22 February 2006

Emergency Physicians and Radiology

GruntDoc ranted:

[Our] hospital where the radiology department has the 'exclusive billing' clause for radiologic services. Right now they don't care if we use our US machine in the ED, but they do care if we bill (even though the ED uses different codes) because it interferes with their exclusivity.

As a different rant, I cannot figure out why we put up with waiting a day or more to have our plain-films over-read. Well, I have it figured out, and just wish I could pretend part of my job wasn't important so I could do it when it's convenient for me.

I won't claim to be the most experienced voice in this field, but from what experience I have, this seems to be a common problem: radiologist groups who will or can not deliver real-time interpretation of plain films, due to high workload and staffing difficulty. Most do give readings of CTs and Ultrasounds, and deliver over-reads of plain x-rays, usually within 24 hours. But from our side of the fence, this creates huge operational problems in the ED -- the massive amount of time spent reconciling the discrepancies between the ED docs' original reads and the final radiologist's report, the potential harm to patients, the pissed-off patients who had to be notified that an "error" had been made, the increased liability from even trivial discrepancies, etc.

As you might expect, it can prove difficult to convince the radiologists to give real-time reads on plain films, especially at night, since they are getting paid either way and it is hard to find docs to work between the hours of 11PM and 7AM. Hospital administration, though sympathetic, may claim they have have little power to compel the radiologists to come around. So many times the ED physicians suggest that since they are, for whatever reason, obligated to deliver care solely on the basis of their own interpretation of the X-rays, that they have provided the service to the patient, assumed the risk, and deserve the compensation.

Beware that when you raise this point, you are igniting a turf war. It's one you can win, though, if you have the will and an adequate political base of support within the hospital. It is important to have defined your goals in advance: some ED groups see this as an important business opportunity and a significant source of revenue worth fighting for. Our philosophy, when we addressed this a few years back, was that we did not want to be reading the X-rays, that we wanted contemporaneous interpretations. So we play the role of "patient advocates," arguing that the best care is a real-time reading of all radiographs by a radiologist. This is a nice tactic to take because it clearly puts you in the white hat, and I think is probably where most ED groups find themselves trending. But it is backed by a real threat that we could bill for the interpretations ourselves if this service is unavailable.

This threat has teeth because, on a routine basis, most payors, most notably Medicare, will only pay once for an X-ray interpretation. If only one bill is received, they pay it without question. If more than one provider attempts to bill for an ER study, the CMS policy is that the provider who performed the interpretation at the time care was delivered to the beneficiary is the individual who will be compensated. Though I have not heard of any OIG investigations on this matter, the implication is very clear that if the radiologists also attempt to submit a bill for payment, that practice would be at the least noncompliant and at the worst, fraudulent.

Similarly, I might suggest to GruntDoc's hospital administrator that the radiology group's "exclusive" contract for interpretive services is also noncompliant and possibly illegal since it would seem to prevent other physicians from billing for services legitimately rendered to beneficiaries.

The other major objection to ED physicians performing the primary reads of ED X-rays is QA, which is required under Medicare part A. The response to this is that it is simply not our problem -- that is a hospital function. If the hospital has to pay the staff radiologists for QA over-reads on X-rays that the ED physicians have already billed out, the hospital may suddenly find that it has a dog in this fight and the pressure on the radiologists to provide timely interpretations may suddenly increase.

Either way, I view this as a win-win for the ED and well worth the effort to fight it out. Either you have the option of billing your own X-rays and the (modest) revenue that would accompany it, or you get real-time radiology reports on all your X-rays and the higher level of quality and security that comes with that service.

And by the way, every word I have written on this subject can be as easily applied to ECGs as well as to X-rays, except that real-time interpretations from cardiologists are much less useful or likely to occur.


Cool Hand Luke said...

My apologies to the several good friends I have that went into radiology, but...I've got an idea. Let's just do away with the radiologist for any type of study read. They can keep whatever procedural stuff lands in their turf, but why have them read anything anyway. My experience as the father of a frequent patient, not a doctor, is that a radiologist's report is meaningless and so full of hedging that it borders on comical. They pepper any written report with phrases that basically paraphrase to, "I may see something in this CT scan. There may be something abnormal somewhere over there by that artery. I won't say that there is or isn't anything there though. For that you will have to get your specialist's interpretation. I'm just paid to make you wait to receive your son's study results so that I can hem and haw when I get to it and then your specialist will tell you what is really on the scan, or not, so that I have no real responsibility for what may or may not be there."

Maybe you see more cut and dry stuff in the ER than the oncology related follow-up we do. Clearly there have to be two reads no matter what if the radiologists are involved. Right? I mean, there is no way you just trust some guy upstairs to make the call. You have to check it out too even if he reads it immediately.

I'm half joking in my rant here. Of course if I'm only half joking then I'm also half serious. Surely there has to be some reason for the radiologist read, but if it is the specialists that do the real interpretation, why not cut out the middle man?

shadowfax said...

I think a lot of specialists might agree with you. For my part, I would be just as happy if I never had to look at another X-ray . . . except that I like pretty pictures. I joke with a radiologist colleague/friend, when he can't give me a definitive reading, what good is the magic x-ray vision if it can't function as a deus ex machina to tell me what is wrong with the patient? The radiologist is like the oracle of medicine, I the lowly supplicant begging for insight (literally). Only, like the oracle's "Know thyself," the radiologists' dicta can be equally obscure "Clinical correlation required."

Seriously, though, there are a lot of X-rays where they spot the fracture that I did not, or they see the second fracture that I did not. So I value and appreciate a good radiologist because they really are good at something which I am not. Now we do have a couple of staff radiologists who are the masters of over-cautious readings full of hedging "possibles," which is pretty useless. But about 90% of our rads are pretty good, and I have no complaints about the service we currently get.

Cool Hand Luke said...

I'm feeling slightly less cranky this afternoon and should point out that we have been getting better and quicker reads as of late.

Josh Gentry said...

Isn't there a push to outsource these readings, especially at night when the folks in India are happy to do it?


shadowfax said...

Yeah, there was some talk about getting a tele-radiology group to do it. But that has a pretty high hassle factor - you need to make sure all these foriegn docs are credentialled and certified and provide reasonable quality. They mostly do, training and technology being well-globalized, but the hospital has a duty to verify it, and the documentation requirements are significant. It would also be like using a nuclear weapon, politically, and we do actually need some live radiologists on site, too. So it worked out well that we were able to negotiate a solution with our existing radiologists.

Truth be told, our situation was probably more a personality issue regarding the radiology medical director. Once the radiology group replaced him, all the problems just sort of went away. It's nice when that works out.

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radiologist said...

I am a radiologist in a large, multispecialty private practice. I am personally insulted by your "rant." Neither I nor my colleagues say inane things like "I may see something abnormal somewhere over there by that artery." We make our reports as specific and helpful as possible. Admittedly, some reports are vague; yes, that could be due to a subpar radiologist, but sometimes it's not possible to be definitive. Do you want us to guess and act sure about it, when it's inappropriate? Also, the vast majority of our studies never go to a speicalist; the radiologist is the only one who ever sees them. Pick on someone else. Radiologist

shadowfax said...

Radiologist -- if this is all it takes to offend you, I suggest you get off the internets. Because I hear some people out here can be mean. Seriously, get over yourself. I can come up with complaining rants about every single specialty, including Emergency Medicine. Some of them are valid, and some are not. Luke's rant (which was not mine but I'll represent for him) is more or less on target for a certain number of over-cautious radiologists. And as I said in response, what good is the magic x-ray vision if it can't function as a deus ex machina to tell me what is wrong with the patient?