Col. Allen Taylor, MD
Col. Allen Taylor, MD

Medicine should never be about the economics, but money does matter. And because it matters, it can create tension by aggravating competition and entitlement. Specialists in medical imaging were already feeling a pinch before passage of the Deficit Reduction Act of 2005 (DRA), which lowered reimbursement for imaging exams at certain facilities. Subsequently, the monetary reward for interpreting medical images is currently low.

However, many medical professionals expect this to change. “I think that there is very little disagreement that these technologies will play an increasingly important role in clinical care, and compensation is just awaiting more refined data and an evolution of thinking on the part of those at CMS [Centers for Medicare and Medicaid Services],” said Geoffrey Rubin, MD, professor of radiology and chief of cardiovascular imaging in the Department of Radiology at Stanford University School of Medicine, Stanford, Calif, and chair of the Cardiovascular Imaging Committee of the American College of Radiology (ACR).

While the battle for fair reimbursement is bringing cardiologists and radiologists together on a national level, locally they may have a hard time sharing resources, reads, and reimbursement. “It’s hard to say this is your half of the scanner and this is my half,” said Col. Allen Taylor, MD, chief of cardiology service at Walter Reed Army Medical Center in Washington, DC.

Yet, the two groups are finding ways to work together. Each solution is customized to the needs of the particular institution: some work out even splits; others develop more fractional plans. “It can clearly work out, but there has to be a win-win. What people consider a win can differ, but when the approach is win-lose, the situation can be contentious,” said Taylor.

How to Share a Machine

Radiologists and cardiologists are forced to share CT and MR machines because of their high costs. “Ultrasound and even nuclear cameras are not that expensive and can be owned by both groups. But CT and MRI scanners cost $1.2 million to $2.5 million, and thus the expense is a major issue,” said John A. Rumberger, PhD, MD, FACC, director of cardiac imaging at the Princeton Longevity Center in Princeton, NJ.

When a hospital approaches a purchase that will be shared, ideally, all groups will participate in the process. “The hospital might go to radiology and cardiology and ask them what equipment they want. In that circumstance, you would hope there is collaboration and agreement,” said Rubin.

Influencing factors will include budget and experience with a vendor as well as that company’s reputation and reliability and the product’s flexibility and performance. “I don’t think there is a set of technology that cardiologists like and then another set radiologists like. Technology-wise, there are good choices everywhere you turn,” Taylor said.

Taylor does recommend, however, sticking with a particular vendor if their equipment is pervasive in the facility. “If radiology has brand X scanners throughout the hospital, going to brand Y is a needless change since everyone will have to learn a new system,” said Taylor.

Once the equipment is purchased, the rest of the details often remain to be worked out. “It takes time to prepare the room. Usually, there is some construction. My experience is that details, such as who uses the scanner and when, come at the very end,” said Rubin.

These details include services and schedules. At the Stanford University School of Medicine, cardiac volume is currently low enough that scheduling does not need to be an issue. “Heads, spines, and joints make up about 80% of the work on an MR scanner with the remainder divided between breast and general body imaging. Cardiac imaging has maybe two or three cases a day,” said Rubin.

Even in such instances, however, details such as on-call hours still need to be worked out. “Do you offer services in the middle of the night?” asked Rumberger. If so, who handles these calls?

Often, these decisions will be impacted by the individual center’s demographics. “I think it really depends on the types of patients you see and the alternatives you have to offer. The machines can be underused or overused. What is the right number for throughput?” asked Taylor. He suggests, for instance, that a big believer in calcium scanning could keep a scanner busy all day, whereas alternative exams for symptoms such as atypical chest pain may be preferred over newer technology. “You don’t want to say you have to do 20 scans a day and find yourself suddenly performing inappropriate scans to hit that volume,” said Taylor.

How to Share a Read

Of course, the big issue isn’t who gets to use the machine so much as who gets to read the image (particularly since a technologist actually captures the images). Naturally, each discipline feels they are uniquely equipped for this task. Cardiologists bring an understanding of the heart’s functions and the clinical context; radiologists bring technical knowledge and imaging experience. Both tend to have a good grasp of anatomy, and both continue to successfully complete readings routinely.

In some centers, one or the other group may not be interested in interpreting cardiac images, and in these instances, arrangements are easily worked out. In other centers, both groups have a strong interest in the technology and want to participate in cardiac reads. In these cases, the groups will have to come to an agreement regarding how reads are completed. Sometimes, the process can be contentious, but they are united in their ultimate goal of delivering high-quality patient care.

Many facilities develop shared arrangements. At the Stanford University School of Medicine, the radiologists and cardiologists read the cardiac MR images together. “We interpret jointly with the cardiologist and radiologist reading together and forming a consensus opinion,” said Rubin. At the Walter Reed Army Medical Center, the two groups alternate. “The reading says, ‘Read in collaboration with radiology or cardiology’ but is usually read by one service only. We flip back and forth. One person reads one scan, and the next reads another, so it is evenly split down the middle,” said Taylor.

Other institutions may divide the reads into two: the heart and the rest. Incidental findings—as “the rest” is known—fall under the purview of the radiologist and are a point of disagreement between the two disciplines. “There is controversy divided along specialty lines in terms of whether one needs to focus on the interpretation of the structures outside of the heart—the lungs, chest walls, and other structures in the mediastinum,” Rubin said.

Radiologists hold it as a basic tenet that an entire film should be read so that findings that may have gone unnoticed for years, such as a tumor in the lung, can be caught early. The problem cardiologists have with this theory in practice is that they believe the potential for false positives is too high and negative outcomes too risky.

“The net health benefit of looking for [incidental findings] has not been the subject of systematic study,” Taylor said. He suggests that while one may assume it is the standard of care, if you sit down and look at the data, you might argue in the end that asymptomatic patients are not helped by looking for alternate findings in non-contrast CT. Similarly, symptomatic patients may benefit from a consideration of relevant conditions—”excluding aortic dissection and pulmonary embolism in patients with chest pain, for instance,” said Taylor—but perhaps not as much from a search for “little bits of lung nodules.”

“People who say we shouldn’t look for anything or everything are probably wrong. The truth likely lies in the middle, and that central core of agreement has not yet been decided upon,” said Taylor, attributing the disagreements to the differences in culture between cardiology and radiology.

How to Share Reimbursement

Complicating the matter of shared reads is the issue of reimbursement. “You really cannot charge for two doctors to read the same scan and provide the same interpretation, but fee splitting is illegal,” said Rumberger. Groups can get around this by dividing the scans into separate portions (ie, cardiac and incidental findings), but the “global professional fee needs to have one name on it,” said Rumberger.

Another option is to share costs and profits, which is usually directed by hospital leadership, according to Taylor. But the issue then becomes efficiency and earning. If a physician is going to pay half of the costs and receive half of the profits, they will likely not want to do 100% of the work, so the division of labor will have to be equitable.

Some institutions may pay an additional interpretation fee to one of the physicians performing the read; the other then claims the primary billing. Rubin suggests that motivation for this scenario is increased business elsewhere in the hospital. “If the activity itself results in an increase in patients coming into the cath lab and an increase in admissions of patients requiring coronary revascularization, then it is to the hospital’s advantage to see the diagnostic service flourish,” said Rubin.

The arrangement, however, will often differ from one facility to the next. “What’s right for one center may not be right for another, but each needs to look for that win-win situation,” said Taylor.

The cause has been taken up at a higher level. “The ACR and ACC [American College of Cardiology] are cooperating to work on reimbursement at the national level,” said Taylor. He would like to see those efforts trickle down to the local level. With reimbursement meager to begin with, it can feel as though the two disciplines are fighting over pennies.

And the money matters, but what matters more is the desire to provide excellent quality care and improve patient outcomes. “I would say that many people performing cardiac imaging now are driven most by a real desire to deal with the excitement over the new technology and what it can bring to clinical care. Any time you are going to make the clinical effort and devote time to tasks that don’t pay the same as others you could be doing, you better love it,” said Rubin. And you also need to learn to share.

Renee Diiulio is a contributing writer for Axis Imaging News. For more information, contact .