Radiology: What’s Coming in 2012

Throughout 2011, most chatter in radiology centered around how healthcare reform would change the industry or how practitioners should manage and use newer modalities. In a look ahead at the next 12 months, many industry luminaries anticipate the same concerns will linger on the horizon even as new ones appear.

Some of the upcoming challenges touch the individual radiologist’s pocketbook; others affect practice. Regardless of the specifics, radiologists will do well to revamp how they view themselves as part of the healthcare system, said James Thrall, MD, Massachusetts General Hospital (MGH) radiologist-in-chief and former American College of Radiology president.

“Radiologists in general must become more imbedded with the medical staff,” Thrall said. “Not only must they respond to the increase in demand for medical imaging, but they must make themselves visible so they can be seen by their peer groups as active members within their facilities.”

Doing so is critical, he said, as the fallout from this year’s challenges is still unclear.

Financial Implications

Radiology’s biggest concern for 2012 is a holdover from last year - bundled payments and reduced reimbursement. Under the proposed accountable care model, radiology reimbursements would be wrapped up in a lump-sum amount that includes facility, physician, and technical payments.

It’s the ambiguity of these packaged payment’s impact that make them the industry’s greatest challenge this year, said, Leonard Berlin, MD, former chair of the professionalism committee with the Radiological Society of North America (RSNA).

“There’s no question that there’s been a definite move to decrease reimbursement for radiology at the Centers for Medicare and Medicaid Services,” Berlin said. “All the projections for radiology reimbursement have it falling, meaning that practitioners, for 2012 and beyond, will need to find a way to maintain and manage a workload that is sometimes heavier for less money.”

The ACR is also concerned about reduced payments. Currently, the organization’s No. 1 priority is working with Congress to extend the temporary fix to Medicare’s sustainable growth rate, the formula used to control healthcare spending. The stop-gap measure, enacted in December 2011, averted a 27 percent physician payment reduction, and the ACR would like to extend the fix permanently.

“We’re also watching carefully to see if we can stop the Centers for Medicare and Medicaid Services from making any multiple procedure payment reductions,” said Cindy Moran, ACR’s government relations assistant executive director, referring to cuts in payment when two or more codes are performed to the same patient by the same physician during a single session. “But we are also assuming, with this being an election year, that we might be faced with a lame duck Congress.”

Changes could also be coming to codes that routinely appear together, said Maurine Spillman-Dennis, ACR’s senior director of health policy. CMS is analyzing whether procedure codes that are often linked 50 percent, 75 percent, and 90 percent of the time can be bundled, reducing overall reimbursement for those services.

“We are involved in an evolution toward a new payment model. The bottom line is that healthcare is turning away from the fee-for-service system and moving toward capitated services,” Spillman-Dennis said. “It will be a challenge for radiology to fight under this new care delivery model and make sure its practitioners are paid for services provided.”

Impact on Practice

As an industry, radiology is fully in the midst of the cloud-computing era, Thrall said. This activity fueled the growth of both telemammography and teleradiology in 2011. Practitioners have polar opposite feelings about these strategies, so what will happen with them remains unclear.

“With telemammography, people have such an emotional reaction to breast cancer, and it’s hard for a general radiologist to include breast imaging in their practice. So, it’s too soon to make a call of what we’ll see with this trend,” he said. “When teleradiology started as a concept, it was never intended to be the final read that it’s often become. It will be interesting to see if a mini-trend develops with in-house radiologists reclaiming those responsibilities.”

Private practice and hospital-based radiologists must take steps against the expansion of teleradiology, Berlin said. If not, the outcome is clear: more radiologists will lose their jobs, and those who don’t will work at reduced income.

In addition, industry leaders also predict 2012 will bring an intensified focus on the unknown, long-term effects of CT radiation. CT scan use is undoubtedly on the rise, according to data from the U.S. Centers for Disease Control and Prevention, but the fact remains, Berlin said, that practitioners do not yet know the tipping point at which dose levels raise cancer risk. Working without this knowledge could put radiologists in a vulnerable position if patients develop negative outcomes.

To educate radiologists about the potential downside to CT scans, as well as the importance of informed consent, RSNA plans to hold a mock malpractice trial in November that examines the hypothetical case of a woman who develops breast cancer eight years after having multiple CT scans for a pulmonary embolism. A mock jury will also deliver a verdict after deliberation, and practitioners will be able to observe the process.

In this same vein, Berlin postulated the industry would see a drop in malpractice lawsuits. The reason is largely economic - it costs, on average, between $50,000 and $120,000 to prosecute a claim. However, he cautioned that the lawsuits that do proceed are more likely to have merit.

Perhaps one of the biggest practice conversations to watch throughout the year will focus on the Mammography Quality Standards Act (MQSA). Under this legislation, facilities must send mammography reports in lay-letter form directly to the patient. The goal is to inform patients about their screening results as quickly as possible. In an attempt to give patients further information, there is talk of also sending patients a copy of the X-rays. But there is a problem with this strategy, Berlin said.

“A lot of patients don’t understand what they’re seeing in these letters,” he said. “Radiologists don’t have the time to address any concerns, so referring physicians get caught up in making complicated explanations they’re often not prepared for.”

Preparing for the Challenges

Many of the trials facing radiology are coming from outside the industry, prompting radiologists to strengthen themselves from within the specialty, Thrall said. In fact, before stepping down from his ACR leadership position, the MGH radiology chief called for management and leadership development programs to help practitioners navigate practice and policy changes. The skills will help radiologists bolster their interactions with referring physicians and augment potential consultative roles.

“Overall, in 2012," he said, "the industry must concentrate on highlighting the vital role it plays in patient care."