Is it Time for Primary Care Radiology?

The following post was written by guest blogger Greg Mogel, MD, chief of radiology, Central Valley Service Area, Kaiser Permanente.

The subspecialization of radiology continues apace and for all the lamentations of loss of our general skills, I’ve never forgotten a bit of wisdom shared with me by an early subspecialist (though the word was unknown at the time, she was just “really good” at OB ultrasound): The radiologist interpreting the study should know at least as much about how to read it as the doc that ordered it.

While that seems obvious, for a few decades now the only indisputable measure of report ‘value’ has been whether it was reimbursable. (Sadly little talk about what clinicians need in a report; mostly what must be included to avoid medicare ‘fraud’). 24/7 subspecialization is becoming the norm although it is unclear whether it is marketing or medicine. In fact, a ‘chest’ radiologist may well thrill a pulmonologist but mystify a nurse practitioner.

I’d like to propose that a focus on the primary care provider be considered a specialty. Shared decision-making to help choose the proper study and generating ‘knowledge’ from the ‘information’ in a previously read dense report is an honest living, even if it’s somewhat RVU-poor.

Radiology might find itself more sustainable as a career if we try to swim in the ‘Blue Ocean’ of bringing value to the overworked primary care provider than the ‘Red ocean’ of fighting over smaller and smaller pieces of anatomic real-estate.

Let’s train for it. It’s good work.

Tweet the author @gregmogel

The Path to Breast Tomosynthesis Coverage

Recently we’ve heard that ACR members have been contacted by industry representatives requesting them to urge the College to support Medicare coverage of breast tomosynthesis. A detailed update of what’s been happening at the College on this issue is on the ACR website.

As radiologists, we are committed to ensuring that our patients have access to life-saving screening for breast cancer, and yet we are also tasked with critically evaluating emerging technology so we can add new modalities and techniques in a responsible way. The ability of tomosynthesis to reduce recall rates and improve cancer detection carries great promise, but further studies are needed to assess its relationship to long-term clinical outcomes, including reduced mortality.

With the spotlight more than ever before on value, it will also be important to learn which subgroups of women might benefit most from these exams (by age, breast density, frequency of examination, etc.).

That said, if we want to understand the effect that tomosynthesis has on outcomes and who will benefit most, the technology must be widely available. We know that availability will be greatly impacted by whether or not the service is reimbursed, so we are urging CMS to cover Medicare beneficiaries for tomosynthesis when it is performed.

We’ve already worked within the payment policy process to develop CPT codes for tomosynthesis and we’ll hear Medicare’s decision on whether they will cover it — and if so at what rate — when the Final Medicare Rule for 2015 is published in or around late October.

Geraldine B. McGinty, MD, MBA, FACR

“Dense” Legislation

While we tend to focus on the Washington D.C. legislative scene, many significant initiatives are generated at the state level. In the past few years, popular legislation mandating notification of high breast density in mammography reports has been passed in many states. The impetus is the premise that patients with greater breast density are at higher risk for breast cancer and/or mammography is not as effective in this population. Opponents argue that:

  1. Such legislation is often an unfunded mandate;
  2. The mandate puts the referring physician and patient in a difficult position by suggesting additional and often expensive ancillary studies;
  3. It is inappropriate for governments to arbitrarily regulate how doctors practice medicine.

To date, 19 states have enacted laws that require breast density notification or breast density disclosure. They include: Alabama, Arizona, California, Connecticut, Hawaii, Maryland, Massachusetts, Minnesota, Missouri, North Carolina, New Jersey, Nevada, New York, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas and Virginia. Reviewing the implementations in different states is instructive in illustrating how various jurisdictions prioritize similar issues.

In some states, the legislation includes language which must be inserted into mammography reports. Working with the state medical association, the Arizona Radiological Society was able to modify onerous language that was originally proposed the bill was signed into law. In Utah, the notification is optional. Illinois legislation mandates that insurance carriers reimburse for subsequent ultrasound screening when recommended by a physician. In Maine, legislation was avoided when the physician community voluntarily agreed to include breast density language in mammography reports. Indiana legislation mandates the state health plan to provide coverage for additional exams for women greater than 40 years old who have high breast density. Missouri was the latest state to pass legislation with Governor Jay Nixon signing the bill on July 2.

The momentum in the states has set the stage for possible “dense” federal legislation. Whether you are for or against the concept of “dense” notification, the take home message is that radiologists need to be active at all levels of advocacy: local, state and federal.

Howard B. Fleishon, MD, MMM, FACR