New Rules of the Game: Medical Directors Assume the Quality Burden

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Demand for radiologists acting as medical directors could jump if a proposed regulation now under consideration by CMS is adopted. The proposed rule would require all nonhospital providers of imaging services to meet Medicare’s existing requirements for IDTFs, which specify that there must be a qualified physician designated to supervise care and the ongoing use of the imaging equipment.
Thomas W. Greeson, JD
Since, under the current rules, only radiologists are deemed sufficiently qualified to perform such supervision, every cardiologist, urologist, orthopedist, or other nonradiologist with in-office advanced imaging capabilities might be compelled to partner in some fashion with a radiologist, and to name that imaging specialist as medical director if and when the proposed new rule goes into effect, according to Thomas W. Greeson, JD, health care attorney and former ACR general counsel .
“CMS refers to the role of medical director at IDTFs as the general supervising physician and defines that doctor as one who is proficient both with the facility’s imaging technology and with the interpretation of the studies generated by that technology.” —Thomas W. Greeson, JD
Overall, the growing demand for quality and accreditation by payors and hospitals is placing a new burden on radiology practices, and some are responding with increased responsibilities for the medical director, with newly created quality positions in the practice, and with a call for compensation in the hospital setting. Call for Accreditation Even without the contemplated CMS rule, Greeson suggests that it is undeniable that the role of medical director in radiology environments is growing in importance. The biggest driver, at the moment, is the call for imaging providers to be accredited as a precondition for winning contracts and securing reimbursement from third-party payors. Greeson, who also is a partner in the Falls Church, Va, office of Reed Smith LLP, says, “As just one of many examples, UnitedHealthcare is putting in place a requirement, effective in the fourth quarter of 2009, that all of its outpatient providers of advanced imaging—MRI, PET, CT, and nuclear medicine—be accredited either by the ACR or the Intersociety Commission for Accreditation. The key requirement, such as that being crafted by UnitedHealthcare and others, is that accreditation hinges on the technical-component imaging services being under the supervision and direction of a board-certified radiologist.” Greeson notes that accrediting bodies like the Joint Commission have historically insisted on radiology medical direction in hospital settings, much as CMS has for IDTFs. Payors also have sought to define the scope of the role played by the radiology medical director more carefully, Greeson adds. Medicare, for instance, came out with a rule two years ago limiting the general supervising physician of an IDTF to being responsible for no more than three such enterprises at a time. “This was aimed at preventing the general supervising physician from becoming stretched so thin that he or she would be unable to have real interaction with the mechanisms and processes for assuring quality,” he says. Indeed, the goal of quality assurance (QA) is at the very heart of the medical director’s role. “The medical director works hand in glove with the radiology department’s administrative director or the chief technologist to see to it that all of the imaging equipment is performing appropriately and that the technologists are performing well,” Greeson says. “It should be remembered, however, that the medical director does not have an administrative responsibility: He or she is not hiring and firing the technologists, for instance. What he or she does have is oversight of the quality of radiologic technologists, and that means he or she should be involved in reviewing their performance evaluations and having input into that process.” Moreover, Greeson says, the medical director should be involved in the medical/radiological physicist’s review of equipment and be the one to sign off on it. “The equipment must be documented to produce quality images,” he explains. “Without that assurance of quality images, the interpretation may not be as effective.” Misleading Title
Alan Kaye, MD, FACR
To some, the title of medical director is a misnomer. One who hews to that opinion is Alan Kaye, MD, FACR, president of Connecticut-based Advanced Radiology Consultants and chair of the radiology department at Bridgeport Hospital there. “I tend to think of the medical director as being the department chair or the practice president—the person who oversees all things physician related,” he says. Advanced Radiology Consultants consists of 21 radiologists who, in addition to providing coverage at Bridgeport Hospital, own eight imaging offices across the state. The group’s organizational chart lacks a medical director’s position but, instead, has slots for radiologists acting in the capacity of section chiefs: directors of ultrasound, body imaging, musculoskeletal imaging, neuroradiology, nuclear medicine, pediatric radiology, and women’s imaging/breast radiology. “The section chiefs perform the role of QA director for each discipline,” Kaye says. In addition to having section chiefs, Advanced Radiology Consultants also has created a nonphysician position for a director of QA. As Kaye explains, “The position is held by a radiologic technologist who oversees our QA program, coordinates the development and implementation of protocols, and maintains documentation of these. This individual administers the various accreditation programs in which we participate. A current project is to evaluate the specificity of the pathology reports we get from the various labs to which we send specimens.” Further, the group employs a physicist as an independent contractor. “Our nonphysician QA director works closely with this physicist to make sure we have the documentation for the physics and machine calibrations,” Kaye says. Not stopping there, the group also has taken the step of developing lead technologists for nuclear medicine, MRI, CT, and ultrasound. “Part of their job is to help make sure that each technologist working with those modalities is maintaining his or her certifications,” Kaye says. “In addition, each of the modalities of CT, ultrasound, and MRI has a chief technologist who coordinates the education programs for our technologists in those areas. We have three mammography specialists, who are expert and experienced technologists who coordinate the mammography technologists.” Kaye says that his group and others like it are facing more demands to ensure quality through avenues such as maintenance of radiologist certification and accreditation programs for the facilities and modalities. “In the context of our practice, that translates into there being more work for the nonphysician director of QA, more instructional responsibilities for the chief technologists, and more burden on the group president-chair to make sure there is compliance with the mandates for quality,” he notes. “Perhaps someday we’ll have a vice-chair for QA who can take over this responsibility from the chair, but in our practice, we’ve clearly not yet arrived at that juncture.” Kaye’s group will undoubtedly want to make any such journey in a careful, unhurried way. “One can make things too burdensome: That risks compliance,” he believes. “The commitment of the resources necessary to have a nonphysician director of QA and lead technologists requires a large practice, with large volumes of exams. It also requires subspecialized radiologists who have the expertise to develop programs and teach others.” The Controversial Issue Because medical direction is a significant responsibility, the radiologist who performs that role for the hospital should be compensated for it, Greeson says. “Historically, hospitals have not paid radiologists for their medical-director services, but now, some hospitals are coming to understand that they need to do so, and at fair-market prices.” He adds, “I personally think it’s appropriate for payment to be made at a quarterly or annualized flat rate or, alternatively, at an hourly rate.” Compensation for medical direction strikes some as controversial. In Greeson’s estimation, however, a greater controversy is brewing with the proliferation of imaging in self-referring physician offices. “Orthopedists, cardiologists, urologists and others—as they bring advanced imaging into their practices—are aware of the looming payor requirements for accreditation,” he says. “Consequently, they’re contracting with radiologists to provide interpretation services, just as they have in the past, but now these groups—in order to be accredited—are, more and more, seeking to designate a radiologist to serve as the medical director. I’m critical of this because it appears that much of this medical-direction service is in name only. There are teleradiology providers agreeing to be designated as the medical directors for scores, and possibly hundreds, of physician practices, feeling they can sign off on quality because they’re seeing the images and therefore they are interacting with the facility, even though that interaction is occurring remotely.” Greeson labels this as nothing less than a scandal. He says, though, that Medicare’s proposed rule requiring all nonhospital providers of imaging services to be treated as IDTFs would help address this issue by limiting to three the number of self-referring offices that a single radiologist could supervise. Also helpful, in Greeson’s estimation, would be a commitment from the accrediting bodies to require the radiologist who provides medical-direction services for self-referring physician offices where advanced imaging is performed to visit those facilities regularly and to be obliged to interact with the technologists and other staff there. “That would go a long way toward making it logistically difficult for radiologists to supervise too many offices,” he says. Another avenue for discouraging too many such arrangements might be an education campaign to alert radiologists of the legal jeopardy they may be placing themselves in by not genuinely having a hand in ensuring quality. “If you claim to be providing medical direction for an office that is hit with a malpractice suit and a faulty piece of diagnostic equipment is to blame, you’ll be implicated,” Greeson warns. “The same would be true of investigations originating with regulatory agencies.” The controversy is not likely to be resolved soon, and Greeson accepts that. It is of greater concern to him that the role of medical director be properly defined and accorded the laurels it deserves. “QA is something that will emerge as increasingly paramount in the delivery of imaging services over the next several years,” he says. “The key to ensuring that quality is delivered is strong medical direction. It’s a role that cannot be taken lightly or underestimated in value.”