Interventional radiologists are losing turf, but they should still be paid for the procedures they perform

Never has the French classical author François de la Rochefoucauld’s observation, “The only thing constant in life is change,” seemed more apropos than it does when we look at today’s radiology practice. Changes in reimbursement, technology, demographics, utilization, competition, service expectations, and legislative oversight add up to an industry hobbled by indecision. Which problem do we take on next?

Here, I am not going to try to tackle such issues as morphing into a multispecialty group; fighting CMS on its proposed cuts in imaging reimbursement; backing efforts to postpone, and reduce, the DRA; finding more staff; and defending ourselves in turf battles. I would like, however, to address one small trend that is just now starting to grow a life of its own—and that is the issue of interventional radiology (IR) exclusivity and call pay.

In the most recent past, many IR physicians had a relatively good life, providing CAQ’d services that ran the gamut from complex (renal stenting and peripheral angioplasty) to the simple (PICC lines), enjoying a vocation that was fulfilling if not even a little self-actualizing. Hospitals, too, were happy with the level of service and coverage they received from the typical IR doc. Everything was in equilibrium.

Then, along came the interlopers…first the cardiologists, and then the vascular surgeons. Licking their chops at the potential improvement in patient care (real translation: their income), they rationalized that since they already were cathing the heart, why not go ahead and do the renals; and then the peripherals; and so on. And, oh, by the way, carotid stenting just seems a natural for someone who knows how to cath/stent the heart, right? And which hospital administrator is going to step in between the facility’s most profitable referrers (cardiologists) and the ungrateful radiology group that does not recognize the value of the patients that the hospital sends it. So, turf was lost.

Next, vascular surgery programs started teaching endovascular procedures—even though a need had not been proven. Newly trained and hospital-recruited endovascular surgeons simply had to have access to the radiology cath lab to use their newly found skills. So, of course, no hospital administrator would even consider supporting a move to deny privileges to these newly recruited subspecialists—and more turf was lost.

Some radiology groups were able to work out sharing and call coverage arrangements with their friendly neighborhood cardiologists and endovascular surgeons—sharing both the good (highly compensated day cases) and the bad (poorly reimbursed simple cases). But for the majority of groups, this is not the case. Most IR groups have been cherry-picked to the extent that their IR exclusivity is for PICCs, Paras, and Thoras at 3 am. Those same cardiologists and endovascular surgeons, who can do the difficult cases from 8 am to 5 pm, cannot or will not do the simple, poorly reimbursed cases in the middle of the night. And your local friendly hospital administrator will remind you that your contract calls for you to provide the service. And woe betide the radiology group that fails to respond when called.

OK, so what’s a self-respecting IR section to do? Quit the hospital? Leave the group? Lie down and take it? All viable options, of course, but let me propose a better one—get paid for it (night coverage). The newest nascent trend is to start getting paid for IR call coverage. Since no other subspecialty is willing to provide the call coverage, then radiologists need to demand to get paid for what others will not provide. Hospitals pay for all kinds of specialists to provide emergency department coverage. Why not IR physicians? Oh, you might hear the argument that you have to provide the coverage because it is part of your contract, or the veiled threat that you should look at all the benefits you get from the captive patients that the hospital sends your way (which sounds like a pretty clear case of a request for a kickback to me). Do not buy it. Go for getting paid for what you do.

As they say, however, the devil is in the details. Once you get the hospital to agree that they must pay you for providing a valuable service, you now have to determine how much you should be paid. But, since this is something new, there is no established market value to which hospital administrators can turn. So, the not-for-profits will tell you that they need to do a market survey to determine the fair market value (FMV) of what to pay you. But, of course, when they try to do the survey, so few data points are out there that they can not come up with a FMV. So, by default, they can not pay you for IR call coverage because they cannot determine the value of that service. Clearly, this is a catch-22 type of argument that even Yossarian would appreciate.

You know, 20 years ago, it was IR-trained radiologists who performed cardiac caths. Now, the cardiologists do them all. Five years ago, very few vascular surgery programs were teaching their fellows endovascular techniques. Now they are. There were no quality or turf problems when the radiologist did the work. In an ideal world, we would return to yesteryear—but we cannot. Times change, life changes. It is now time for all IR radiologists to get paid for IR call.

Fred Gaschen, MBA, is executive vice president of Radiological Associates of Sacramento and a member of  Axis Imaging News’ Editorial Advisory Board.