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Weekly UpdatesAs the number of radiologists in practice and the number of residents entering the radiology field dwindle, the need for physician extenders in radiology becomes more evident. The concept of advanced-level radiologic technologists is not new; educational programs were first developed in the 1970s. However, there was little support for those programs because the need to introduce a nonphysician clinician into the radiology environment could not be demonstrated clearly or justified at the time. (1) The radiologist practitioner assistant (RPA) program at Weber State University in the mid-1990s produced the next wave of radiology physician extenders. (2)
In March 2004, an Advanced Practice Advisory Panel consisting of representatives from the American College of Radiology (ACR), American Society of Radiologic Technologists (ASRT), American Registry of Radiologic Technologists (ARRT), state regulatory agencies, radiologic science education programs, medical imaging manufacturers and RPAs met in Washington, District of Columbia, to explore key issues surrounding the development of the radiologist assistant (RA) career track. This advanced-level career pathway was developed to provide career development options for technologists and to bridge the potential patient care gap caused by the deficit of radiologists.
The registered radiologist assistant (R.R.A.) role was developed to meet these needs. R.R.A.s are ARRT-certified radiologic technologists with a minimum of a baccalaureate degree who have completed an advanced academic program with a nationally recognized RA curriculum and a radiologist-directed clinical preceptorship. With radiologist supervision, R.R.A.s extend the capacity of radiologists in the diagnostic imaging environment by performing patient assessment, patient management, fluoroscopy and other radiology procedures.
Specifically, the ACR supports the development of the R.R.A. role, stating that "ACR officials believe the development of the radiologist assistant position will relieve some of the time pressures experienced by radiologists due to ongoing workforce shortages, thereby permitting them to devote available resources to more productive patient care tasks." (3) R.R.A.s also make initial observations regarding diagnostic images, but do not provide an official interpretation (final written report) as defined by the ACR Standard for Communication: Diagnostic Radiology. (1)
A review of literature revealed limited quantitative evidence of the benefit of R.R.A.s to radiologists because the career identification is still in its infancy. Although radiologists continue to be solely responsible for interpreting exams, R.R.A.s perform certain procedures and patient care tasks as physician extenders that could improve overall productivity and cost savings in radiology departments.
This case study, or profile of clinical productivity, was designed to assess the value of R.R.A.s in improving radiology department productivity by freeing radiologists' time and increasing reimbursement revenue. Also, this study demonstrates an opportunity to improve quality of patient care and identifies some of the R.R.A.s' most frequent roles and responsibilities in the health care setting. Under faculty direction, RA students from Midwestern State University conducted this nonexperimental descriptive study to document their patient management, time savings and potential reimbursement revenue impact.
Review of the Literature
Radiologist Shortage
In the early 21st century, most experts predicted that there would be a shortage of radiologists and radiologic technologists, especially in rural areas. The reasons were multifaceted and included the following: The number of procedures increased 4.5% annually, the number of relative value units increased by about 6% and the number of radiologists expected to retire was higher than the number of radiology residents expected to enter the work force. (4)
According to the Physician Compensation Report, an annual increase in image volume between 7% and 17% was expected. In the same report, 35% of radiologists surveyed thought that they read too many studies and 33% believed that patient quality of care had decreased because of the radiologist shortage. (5) One study specifically suggested that increased use of teleradiology services and radiologist assistants might provide solutions to the radiology shortage. (6)
More recent studies have indicated that the radiologist shortage has eased overall because of increased radiologist productivity. (7) Between 2000 and 2003 the total number of imaging procedures continued to increase as predicted (about 20%). The number of outsourced interpretations did not displace much of the workload. There was a 10% to 20% decrease in the number of radiology residents and no decrease in the retirement rates of radiologists. Despite factors that would suggest a pending crisis, radiologists' average annual work hours remained relatively constant. This means that productivity during those work hours must have increased sharply to offset the reduced work force available. If this trend continues, R.R.A.s will play an increasingly important role in improving the productivity of the medical imaging department.
Reimbursement
Other physician extenders such as nurse practitioners (NPs) and physician assistants (PAs) have been in the work force longer, and more data have been collected for those fields. Although it is possible to compare the roles of these other physician extenders to R.R.A.s in many ways, there are also important differences.
NPs and PAs can bill independently for certain services. NPs receive direct reimbursement from Medicare, but reimbursement for PA services, even when billed independently, is sent to the employing physician. (8) Supervising physicians may bill for services provided by PAs. This includes procedures performed, as well as patient evaluation and management. Although billing for services provided by physician extenders is not complex, some regulations, as well as interpretation of the rules, vary by state and payer. Medicare reimburses services provided by PAs because they have a provider number, but Medicare is still contemplating the logistics of doing this for R.R.A.s. (9) As of January 1, 1998, Medicare pays the PAs' employers for medical services provided by PAs in all settings at 85% of the physician's fee schedule. This includes hospitals (inpatient, outpatient and emergency departments), nursing facilities, home offices and clinics, and first assisting at surgery. (10) Eventually this may be how R.R.A. services are reimbursed, but no final decisions have been announced by the Centers for Medicaid and Medicare Services.
Methods
Although the data in this study represent only a small sample of data collected by RA students and many liberties were taken with averaging values, it is hoped that the quantitative and qualitative data will initiate dialogue between radiology groups and hospital administrators and prompt more objective observation of the effectiveness of R.R.A.s in clinical settings.
For this study, 4 second-year RA students who were enrolled in the Midwestern State University radiologist assistant program collected data related to a subset of their clinical competency requirements during a period of 336 clinical hours (42 regular 8-hour workdays) during the fall of 2005. The students were from 4 different clinical sites in 3 states and represented a mix of both urban and rural clinical settings. Based on their clinical experiences, they chose to collect data for 10 procedures and 4 patient management tasks commonly performed by all of them. For the purposes of this study, "reimbursement" refers to the Medicare compensation provided to the physician for the procedure or services performed. Medicare rates vary for different areas of the country; therefore, the rates for the geographic areas (ie, Texas, Oklahoma and Alabama) of the students in this study were averaged.
Results
Table 1 shows a profile of the different clinical sites included in the study and the total exams performed. It also identifies the most frequent exam performed by each RA student. An average of 3.4 cases per student per day were performed during this time.
To be eligible for the R.R.A. certification exam, the ARRT requires students to perform specific clinical competencies. Table 2 shows the average number of ARRT-mandated clinical competency procedures the students performed within this time period. It also indicates the mean reimbursement rate and time needed to perform each procedure.
The time needed to perform these procedures ranged from 14.68 minutes to 31.77 minutes, with an average of 25.52 minutes. The total number of these procedures during this period was 128.75. The average daily time savings for the mandatory procedures was 86.75 minutes. The range of average reimbursements for the procedures was $15.94 to $1204.74, with an average reimbursement of $198.57.
Although no conclusion has been reached on Medicare reimbursement for procedures performed by R.R.A.s in nonhospital settings, an 85% Medicare reimbursement rate was applied for the purposes of this study. Table 2 shows the results of multiplying the hypothetical R.R.A. reimbursement rates by the total number of cases performed by the RA students during the 42-day period to yield a total of $15 924.04 that a radiology group would collect for these procedures if they were performed by an R.R.A. during the 42 days under observation. Additionally, radiologists would gain an extra 86.75 minutes per day that could be devoted to interpretation of other examinations. Assuming a 250-day year, the revenue for the radiology group could be approximately $94 785.95, based on these estimations.
Another critical motivation for developing the R.R.A. career option is to improve patient care. Patient care activities include tasks such as obtaining a patient history and physical examination, obtaining informed consent, conducting patient follow-up and facilitating the patient workup. Table 3 shows the average number of patient care activities and the time spent doing those activities.
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