WASHINGTON -- For years, radiologists have been involved in some of the ugliest turf battles in medicine, but policy experts and advocates at the American College of Radiology's (ACR) annual meeting here said to gain anything legislatively they must stop fighting other physicians.
"You cannot win things alone," said David Rosman, MD, MBA, of Massachusetts General Hospital.
That is the lesson he, other radiologists, and others learned after decades of power struggles with other specialists -- cardiologists and orthopedists, chief among them.
But can these groups work together?
Rosman plugged membership in the American Medical Association as one of radiologists' key vehicles for gaining leverage in payment and policy debates.
Fighting and Losing
Radiologists have lots of experience wrestling other specialties for ownership of traditional radiology services, explained Joshua Cooper, senior director of government relations and economic policy for the ACR.
It started with x-ray machines. Then in the early 1990s, non-radiologists began buying CT and MR scanners. These doctors -- mainly cardiologists, gastroenterologists, and orthopedic surgeons -- realized they could get paid for the technical aspects of imaging, and then hand off the results to radiologists for interpretation, explained Cooper.
Radiologists were appalled. They argued that a single doctor referring a patient back to him or herself for a test was no different than a single doctor prescribing a medication to patients and then selling them the same medication -- which is illegal.
Other specialists countered that self-referrals are more convenient for patients and accelerate the time to diagnosis, noted The Washington Post in 2009 (the last time the ACR came close to winning the dispute, according to Cooper).
The sharp disagreement over self-referrals touched off what Cooper called "one of the fiercest inter-specialty debates in medicine."
Meetings of the American Medical Association got "nasty" where harsh insults and name-calling became the norm.
In 1992, Congress enacted the Ethics in Patient Referrals Act, better known as the "Stark Law" after its chief sponsor, then-congressman Fortney "Pete" Stark (D-Calif.).
The law barred doctors from referring patients to anywhere they had a financial interest (e.g. preventing a referral to use a physicians' own scanning equipment). However, the law had an escape clause, the In-office Ancillary Service Exemption (IOASE) which, as the name suggests, gives physicians the right to self-refer if the imaging equipment they own is located in that office.
The ACR lobbied Congress to get rid of the IOASE loophole. The College tried to argue that self-referrals were the primary reason for skyrocketing costs but other responded that repealing the IOASE would disrupt the doctor-patient relationship and limit patient access.
Congress's response was to cut payments for the technical portion of advanced imaging services, said Cooper, making no one happy.
Other efforts to protect radiologists' scope of practice have been marginally successful, he said. For example, the Affordable Care Act includes a requirement that physicians must inform their patients of any other imaging services within a 30-mile radius before performing a test.
But repeated efforts to get the IOASE repealed ended in failure.
"We have not closed the loophole, but we have nibbled around it," said Cooper, calling the experience one of the most frustrating in his 19 years of working with the ACR.
New Tack
What he learned is that Congress is completely uninterested in resolving "squabbles" between specialties.
So the ACR took a new approach, turning away from turf wars and focusing on collaboration, which Cooper said has been a much more successful strategy.
So far the ACR has helped pass legislation:
- Requiring accreditation for all advanced medical imaging facilities reimbursed by Medicare
- Mandating that referring physicians review appropriate use criteria (AUS) before ordering scans involving advanced medical equipment using clinical decision support
- Averting cuts from Multiple Procedure Payment Reductions (MPPR)
In the case of the MPPR cuts, the ACR gathered support from other specialists, after the Centers for Medicare and Medicaid Services hinted other specialties could be targeted next -- which the College was quick to spotlight.
AMA Is Key
Rosman, for his part, agreed with the ACR's new philosophy on collaboration.
One of the most effective ways for radiologists to collaborate is to make their voices heard at American Medical Association meetings. Rosman spent much of his presentation trying to persuade ACR members -- especially those who are also members of the Society of Interventional Radiology (SIR) -- to join the AMA.
In the AMA's House of Delegates, physicians earn one seat for every 1,000 members of their respective societies, he explained. If every ACR member were also an AMA member, Rosman noted, there would be 38 radiologists in the House of Delegates.
As it stands, though, just five of the 530 delegates are ACR members and only one is a SIR member, Rosman said. SIR is about to lose that seat because it is 40 members short of the membership threshold.
And without a seat in the House of Delegates, organizations can't present codes before the RVS Update Committee (RUC), the group responsible for determining how much to reimburse specific procedures. Thus, SIR may soon be shut out of the RUC.