Radiology is at a decisive juncture. Pending CMS rules could put an end to a great deal of opportunistic imaging.

Cheryl Proval

If radiology wants to be the arbiter of imaging quality, then should it stand ready to protect the quality of all exams, including the mundane but sublime radiograph?

You know radiology is feeling the pinch when you get an e-mail from a reader complaining about x-ray machines in referrers’ offices.

That was my initial thought. Every doctor’s office and urgent care clinic is equipped with at least one of these once-phantasmagoric machines, and I have never heard a radiologist complain about a referrer putting in an x-ray machine. In fact, if all of the studies produced by x-ray machines—the broken pediatric bones, the chiropractic “evidence” of injury, the cough-induced chest radiographs—were suddenly and without warning to land overnight on the radiologist’s desk, you could hear the howls from here to Alaska. But before I hit delete, I decided to consider his position. After all, the radiograph is where it all began. And, besides, a chest radiologist once told me that the chest radiograph is one of radiology’s most challenging examinations. Is there a reason radiologists should not care about the quality of the ubiquitous x-ray?

Radiology is at a decisive juncture. After years of lobbying by the American College of Radiology (ACR) and the National Coalition for Quality Diagnostic Imaging Services (NCQDIS), the Centers for Medicare and Medicaid Services (CMS) appears to be getting serious about tightening the noose on self-referral. In fact, the agency’s proposed 2008 Medicare Physician Fee Schedule is a virtual lockdown on many known Stark loopholes and, if passed as proposed, could put the laws in place to end a great deal of opportunistic imaging. In a January 2005 letter to MedPAC, the ACR estimated that the government could save $2 billion to $6 billion over 10 years, just by implementing quality standards for equipment and staff and imposing standards for those who interpret images. The Wall Street Journal quoted a recent McKinsey & Co study that pegged physician annual profit from endeavors to which they self-refer—including specialty hospitals, ambulatory surgical centers, imaging centers, and other outpatient diagnostic sites—at $8 billion.

Clearly, the intent of CMS is to recover savings by eliminating unnecessary imaging. But the position of the ACR and the NCQDIS has been that imaging is best performed by imagers, and, if that is the case, imaging needs to perform its duties as the imaging police, whether the study is a $5 hand radiograph or a PET scan. And if radiology is to join the campaign for quality imaging, the common and lowly paid radiograph deserves the same attention as higher-paying cross-sectional imaging. But how should radiology approach the subject of the quality x-ray, a study that is at once the most mundane and sublime of all? Medicare Part B paid for 17,157,819 x-ray studies performed in physician’s offices in 2003, and only 6,331,725 were for claims paid to radiologists, an anemic 37%.

Which brings us back to the e-mail from the radiologist from Michigan. He wrote the following: “Look into states where ‘limited x-ray licenses’ are made available to non-trained office staff. What is happening [in my state] is that outpatient and small offices are taking their front-desk and secretarial staff and having them ‘shoot’ x-rays. Then they send them to me for interpretation. The equipment is ancient, and the positioning is terrible. As a radiologist, I can attest to the awful quality, with many studies ‘severely limited’ or ‘non-diagnostic.’ But the practice is booming, it pays the same as high quality studies…and it’s picking up speed.”

The author of the e-mail, Richard M. Chesbrough, MD, left academic practice several years ago to labor in the fields of private practice and witnesses first-hand the product of this system. “In Michigan, you can take a front desk secretary and send her to a weekend course, and, in Michigan, she can have a limited x-ray license,” he related. “Then, of course, they may have old equipment and old processors on top of poor positioning.”

Even if the technology and processors are first rate, the images are frequently nondiagnostic. Imagine a wedding photographer who took an album full of exquisitely detailed photographs in which the couples’ heads were cut off, Chesbrough posited. “Would you pay the full $3,000 for that?” he asked. “That’s what’s happening today. In a significant proportion of these studies, the top of the lungs are cut off, half of the chest is off the film, they’re too light, too dark, the positioning is not standard: for a knee or elbow, you need an AP and a lateral, and they may send you two oblique. Should the insurance companies pay full price for that?

“If the ACR wants to be relevant in today’s world, if nothing, it has to stand up for quality in imaging,” Chesbrough continued. “There has to be decent quality equipment, technologists have to have some level of documented training that meets the standards, and then you can talk about who reads it.”

I could not agree more.

Cheryl Proval is business editor for Axis Imaging News. For more information, contact