Turf wars in radiology: The quality of imaging facilities operated by nonradiologist physicians and of the images they produce

National Trends in the Utilization of Skeletal Radiography From 2003 to 2015

PURPOSE

Examine recent trends in the use of skeletal radiography and assess the roles of various nonradiologic specialties in the interpretations.

METHODS

Medicare Part B fee-for-service claims data files from 2003 to 2015 were analyzed for all Current Procedural Terminology, version 4 (CPT-4) procedure codes related to skeletal radiography. The files provide examination volume, and we calculated utilization rates per 1,000 Medicare beneficiaries. Medicare's physician specialty codes were used to determine the specialties of the providers. Total utilization rate trends were analyzed, as well as those for radiologists and nonradiologists. We determined which nonradiologist specialties were the highest users of skeletal radiography. Medicare place-of-service codes were used to identify the locations where the services were provided.

RESULTS

The total utilization rate per 1,000 of skeletal radiography within the Medicare population increased 9.5% from 2003 to 2015. The utilization rate for radiologists increased 5.5% from 2003 to 2015 versus 11.1% for nonradiologists as a group. Among nonradiologist specialties in all health care settings over the study period, orthopedic surgeons increased 10.6%, chiropractors and podiatrists together increased 14.4%, nonphysician providers (primarily nurse practitioners and physician assistants) increased 441%, and primary care physicians' rate decreased 33.5%. Although radiologists do almost all skeletal radiography interpretation in hospital settings, nonradiologists do the majority in private offices. There has been strong growth in skeletal radiography in emergency departments, but a substantial drop in inpatient settings.

CONCLUSIONS

The utilization of skeletal radiography has increased more rapidly among nonradiologists than among radiologists. This raises concerns about self-referral and quality.

Turf issues in radiology and its subspecialties

Turf issues in medicine affect policy, practice, and, most importantly, patients. This article explores turf issues from several perspectives. The issue and scope of the problem is first discussed, followed by a brief history of turf delineation. Contributing and connected factors are considered, taking into account some consequences of turf battles and their impact on related topics. Finally, this article focuses on proposed strategies to successfully confront the questions, if not overcome the problems encountered. To better inform the deliberation and strengthen the credibility of any conclusions, the evidence and controversies must be regarded from beyond merely the radiology perspective.

Turf wars in radiology: possible remedies for self-referral that could be taken by federal or state governments and payers

The time seems to be ripe for reforms that will address the rapid growth of self-referral in diagnostic imaging by nonradiologist physicians. The authors present a possible course of action containing six elements that federal or state governments and/or payers could take that would assist them in their efforts to control this ubiquitous problem: (1) a legislative ban on self-referral for certain types of imaging, (2) mandatory accreditation and/or site inspections of all imaging facilities, (3) the limitation of imaging privileges among nonradiologists, (4) the required precertification of all self-referred imaging examinations, (5) the auditing of records of physicians who self-refer, and (6) certificate-of-need laws.

Update on the Diagnostic Radiology Employment Market: Findings Through 2005

OBJECTIVE

The purpose of this study is to analyze and summarize the latest data describing the diagnostic radiologist employment market.

MATERIALS AND METHODS

Three sources of data--vacancies in academic radiology departments as of July 1, 2005; the ratio of job listings to job seekers at a major placement service; and the number of positions advertised in the American Journal of Roentgenology and Radiology-are presented and compared with previous data.

RESULTS

Vacancies in academic departments averaged 4.5 in 2005, an increase of 16% from 2004 but a decrease of 16% from the 2001 peak. Vacancies increased from 2004 in all specialties except nuclear medicine and "other," and vacancies decreased from 2001 in all specialties except pediatric radiology and purely research positions. Job listings per job seeker increased 8% from 2004 but remain far below peak levels. The total number of positions advertised decreased by 6% from 2004, reaching the lowest level since 1998. In 2005, 42% of the total advertised jobs were academic, as compared with 45% in 2004. Proportional decreases were seen between 2004 and 2005 in total advertisements per region except the Northwest and California. The largest proportional increases in subspecialties occurred in general radiology, abdominal imaging, and "other."

CONCLUSION

Data from the American College of Radiology Professional Bureau and a survey of academic radiology departments show an increased demand for diagnostic radiologists in 2005, whereas data from the help wanted index show a decrease. In addition, the regional distribution of advertisements and the proportion of advertisements for certain specialties have shown some shifting in 2005. We believe the job market remains strong, with regional and specialty shifting.

Turf Wars in Radiology: Privileging and Site Accreditation Programs—What They Have Accomplished for Commercial Health Plans

In recent years, some commercial health plans have instituted privileging and site accreditation programs for providers of diagnostic imaging. This article describes how these programs work and points out that they can help restrict self-referral and the overutilization that accompanies it. Another advantage is that they can help eliminate low-quality providers. Radiologists should encourage health plans in their area to develop and implement these measures.

The 2005 Robert D. Moreton Lecture: The Inappropriate Utilization of Imaging Through Self-Referral

Self-referral in diagnostic imaging has adverse consequences for our health care system. It inevitably leads to overutilization. If untrained physicians try to interpret images, they will make avoidable errors. Imaging facilities operated by untrained physicians are more likely to produce poor-quality examinations. These statements are backed up by abundant evidence in the medical literature. Major payers such as Medicare and the Blue Cross Blue Shield Association are aware of the problem. There are a number of possible remedies, and it remains to be seen whether they and other payers will adopt them.

Update on the Diagnostic Radiologist Employment Market: Findings Through 2004

OBJECTIVE

The objective of this article is to summarize the latest information concerning the diagnostic radiologist employment market.

MATERIALS AND METHODS

Three sources of data are presented and compared with previous data: vacancies in academic radiology departments as of July; the ratio of job listings to job seekers at a major placement service; and the number of positions advertised in Radiology and the American Journal of Roentgenology.

RESULTS

Vacancies in academic radiology departments averaged 3.9 in 2004, down 29%, and decreased for all subspecialties as compared with 2001, but the number of vacancies remained very similar to that for 2003. Job listings per job seeker were 1.1 in 2004, stable over the past 2 years but at the lowest level since 1997. The overall number of positions advertised declined by 14% in 2003 compared with 2002 and by an additional 17% in 2004, reaching the lowest level since 1998. In 2004, 45.3% of positions advertised were academic. Comparing 2003-2004 with 2001-2002, all geographic regions exhibited absolute declines in advertisements except the Northeast, which showed a 1.5% increase. Absolute increases occurred for musculoskeletal and emergency radiology positions. Statistically significant proportional decreases occurred for general radiology, vascular/interventional radiology, and pediatric radiology.

CONCLUSION

Three separate data sources confirm a substantial and broad-based multiyear decline in the strength of the demand for diagnostic radiologists, with some shifting in relative demand for subspecialties. It is not clear if the decrease continued in 2004 or if 2004 demand was similar to that of 2003. Data are relative and do not indicate the employment market is weak in absolute terms.