ACR Bulletin

Covering topics relevant to the practice of radiology

Radiology’s History of Independence

How did our profession become free within payment systems?
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Strengthened by this freedom and security, radiology professionals can pursue innovation, bold and revolutionary ideas, and make remarkable contributions to patient care.

—Ezequiel Silva III, MD, FACR
October 30, 2018

Independence Day commemorates our country’s Declaration of Independence from Great Britain’s rule. That decision to become an independent nation has stood the test of time. The United States of America is now the oldest enduring republic in the history of the world. Similarly, the specialty of radiology has itself declared independence several times during its history. Granted, the stakes were lower, but in each instance that decision has also stood the test of time. As a result, radiologists have been the beneficiaries of the ACR’s vision, and radiology is a robust, rewarding, and influential profession.

Today, our independence is no longer secure. We are experiencing pressures to cede our independence to larger entities, non-radiologists, and even AI. Maybe now is the time to do so. But before we choose to relinquish our independence, it is worthwhile to revisit decision points in our past, when we chose independence for our benefit:

  • The founding of Medicare
  • The creation of diagnosis-related groups (DRGs) for hospital inpatient payments
  • The establishment of the resource-based relative value scale (RBRVS) used to determine how much physicians should be paid

In the early 1960s, Medicare was crafted to include two parts: Part A to pay hospitals and Part B to pay physicians. Initial proposals had radiology paid under Medicare Part A, which could have made radiologists overly dependent on the hospitals. We declared independence. With the help of ACR’s first lobbyist, J.T. Rutherford (a former Democratic U.S. congressman and state legislator), we became a part of Medicare Part B, recognized and paid in the same manner as other physicians. We wanted recognition as independent physician professionals. We demonstrated our willingness to assume not only the associated status but also the responsibility.

Then in the 1980s, a new system of payment was created that involved paying hospitals for inpatient services. This system involved single, bundled payments to hospitals for inpatient care based on DRGs. In President Ronald Reagan’s 1987 budget, radiology professional services would have been paid for under the DRGs. From that single DRG payment, radiologists would have been paid separately at whatever rate the hospital was willing to pay. We resisted and, again, declared independence, allowing us to be paid the same as the other physicians in the hospital. As a result — and to this day — our professional fees are paid separately from the hospital’s payments.

A decade later, in the early 1990s, the RBRVS was created as the means to pay physicians within the Medicare Physician Fee Schedule. The ACR had already created a radiology relative value scale (RVS) for the Civilian Health and Medical Program of the Uniformed Services. Our independent spirit prompted the creation of a separate resource-based fee schedule. Rather than re-create a new RVS for radiology, we advocated for the integration of our existing fee schedule into the broader RBRVS, ensuring separate recognition of our services

Because of these actions, which have proven to be the right choice from a financial perspective, radiologists are independent within payment systems. Strengthened by this freedom and security, radiology professionals can pursue innovation, bold and revolutionary ideas, and make remarkable contributions to patient care. We have embraced the responsibilities that come with independence and accepted the challenges throughout our history, building a powerful, influential, and lasting medical specialty.

Today we, once again, face challenges to our hard-won independence. Some of these challenges are internal, such as the pressures to sell our practices to larger entities. Other challenges are external, such as the complicated payment models that threaten to turn radiology into a commodity rather than a professional service. In this climate, what will become of our independent spirit? Can we retain our independence while redefining our identity and expanding our influence? I do not know the answers and time will tell. But let us not forget our history of standing for independence. Let us be inspired by it.

Author Ezequiel Silva III, MD, FACR  Chair, ACR Commission on Economics