Keeping imaging procedures in-house: why it makes sense

Recent statements by the American College of Radiology have served to draw a line in the sand between radiologists and other physicians who perform imaging procedures in their offices and clinics.

These statements have claimed that nonradiologists are responsible for a proliferation in imaging procedures; that many of these procedures are inappropriate and unnecessary; that cardiologists, Ob/Gyns, orthopedists and other nonradiologists who provide imaging services are serving their own economic interests; and that the images produced by nonradiologists are of lower quality than images done by radiologists.

Most troubling is ACR’s contention that financial motives are driving decisions by cardiologists and others to provide these services outside of a hospital or an imaging facility. Undoubtedly financial concerns are a top worry of James Borgstede, MD, the chair of the ACR board of chancellors, who said his group is “concerned about a loss of turf.”

The American College of Radiology contends that only people who do four or five imaging techniques should be doing these procedures. In other words, imaging procedures are best when performed by radiologists, according to the ACR. The group is taking its argument to payers in several states, arguing that reimbursements should only go to radiologists.

Gone on record

The American College of Cardiology, together with 21 other professional organizations, has gone on record opposing the ACR’s position. On February 10, the Coalition for Patient-Centered Imaging (CPCI) provided comments to the Subcommittee on Health Committee on Ways and Means, outlining the advantages of office-based imaging services for patients. This was in anticipation of the Medicare Payment Advisory Commission’s report to Congress in March, expected to include recommendations related to imaging services.

The American Medical Association’s House of Delegates has affirmed that it will work with state medical societies and specialty societies to oppose any legislation or regulations that would seek to repeal the in-office ancillary exception to physician self-referral laws, including those that apply to imaging services.

Carl J. Pepine

My belief is that these tests are best done in the setting where a physician understands the disease process, and the technology, and can appropriately interpret and utilize the test findings. Patients are better served when they can have their imaging procedures done within their physician’s office, rather than scheduling another appointment at a different location with someone without the ability to customize the test and integrate the results for the patient’s clinical findings. Organized cardiology has clear criteria governing the credentials and training required for performing imaging procedures and has published evidence-based guidelines outlining the appropriate use of this technology.

While I have spent 30 years in the cardiac catheterization lab, currently I don’t personally perform any imaging procedures. However, I have the highest regard for those performed and interpreted by cardiovascular specialists with a thoughtful knowledge of the patient. This is analogous to my regard for the MRIs of my shoulders, knees and neck that were interpreted by my orthopedic surgeon or my neurosurgeon, those who were best able to interpret and integrate the findings with my symptoms.

The notion that CV imaging procedures are increasing is true. It is also true that the number of patients with cardiovascular disease is increasing. Some of this increase relates to the aging of our population since increased age is a prime factor for the development of cardiovascular disease, along with epidemics of other risk factor conditions, such as obesity, diabetes and metabolic syndrome. But death rates for people with cardiovascular disease also continue to decline, in part, because we have been successful in our approach to patients with established disease. The net result of the foregoing is an increased prevalence of cardiovascular disease. This population with cardiovascular disease also has a number of conditions like heart failure and/or atrial fibrillation. This all means that there are increasing numbers of patients who could benefit from evaluation by imaging procedures.

Enhance disease management

Because of this, increasing numbers of patients are seeking improved quality of life and are also in need of secondary prevention measures. The imaging procedures that are offered within the offices of cardiovascular specialists, when properly integrated into the care of these patients, provide a unique opportunity to enhance disease management.

The number of patients with cardiovascular disease is increasing by the millions, and we should anticipate that the number of imaging procedures will go up as a result. It should come as no surprise that many of these procedures have now moved into the offices of physicians and away from hospitals. This is where these patients are receiving care. Furthermore, incentives were placed in Medicare reimbursements years ago to keep patients away from the hospital because of the perception that the rising costs of care for this enlarging group of patients would be better contained.

Our profession has seen the development of new technology for cardiac imaging, including multislice CT coronary angiography and MRI. We have CT that is 64 slices, giving spectacular pictures. New MRI gives great images and has the ability to do a lot of other things like late enhancement, plaque imaging, etc. New indications for existing technology are helping to increase the demand for these procedures.

I believe that a physician who is properly trained and credentialed should have the option of doing imaging procedures. The people who are best suited are the physicians who provide the majority of their patient’s subspeciality care.

None of these noninvasive tests are perfect. They are best utilized when they can be interpreted and integrated with the patient’s other findings, like the patient’s history, physical and other test results. The person optimally suited to do that is the person with the best training who is closest to the patient.

Qualified clinicians who are appropriately trained and credentialed to perform noninvasive testing in their subspeciality area– whether they are cardiologists, orthopedic surgeons, urologists or obstetricians — are the ones to interpret these procedures.

I consider CV imaging at the point of care, whether in office, the emergency department or hospital, interpreted by a cardiovascular specialist, to be a vital part of the diagnosis and treatment regimen for our patients.