Extended Benefit
The issue of physician extenders (PE) in radiology--including specialized radiologic technologists--took center stage with a key Friday session of the 24th annual Economics of Diagnostic Imaging conference. The topic was certainly a timely one: 49 percent of the 180-plus attendees of the Arlington, Va., symposium indicated that they already employ some form of PE in their radiology practice.
“I’m a true believer that appropriately trained and supervised physician extenders can really enhance a practice,” said Richard Duszak, MD, FACR, vice chair of the American College of Radiology (ACR) Commission on Economics. Dr. Duszak detailed ways in which practices can use various types of PEs--radiologist assistants (RAs), radiology practitioner assistants (RPAs), nurse practitioners (NPs) and physician assistants (PAs)--to realize lifestyle benefits (create more time off for practice radiologists), increase professional satisfaction (free up physician time for higher-intensity services) and derive economic benefit.
Dr. Duszak spent much of his session identifying the unique characteristics of the various PEs, separating them into two categories--non-autonomous practitioners (RAs and RPAs) and semi-autonomous practitioners (NPs and PAs).
RAs are advanced-level technologists from baccalaureate or masters programs (11 RA programs exist nationwide). They take responsibility for patient assessment, education and management; perform fluoroscopy and other radiologic procedures; and make initial image observations. They’re unable to perform interpretations (preliminary or final) of any radiology exam or transmit observations other than those of the supervising radiologist. RAs are certified by the American Registry of Radiologic Technologists (ARRT) and recognized by the ARRT and the American College of Radiology (ACR). While the RA position is recognized in at least 11 states, RAs aren’t recognized by Medicare as mid-level practitioners--an important distinction, noted Dr. Duszak.
RPAs, by comparison, are the product of a single baccalaureate program that was formerly what he characterized as a “rigorous” nondegree program: Weber State University in Ogden, Utah (the program also now meets criteria for RA designation). RPAs have one certification body: the Certification Board for Radiology Practitioner Assistants (CBRPA). The ACR, said Dr. Duszak, lacks a position statement on RPAs and didn’t provide input into the program at the time of its development. Dr. Duszak described RPAs as having a scope of practice that is flexible to permit expansion as well as a measure of independence in clinical performance and decision making. At least three states recognize the RPA designation, he said, but Medicare doesn’t recognize RPAs as mid-level practitioners--rendering practices unable to bill Medicare directly for their services.
While RAs and RPAs can facilitate GI fluoroscopy in the inpatient setting, they can’t perform it on Medicare outpatients. Neither RAs nor RPAs can perform GI fluoroscopy in the office setting, place a peripherally inserted central catheter (PICC) or interpret imaging studies.
Dr. Duszak cautioned that both positions have a narrow window of use. He also cautioned practices that use RAs and RPAs in ways that aren’t fully compliant with federal and state statutes. He noted that inter-society dialogue continues with the hope that the RPA designation will be incorporated into the RA designation. He also expressed doubt that Medicare will recognize these positions as mid-level practitioners in the near future. Still, he said RAs--which, like RPAs, command an average salary of roughly $80,000 to $100,000--were “a huge asset” to his former radiology practice in Pennsylvania.
Turning to semi-autonomous practitioners, Dr. Duszak noted that both NPs (mid-level practitioners who are RNs with master’s degrees) and PAs (mid-level practitioners who complete what he characterized as a “medical school minus” master’s program) are recognized by Medicare and most state medical boards. Both practitioners can perform PICC lines as well as spine and joint injections; neither type of practitioner can supervise diagnostic studies nor, in many jurisdictions, interpret imaging studies. NPs command an average salary of roughly $73,200, with PAs earning an average of roughly $84,400, he said. Dr. Duszak recounted his former practice’s success with hiring two PAs for interventional radiology during a “difficult” physician recruiting environment and amid a desire to expand clinical services. Although PA billing proved to be less than the combined salary and benefits of the two positions, he said his practice derived major economic benefits in the form of freed-up physician time, improved clinical service and increased referrals.
Better service was a key point in a subsequent talk delivered by Frank J. Lexa, MD, MBA. He described how radiologists can prevent their practices from becoming a commodity--a mass-produced, unspecialized product that he called
“a business failure”--and add value in health care to re-establish a “contract of trust” with patients.
“Almost anything can be decommoditized if you understand your industry … [and] what people want from you,” said Dr. Lexa, clinical professor of radiology at the University of Pennsylvania Medical Center and adjunct professor of marketing at The Wharton School. He suggested conducting more public outreach efforts and surveying patients with easy-to-complete forms to gauge their expectations. He noted that technologists are more important than front-desk personnel for allaying patient fears and making personal contact--key components in any practice’s decommoditization effort. “I think we can do great things if we [become] something besides being people who put words beside images [in reports],” said Dr. Lexa.