For most of my career, I have written about advances in health care as a repetitive theme. The themes were primarily radiologic. I started just in time to write about mammography, angiography and angioplasty, head and body computed tomography (CT), megavoltage radiotherapy, technetium 99, and gamma cameras. Later it came to ultrasound, magnetic resonance imaging, expansion of interventional procedures, stents, three-dimensional imaging, CT colonoscopy, digital imaging, teleradiology, and every progressive thing in the discipline where I earned my living by writing and talking about it.
Part of my usual theme was to describe how these advances in imaging and treatment should be and were radiologic contributions to advances in modern medicine. And, as such, why they were part of radiology rather than some other medical discipline. Any success I had in telling those tales had a favorable impact upon definitions, legislation, regulations, classifications, and compensation. All of this related and still does to turf struggles between radiologists and other physicians whose patients benefit from advances in radiology. So many of those other physicians are poachers on what we regard as radiologic technology for which you are trained and they are not.
But then, those of you nearing my vintage could not claim any formal training in the use of technology that came to being long after you finished your residency or fellowships. Instead, you were into on-the-job approaches of seminars, literature, and hands-on experience. Indeed, the whole concept of continuing medical education is based upon the concept that anyone who does not keep up with things should not be allowed to continue practicing, or billing for services, or claiming special competence.
One example of this is mammography. A 1992 federal law defining who could perform and be paid for mammography made mandatory the voluntary standards developed by the American College of Radiology and espoused by the American Cancer Society. That same legislation included the first specification that the Medicare program should pay for screening procedures—mammograms—for women with no clinical indications of breast disease. And the regulations specified that only physicians certified by the American Board of Radiology and with specific training in mammography could direct mammography centers or interpret breast images. So, by writ of the Congress, mammography was part of radiology. The converse side of this was that the same legislation set a fee for screening mammography, which has remained short of costs. The result is that the radiologists offering screening mammography have declined in numbers in recent years. So access to mammograms has become much more difficult in many communities.
Another example of federal control of one aspect of radiology is the requirement that physicians wishing to use artificial radioisotopes must obtain licenses from the Nuclear Regulatory Commission (NRC). This licensure requirement started shortly after the Atomic Energy Commission (now the NRC) started providing radioisotopes for medical uses in the early 1950s. The ABR, the American Board of Nuclear Medicine, a group of cardiologists, and other physicians have all appealed to the NRC to recognize their training requirements and certification as a qualification to obtain an NRC license. For a half century and more, the contention for NRC acceptance has prompted the ABR, the residency review committee, and their counterparts to revise their training specifications to meet the NRC’s specific requirements. The irony is that the NRC requirements are directed at the understanding of the nature of radiopharmaceuticals and the safe handling of radionuclides. The NRC takes no role in how persons and institutions with NRC licensure can apply the radioisotopes they are licensed to obtain. All of this seems likely to continue ad infinitum.
Yet another example of the feds dictating radiologic procedures is the addition of Medicare payment for colon screening. Back in 1993, groups of gastroenterologists noted the mammography screening program and organized a campaign to get Medicare compensation for colonoscopic screening procedures. They argued that colon cancer attacks both genders and that early detection leading to the removal of polyps or diverticuli would be greatly beneficial. They contended as well that Medicare should pay for screening endoscopic procedures, which they performed, but not for barium enemas, the traditional technique for studying the large intestine. They also cast aspersions against the dynamic growth of virtual colonoscopy. A recent decision by the Medicare program to not pay for CT colonoscopy is now in an appeal process, where some of my successors at the American College of Radiology are mounting arguments to members of Congress and to private health insurers.
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