, the ACR launched its Dose Index Registry (DIR), a national database into which practices can send information about the dose rates they use with patients. Information is sent to the DIR through software installed either in the scanner or PACS. Practices receive periodic reports that allow them to compare their dose rates to other practices, helping them identify rates that are either too high or too low.

As of March 13, Ellenbogen said, more than 650 facilities participate worldwide in the DIR, 338 of which are fully active. The database houses information on 3.5 million exams and 7.5 million scans. As of the RSNA meeting, he said, the numbers are likely twice as big.

To date, the DIR has mainly collected data on CT scans, he said, because 25 percent of the radiation dose most people are exposed to comes from CT. Efforts are underway now to include computed and digital radiography, as well as fluoroscopy.

The ACR has also actively supported the use of clinical decision support tools that help referring physicians identify the most appropriate imaging study for each patient situation.

“We believe that decision support is an important initiative that we need to ensure the imaging we do is appropriate and necessary, getting us away from exams that hav[[{"type":"media","view_mode":"media_crop","fid":"21600","attributes":{"alt":"Paul H. Ellenbogen, MD, FACR","class":"media-image media-image-right","id":"media_crop_5472683042666","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"1502","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Paul H. Ellenbogen, MD, FACR","typeof":"foaf:Image"}}]]e no benefit or value,” Ellenbogen said. “The ACR thinks that, in some ways, radiology benefit management groups have not done a good job and that decision support will be the better way to go.”

There are many clinical decision support products available, including ACR Select, he said. The free, web-based product, like other such products, alerts referring physician when they’ve ordered an inappropriate study. It does not, however, prevent the physician from overriding this red flag. In those cases, many clinical decision support products require the referring physician to include a reason for the override.

“We are working with the government to indicate our support for some sort of clinical decision support,” Ellenbogen said. “We aren’t mandating you use ACR Select, but we are trying to mandate that you use some type of decision support.”

Advocacy and Imaging 3.0

In the face of continued reimbursement cuts and the growing emphasis on primary care, radiology and its practitioners must increase advocacy efforts that highlight the value and importance of imaging services, said Bibb Allen, MD, vice chair of the ACR Board of Chancellors.

“In effect, radiology has a presence problem. The public may not realize we’re physicians, and other physicians perceive that radiologists are underworked and unavailable,” he said. “Hospital administrators often view radiologists as competitors, and policymakers only hear about our reimbursement issues. We must prove our relevance.”

To reach this goal, the ACR launched its Imaging 3.0 initiative. This effort, Bibb said, will help radiologists transition from clinician into imaging consultant for referring providers, show providers how to integrate themselves into more facility-wide activities, and will teach them to more actively include patients in the care process.

[[{"type":"media","view_mode":"media_crop","fid":"15658","attributes":{"alt":"Bibb Allen, MD","class":"media-image media-image-right","id":"media_crop_1424758431088","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"768","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Bibb Allen, MD","typeof":"foaf:Image"}}]]“It will take a cultural transition to encourage radiologists to own all aspects of imaging care - to provide better, not just more care,” he said. “We must deliver every bit of imaging care that is beneficial, necessary, and best and not deliver what isn’t essential.”

Mastering this shift is critical as the healthcare system moves away from fee-for-service toward value-based care. It’s no longer enough, he said, to use radiology’s tools - PACS, RIS, speech recognition, etc. - to maximize productivity. Providers must now think about delivering care in the most efficient ways.

And, as radiologists become more comfortable with this initiative, Bibb said, they must add their voices to the chorus already lobbying the U.S. Congress not to cut reimbursement for the critical services radiology provides.

Academics and education

Concern in recent years over whether radiology was training enough residents has given way to worry over whether there will be enough jobs available for new practitioners, said Kimberly Applegate, MD, MS, vice chair for quality and safety in Emory University School of Medicine’s pediatric imaging division.

“At present, there should be a job for all finishing residents, but it may not be in their preferred geographic area, subspecialty, or practice,” she said. “We should be mindful of managing resident expectations and telling them to be thoughtful. They won’t necessarily be able to stay in the area of the country they want to be in.”

According to statistics from the Association of American Medical Colleges, the greatest job growth in the next five years will be in the South and Southwest regions of the United States. There’s also increased demand for several subspecialties, including interventional radiology, as well as general, musculoskeletal, neurological, and breast imaging.

There are also a variety of opportunities for residents and fellows to learn more about the volume-to-value transition, she said. National meetings, including the ACR’s resident and fellows section, will now offer special programming for these groups. In addition, training web modules will also be available through the ACR’s Radiology Leadership Institute.

It’s during these meetings and modules that residents and fellows will learn how to fulfill the growing demand for metrics that show how providers add value to patient care, Applegate said. Practices and providers will now be required to submit this data to CMS, private payers, and certifying bodies, such as The Joint Commission and the Accreditation Council for Graduate Medical Education. The ACR offers guidance on satisfying these metrics in its Imaging 3.0 toolkit.

“Demand for quality and performance metrics will only continue to increase,” she said. “We must take advantage of the opportunities to coordinate and contribute to the evolution of these metrics.”

Economics and government regulation

From the economics and policy angle, radiologists should focus on their payments and what will happen to them in 2014, said Geraldine McGinty, MD, chair of the ACR’s Commission on Economics.

[[{"type":"media","view_mode":"media_crop","fid":"15598","attributes":{"alt":"Geraldine McGinty, MD","class":"media-image media-image-right","id":"media_crop_1844065909167","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"733","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right; margin: 5px;","title":"Geraldine McGinty, MD","typeof":"foaf:Image"}}]]“We are really moving toward a system that looks like we will be paid like the DRG episode of care rather than by fee-for-service,” McGinty said. “That doesn’t mean fee-for-service is going away, but we should still move to optimize what we do on the institutional-service basis.”

The federal government’s focus on expanding reimbursement for primary care services and the pressure on radiology to further manage utilization and control inappropriate imaging are both likely to make recouping sufficient repayment difficult for providers, she said.

Bundled codes - the fusion of codes for two procedures frequently performed together, such as abdominal and pelvic CT - continue to concern the ACR, she said, because it always results in less payment for the provider. Breast biopsy codes are the latest group to undergo bundling.

Still, the ACR has had trouble getting providers to complain about the cuts.

“If we were getting cut by 50 percent, it would be easier to mobilize our community, but the changes have been multifactorial,” she said. “We’re seeing a chipping away at different aspects of payments, and we’ve accumulated significant cuts to what we do. Still, getting a mobilized response has been challenging.”

In addition, despite ACR efforts, CMS still plans to implement the multiple procedure payment reduction (MPPR) that will give providers full payment for the highest reimbursement procedure but only partial payments for other procedures performed on the same patient on the same day.

The 2014 Final Rule from CMS also calls for separate cost centers for CT and MRI with a potential double-digit payment reduction. It isn’t yet clear when this move will be implemented, however, McGinty said.

Radiation Oncology

Although radiation oncology and diagnostic radiology are different specialties, they frequently face some of the same issues. And, recently, for radiation oncology, that issue has been self-referrals, said Albert Blumberg, MD, ACR president and radiation oncology vice chair in the Greater Baltimore Medical Center. The problem is particularly acute in urology for two procedures: intensity-modulated radiation therapy (IMRT) and image-guided radiation therapy (IGRT).

“Because IMRT and IGRT are so well reimbursed, urologists have realized they have the opportunity - since they control access to the patient - to capture the technical fees for themselves,” Blumberg said. “They’re hiring their own radiation oncologists and are only referring their patients there.”

Recent documentation, he said, revealed that approximately 90 percent of these procedures are self-referred. And, little has been accomplished to stop this problem.

Currently, Maryland is the only state with stringent laws prohibiting self-referrals. Through court action, the state has been able to eliminate instances when they occur. Blumberg recommended radiologists and radiation oncologists reach out to their state societies to express concern about self-referrals and ask that the organization work with the respective legislatures to squelch the practice.

“You might not realize that you have a lot of input in state societies about what happens to you as a physician,” he said. “But, as physicians, we’re all affected by the Board of Physicians, and through input in our state radiological and medical societies, we can have our radiology oncology voices heard."