Author + information
- Michael J. Wolk, MD, FACC, President, American College of Cardiology*
- ↵*Address correspondence to:
Michael J. Wolk, MD, FACC, 520 East 72nd Street, New York, New York 10021
In recent months, conversations about the growth in medical imaging have become blurred with distortions, even devolving into a debate of whether imaging performed by cardiologists and other highly trained physicians is safe for our nation's seniors. All of this is coming from our radiology colleagues. They promise state and federal lawmakers a cash windfall if they would just limit the practice of medical imaging largely to one specialty—radiology (1).
Now the fate of medical imaging and the ever-important evolution of medicine in this country are being debated in state legislatures, Capitol Hill, in the offices of insurance executives, and on the pages of the New York Timesand Wall Street Journal. No practice is immune to the attacks on cardiologists' ability to provide imaging services. This is a fight that affects every one of us, and it is a fight that will take considerable resources and commitment to eventually win.
And we will win. We mustwin this fight for our patients who depend on our sound judgment and clinical competency for their cardiovascular care. The bottom line is that patients deserve optimal care delivered by a qualified professional, whether it is a radiologist, cardiologist, or any other trained specialist.
Victims of our own success?
Progress is often met with resistance and uncertainty. This maxim holds true when applied to recent developments in cardiac imaging. Much attention has been focused on the growth in volume of medical scans, especially the rise in tests performed in outpatient office settings rather than in hospitals. Critics of the growth in imaging, led by the radiology community, point to “inappropriate” or “unnecessary” tests performed by non-radiologists (2). Others recognize that advanced imaging equipment has changed the way that cardiologists, oncologists, obstetricians-gynecologists, urologists, family practitioners, orthopedists, and many other physicians deliver care. By integrating diagnostic scans into the overall patient care plan, cardiologists and other specialists can provide patients with a continuity of care that provides quick and effective results. Imaging is not as black and white as some depict. Growth is not necessarily bad, especially when growth improves patient care and controls long-term costs.
That the number of imaging tests is on the rise is an indisputable fact—the number of imaging procedures billed to Medicare grew 9.4% in 2002—but determining the causes for this growth is multifaceted (3). The rise in cardiac imaging has paralleled a decline in the rate of death from heart disease and an improvement in the quality of life for those living longer with heart disease (4–6). Yet, despite these advances, cardiologists are under attack for utilizing this life-saving technology.
The radiology community is quick to blame non-radiologists for the rise in medical imaging and maintain that utilization rates are higher when clinicians own and operate imaging equipment for diagnostic and therapeutic purposes (7,8). In a January 3, 2005, editorial published in Modern Healthcareand appropriately titled “Radiology for Radiologists,” the American College of Radiology (ACR) Board of Chancellors Chair James Borgstede, MD, wrote: “Although there are certainly appropriate instances of non-radiologist physicians using these imaging services, many of these examinations may be unnecessary and ordered for the chief purpose of supplementing the income of that physician” (9).
However, most estimates, including those by the Medicare Payment Advisory Commission, overstate imaging growth because they fail to take into account shifts in the site of service (3). Refinements in imaging technology have encouraged the move from invasive tests performed in hospitals to less invasive and more accurate diagnostic tools and image-guided therapy performed by professionals in an outpatient setting.
Detractors of the cardiologists' role in providing diagnostic scans have also called into question the quality of tests performed by non-radiologists (10). Although no credible data exist to support this claim, the ACR and others continue to look for ways to narrowly define who is an appropriate imaging provider and where these tests may be administered. Limiting access to providers and services is an inappropriate way to manage increased patient need for imaging tests.
The truth is, more patients will need diagnostic services if the U.S. health care system is going to shift to a proactive model of disease management rather than a reactive system focused on the end-stage treatment of illnesses. Limiting diagnostic scans to radiologists inappropriately excludes qualified physicians from performing life-saving tests in the most patient-friendly setting. Plus, it sets the stage for a disaster in the near future when our exploding patient base outstrips the radiologists' ability to meet demand in a timely fashion.
Taking a stand
Inappropriate and unnecessary treatment protocols—including imaging services—are unsupportable from any vantage point (11). Excessive use of any technology is bad practice and a burden on our health care system. The American College of Cardiology (ACC) supports appropriate utilization of imaging devices by trained professionals regardless of specialty affiliation. This position is currently being formalized into accreditation standards and appropriateness criteria, keeping in mind that patients come first.
Unfortunately, patients are getting lost in the debate. The ACR and its allies are so consumed with protecting their “economic turf” that they have failed to address the growing patient population that needs these imaging services. The true motivation driving the radiology community was spelled out in a December 2004 article published on the Radiological Society of North America's web site, warning that “radiology must take an active role in cardiac imaging or run the risk of being left out of this burgeoning field” (12).
Cardiologists are not alone in this fight. The ACC has joined with cardiovascular specialty groups and numerous other physician organizations to defend the right of qualified professionals to provide imaging services to their patients. Through coalitions like the Physicians for Patient-Centered Imaging and the Cardiovascular Imaging Collaborative, we are telling the other side of the imaging story and reminding policymakers that patient care is at stake. With all the discussion around rising volume and increased cost, it is imperative that people understand that imaging allows physicians to diagnose disease earlier, treat conditions faster, and evaluate outcomes more efficiently. Before limiting patients' access to imaging services, legislators, government agencies, and private payers need to take a long-term view at the costs and benefits of imaging technology. This is where the ACC will need your help.
It will require a personal commitment from every member of the ACC to protect our right to provide imaging services to our patients. This means taking the time to talk with your state legislators and members of Congress, to work with private payers, and to contribute to the ACC Political Action Committee (PAC) (http://www.epacweb.com/acc). Already the ACR has amassed a $1 million PAC; they mean business. Now it is time to show our collective muscle. By standing together, we can win this fight. If we splinter, then our message will be lost. In the end, we all need to be vocal proponents of appropriate utilization of imaging technology and strive to work with all imaging providers to ensure that patients get optimal care from qualified physicians.
- American College of Cardiology Foundation
- ↵Thompson T. ACR to pitch Congress on ‘designated physician imagers’ for Medicare. Available at: http://www.auntminnie.com. Accessed January 12, 2005.
- ↵Pasturis P. Scan-dalous. Available at: http://www.forbes.com/healthcare/2004/07/27/cx_pp_0727medimaging_ii.html. Accessed July 27, 2004.
- Medicare Payment Advisory Commission
- American Heart Association
- American Heart Association
- Mayo Foundation for Medical Education and Research. Cardiac rehab: healing mind and body. Available at: http://www.mayoclinic.com/invoke.cfm?id=HB00017. Accessed January 12, 2005.
- ↵Abelson R. An MRI machine for every doctor: someone has to pay. New York Times. March 13, 2004, Section A, Page 1, Column 6.
- Data has been sought from the National Imaging Associates, who did not provide the requested information.
- ↵Borgstede J. Radiology for radiologists. Available at: http//www.modernhealthcare.com. Accessed January 7, 2005.
- Wolk M.J.,
- Popp R.,
- Smith S.,
- DeMaria A.
- ↵Radiology Should Assume Leadership in Cardiac Imaging, Experts Say. Available at: http://www.rsna.org/publications/rsnanews/dec04/cardiac-1.html. Accessed January 12, 2005.