One Size Does Not Fit Allone size does not fit all

My practice is located on Long Island, New York, and is a largely outpatient multi-specialty and multi-site group, in which 35 of the 65 doctors are radiologists. There, my own role is to exclusively interpret breast imaging.

The environment is competitive because of several other imaging centers within a couple of miles of my office. Our radiologists worry about declining reimbursement as well as how to compete when the large hospital system in our neighborhood is employing many of our referring physicians.

The chair of our Committee on General, Small, and Rural Practices, Robert S. Pyatt, MD, FACR, couldn't be in a more different practice environment. Bob works in a 10-person group that covers two hospitals for a population of about 170,000 people over a 1,200 square mile area in rural Pennsylvania. Besides the concerns we all share, his group worries about how to replace retiring radiologists.

We also have many committee participants who come from academia. David A. Rosman, MD, chair of the ACR's Integrated Care Network, trained at Massachusetts General Hospital in Boston and has stayed on as attending physician there. The need to balance education and research commitments with clinical work are concerns for him and his colleagues.

I offer these profiles to illustrate the broad range of experiences that contribute to the voice of economics at the ACR. As we build our advocacy strategy, we are always conscious of the fact that policies that have a positive impact on one sector of our imaging community may be perceived differently by another.

Comparing Consequences

One policy which affected various radiology practices different was the CMS imposition of a professional component Multiple Procedure Payment Reduction (MPPR), which has a lesser influence on larger groups where radiologists are often practicing within their subspecialty. For example, a neck and a chest CT might generally be read in a larger group by two different physicians rather than in a small group where one physician may read both. The extension of the MPPR across members of the same group, as threatened in the 2012 Medicare Physician Fee Schedule, may have seemed much more onerous to the larger than to the smaller groups, who may have felt they had already absorbed the blow. In principle, the ACR believes that there is no meaningful duplication of professional component work when two services are performed together and will continue to oppose any CMS policy that maintains this reduction.

The world of hospital billing is complex. I am indebted to our excellent staff and to the service of James V. Rawson, MD, FACR, who has chaired the ACR Committee on Hospital Outpatient Prospective Payment System/Ambulatory Payment Classifications (HOPPS/APC) for many years, for helping me to understand its nuances. Last year, the committee succeeded in making sure that the new combined CT abdomen and pelvis codes had a place in the HOPPS fee schedule, rather than having the combined code be recognized by the old single unit APC codes at a much lower rate. Why should radiologists cheer for increased reimbursement to hospitals? Our hospital-based colleagues are advantaged by their services being appropriately reimbursed in their dealings with hospital administration. Those of us in the community who are beginning to deal with episodic and bundled payments can learn much from the experience of the HOPPS world, both good and bad, so the commission's efforts in this area are beneficial to everyone.

Teleradiology is a disruptive technology that has impacted our members in many different ways. On the positive side, coverage at night can be provided to afford a better quality of life to radiologists. However, the freedom to read cases remotely can also put the job of another at risk. The ability to obtain a second opinion from an expert is a positive factor, but also permits predatory vendors to offer interpretations at knock-down prices that ignore the importance of the consultation between physicians. Teleradiology, both the good and the bad, is now a part of our landscape and the College has made a strategic decision to devote a task force to this topic, which is chaired by our economics commission Vice Chair Ezequiel Silva III, MD.

Planning for the future is a high priority for the economics commission, especially during this time of rapid change. The transition to a value-based, rather than volume-based, system seems inevitable for at least a portion of our services. But jumping into the gap between those payment models is understandably scary for those of us who have lived with a fee-for-service model for so long. How this looks on Long Island may be very different from how it looks in rural Pennsylvania or on Fruit Street in Boston. Learning from those practices that are further along the process of building integrated care models, and understanding the challenges presented by rural and underserved populations, can only enhance the toolkit that we plan to offer our members as they navigate this new world.

The "ideal imaging practice" is a concept that we are building with the clear recognition that one size does not fit all. The need to develop a more patient-centered system will be non-negotiable and I would challenge you all to think about what this will mean for your own practice. Preserving access to care is critical in certain rural and poor urban areas. Defining quality is important everywhere. Our economics efforts will center on understanding the key differentiators of quality and advocating for payment models that support them.

I'd love to hear your feedback. Please e-mail me at This email address is being protected from spambots. You need JavaScript enabled to view it. with your comments.

Geraldine McGintyBy Geraldine B. McGinty, MD, MBA, Chair

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