First, Do No Harm
By Curtis Kauffman-Pickelle

The past few weeks have witnessed some rather remarkable national press reports about this marvelous profession that is the broad field of diagnostic imaging, and in each round of news coverage we have viewed both the opportunities and threats inherent in the practice of radiology in the public realm…well out of the shelter of the reading room.

First the great news: the spotlight shown brightly as radiology once again assumed its rightful place in the pantheon of clinical leaders by designing and participating in a wide-scale study on the efficacy of breast MRI in discovering occult cancer in the contralateral breast of breast cancer patients, recently published in the New England Journal of Medicine [1]. As you will discover by reading the interview in this issue with Scottsdale Medical Imaging’s Dan Maki, MD, one of the principal researchers in the ACRIN study, it bodes well for the future of breast MRI in the imaging center setting. Good science, good action steps to help save lives.

Conversely, it was not such a good day for radiology when an article [2] published in the Wall Street Journal discussed a different study that measured the effectiveness of mammography with CAD as compared to mammography alone.

>> click here to read more >>

Legislative Report:
A Fast Start
By Howard B. Fleishon, MD

This year already has proven to be a busy one for legislative activity in radiology. The heightened level of interest has to do with several key factors. With the presidential election approaching in 2008, health care and its funding will continue to be a hot topic for debate; and as medical imaging costs and utilization continue to skyrocket, radiology will remain in the legislative and regulatory spotlight. Some early 2007 national and state highlights follow.

The National Front

HR 1293 is the latest version of the movement to roll back the Deficit Reduction Act (DRA) of 2005 imaging cuts. The American College of Radiology (ACR) has worked with the Access for Medical Imaging Coalition to introduce the legislation. The bill currently has 59 cosponsors. The DRA rollback will be the focus when radiologists lobby their congressmen during the ACR annual meeting in Washington on May 23.

The Mammography Quality Standards Act (MQSA) is also up for renewal. MQSA is subject to congressional reauthorization every 3-5 years. The process gives stakeholders the opportunity to propose new or updated measures to assure the quality and access of breast imaging for all women. Although a specific bill has yet to be introduced, several topics likely will be addressed in forthcoming proposals, according to Josh Cooper, the ACR’s senior director, government relations.

>> click here to read more >>

RBM Standards:
Too Much of a Good Thing?

Most providers of quality diagnostic imaging welcome more stringent quality standards invoked by payors in the belief that higher standards will eliminate inferior providers from their markets. But as payors increasingly resort to employing radiology benefits management companies (RBMs) to help control escalating imaging costs, outpatient-imaging providers are encountering a bewildering array of standards to meet. And projections from the Advisory Board suggest that the influence of RBMs will grow.

Many RBMs are requiring compliance with equipment specifications that are not encountered in the accreditation standards of respected accrediting bodies such as the American College of Radiology (ACR), the Intersocietal Commission for the Accreditation of Nuclear Laboratories (ICANL), the Intersocietal Commission for the Accreditation of Magnetic Resonance Laboratories (ICAMRL), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In addition, various RBM standards that have emerged ask outpatient imaging centers to divulge financial ownership interests, keep a minimum 40-hour work week, and have a board certified radiologist on-site full-time

Consider the following requirements found within the standards used by competing RBMs:

DRA Defense:
Volume Vs Quality and UM
By Nicole Pliner, MHSA

I recently attended an outpatient imaging center conference where, not surprisingly, surviving the DRA, dominated the discussion. It also was no surprise that increasing volume was the prevailing recommendation for solving the issue. Economically, it makes sense. When the price goes down, a company must attract more customers and serve them more efficiently.

What was a surprise, however, was how little quality of care and utilization management factored into the discussions. While aggressive marketing, increasing referral bases, and subsequently increasing volume are no doubt survival strategies, they will not in themselves, position imaging centers for long-term survival. In my opinion, the successful imaging centers will be those that can demonstrate both quality and mechanisms for managing utilization. If imaging centers focus solely on volume alone to drive survival, they will be shortsighted.

>> click here to read more >>

Q & A with Daniel D. Maki, MD:
A Very Good Month for Breast MRI

March initiated what could be a sea change in the diagnosis of breast cancer in high-risk women, with results of a breast MR study published in the New England Journal of Medicine and, in the same week, new guidelines issued from the American Cancer Society (ACS) that recommended breast MR as a screening tool for high-risk women.

The breast MRI trial, conducted by the American College of Radiology Imaging Network (ACRIN) and financed by the National Institutes of Health, evaluated the effectiveness of using breast MRI of the contralateral breast in 969 women with recently diagnosed breast cancer. MRI detected clinically and mammographically occult breast cancer in the contralateral breast in 30 of 969 women who were enrolled in the study (3.1%). All participants underwent dynamic contrast-enhanced breast MRI on a 1.5T or greater magnet. Biopsy was performed in 121 of the 969 women (12.5%), and 30 of the specimens were positive for cancer (24.8%); 18 of the 30 specimens were positive for invasive cancer. The mean diameter of the invasive tumors detected was 10.9 mm.

“The implication for imaging centers is that there is the potential for a lot more breast MR to be performed.”

—Daniel D. Maki, MD

Participating imaging sites included both academic institutions and private practices. ImagingBiz.com recently spoke with one of the study’s 13 co-authors, Daniel D. Maki, MD, representing the 42-physician practice Scottsdale Medical Imaging Ltd, Scottsdale, Ariz. Maki, fellowship trained in MRI and thoracic imaging and ACRIN Trial 6667 coordinator for SMIL, discussed the implications of the study and the new ACS guidelines for both patients and the imaging center business. He also commented on the value of private practice participation in ACRIN studies.

>> click here to read more >>

Two major imaging center organizations released their annual 10-K reports last month, providing the first official projections of the impact of the DRA on corporate imaging center companies. Not surprisingly, the DRA figured prominently in the risk factors section for both MQ Associates, Alpharetta, Ga, which owns MedQuest, and Alliance Imaging, Anaheim, California.

MedQuest, which owns and operates 90 imaging centers in 13 states, reported a net revenue of $273.5 million in 2006, with managed care and commercial payors representing more than 50% of revenue. Medicare and Medicaid was limited to 26.4%. MedQuest estimated that if the reimbursement reductions contained in the DRA had been in full effect during the year ended December 31, 2006, the impact on MedQuest’s financial results would have been an $11.0 million reduction in net revenue, and projected a similar impact for 2007 if payor and scan mix remain the same.

The report authors also noted that its estimated impact of the DRA does not include the impact of third party payors, other than Medicare, implementing comparable reductions in reimbursement.

“If other payors were to implement reductions, our results of operations, cash flows and overall financial condition would be further adversely affected. We are unable to anticipate or estimate the possibility or extent of potential reductions by non-Medicare payors.”

—MQ Associates 10-K Report

>> click here to read more >>

Night and Day Hawks:
Fools Rush In?

Only time will tell whether Massachusetts General Hospital blundered into Rhode Island to take over reading services for 359-bed Kent Hospital in Warwick, RI, or whether this is the beginning of a chapter of unrestrained growth for teleradiology. Certainly every night and day hawk out there is sitting on the sidelines waiting to see how this plays out.

The situation in brief: Massachusetts General Hospital, Boston, has proposed to take over reading services at Kent Hospital, previously served by Toll Gate Radiology, Warwick, RI. Toll Gate is a teleradiology customer itself, contracting with Nighthawk Radiology, Couer d’Alene, for evening and weekend coverage, according to an article posted on auntminnie.com.

Two questions occurred: What happened to end the gentlemen’s agreement among radiology groups to respect local terrain? And if this was inevitable, why did the progressive and entrepreneurial academic group at Rhode Island Hospital and Brown University allow this to happen in its own backyard?

It could turn into a real slugfest between local and national radiology.

Doc Pay on the Docket

Will Congress replace the sustainable growth rate (SGR) factor with an alternative spending target? Or will it scrap the whole system, including the resource-based relative-value scale (RBRVS) on which the Physician Fee Schedule is based?

The Medicare Payment Advisory Commission (MedPAC) just released the report that Congress requested through the DRA, exploring some alternative mechanisms for controlling Medicare’s physician costs. According to an article in Imaging Economics, the commission was divided on whether or not to replace the SGR’s Gross Domestic Product with a different expenditure target, but MedPAC did suggest that Congress pursue one of two recommended pathways.

>> click here to read more >>

New Accreditation Requirement:
Physician, Fix Thyself

The American College of Radiology has announced that all new accreditation applicants must include a physician peer-review component, effective April 1, according to an announcement posted on the ACR web site. The only exceptions to this requirement are the Mammography and Stereotactic Breast Biopsy Programs, Ultrasound Guided Breast Biopsy Module, and the Breast Ultrasound Program.

The announcement notes that all examinations at a facility should be reviewed for accuracy and appropriateness as part of an overall quality review program. While not mandatory, the ACR’s RADPEER program requires radiologists to score, using a four-point system, priors that are reviewed in the course of reading a current study. In order to be approved, any other peer-review system must include the following characteristics:

• Double reading: two MDs interpreting the same study
• Random selection of studies to be reviewed on a regularly scheduled basis
• Exams and procedures representative of the work of each physician's specialty
• Reviewer assessment of the agreement of original report with subsequent review (or with surgical or pathological findings);
• A classification of peer review findings with regard to level of quality concerns;
• Policies and procedures for action to be taken on significantly discrepant peer review findings;
• Summary statistics and comparisons generated for each physician by modality; and summary data for each facility/practice by modality.

>> New Accreditation Requirements >>

>> RADPEER >>