Recruitment Retention and Skills – Rural America’s Radiology Challenge

The ACR and the SIR, working together in a joint task force, recently made recommendations in the form of a consensus document to expand access to image-guided procedures for patients living in rural areas or served by small, independent IR practices.

Researchers Laura Findeiss, MD, of Emory Healthcare and Tim Swan, MD, of Marshfield Clinic Health System, and one of ACR’s board of chancellors, coauthored a report published online in the October 7 JACR. Their report focuses on recruiting, training, and retaining interventional radiologists in rural areas and small practices. For example, recent studies reveal:

• Only 347 counties of the 3,142 counties in the United States have practicing interventional radiologists residing in the counties.
• Only 869 counties had any radiologist present to perform image-guided procedures.
• 8% of hospitalized Medicare beneficiaries require at least one IR procedure during hospitalization, yet only 5% of IR procedures occur in rural areas.

Study authors comment, “As IR procedures lead to cost savings and a decrease in length of hospital stay, the absence of an interventional radiologist may exacerbate the economic challenges faced by rural hospitals.”

The task force broke down IR procedures into 3 levels of complexity. They classified 12 procedures as Level 1 — relatively easy procedures that constitute a portion of an economically- feasible IR framework. They also utilized data from the annual ACR survey, where questions seek to determine the competency and comfort of radiology residents when performing the 12 level 1 IR procedures — judged as relatively easy. The results are the percentage of residents who felt comfortable performing each of the level 1 IR procedures.

• Abscess drainage – 43%
• Arthrogram/Joint aspiration – 36%
• Breast biopsy – 39%
• Exchange of suprapubic/gastronomy catheter – 39%
• Lumbar epidural steroid injection/facet block – 18%
• Lumbar puncture (e.g., CSF drainage, myelography) – 36%
• Lung biopsy – 29%
• Paracentesis/Thoracentesis – 68%
• Peripherally inserted central catheter – 43%
• Sacroiliac joint block – 18%
• Solid organ biopsy – 46%
• Thyroid fine-needle aspiration – 36%

The study’s authors discovered that “limited data suggests that diagnostic radiology residency programs may not provide adequate training for the performance of level 1 procedures.” They commented, “Presently, diagnostic radiology residents are required to perform only 25 image-guided biopsies or drainages during training. Consequently, the typical graduating diagnostic radiology resident may not be prepared to perform level 1 procedures.”

“The task force recommends that the radiology training environment be assessed for deficiencies in procedural training and that the radiology residency curriculum be modified to ensure diagnostic radiology competency in level 1 procedures. Additional postgraduate training opportunities can be offered by the ACR and SIR to target specific procedural training deficiencies.”

 

The Rural Challenges Point to Localized Solutions

A 2017 survey of Society of Interventional Radiology (SIR) and ACR members revealed:

• 29% of rural practices fell short of providing needed IR services
• 59% of rural respondents had difficulty recruiting interventional radiologists
• 40% also experienced problems retaining them
• 56% of interventional radiologists are reluctant to perform diagnostic work
• 49% are unwilling to practice in a rural setting
• 68% mentioned inadequate case complexity
• 66% complained of case volumes in rural practices

Yet, 76% of respondents agreed that the presence of an IR service stabilizes hospital radiology service contracts, while 84% endorsed the value of IR services beyond the revenue generated by IR procedures.

Following the 2017 study and recognizing the negative downstream effects of the interventional radiology workforce challenge on patients, communities, the specialty of interventional radiology, and the house of radiology, ACR and SIR established a joint task force specific to smaller and more rural practices to explore and focus on 4 topics.

1. The value proposition to radiology practices of providing more access to IR service
2. Distinguish the critical workforce and community characteristics to identify where better recruitment and retention efforts are needed
3. The impact of interventional radiology on hospital and health systems and communities, such as population-based patient outcomes, care-delay costs, and lost revenues from leakage of patients — to provide a basis for recruiting interventional radiologists
4. Explore alternative interventional and diagnostic radiology contracting models to address the instability of recruitment and retention of interventional radiologists

Table 1: Aggregated practice types and descriptions

Practice Type	Description
“Hub and spoke”	Multiple smaller facilities with limited interventional radiologic/image-guided procedures and/or temporal availability; referral pathway to larger facility for complex or after-hours procedures
Single/Small	Diagnostic radiologists perform both level 1 procedures and diagnostic services
Independent contractor interventional radiologist	Interventional radiologist covers several small facilities in geographic region
Hospital contracted interventional radiologist	Interventional radiologist is employed by or contracts directly with hospital/system, not employed by radiology practice
Mixed diagnostic/interventional radiology	Radiology group: interventional radiologist does level 2 and 3 procedures and reads general diagnostic radiologic studies; diagnostic radiologist performs level 1 procedures and reads subspecialty diagnostic radiology

 

Table 2: Examples of revenue and expense items to consider

In development of financial model

 

Revenue Items	Expense Items
Technical, professional, and global reimbursement	Capital equipment
Procedure CPT codes and volumes	Device inventory
Projected downstream imaging revenues	Staff salaries and fringe benefits
Evaluation and management charges	Clinic space lease/purchase
Projected value of added service lines (hospital revenue)	Coding and billing services
Bed opportunity benefit/improved margin per DRG due to savings from decreased length of stay
Value of patient retention, per service line

 

After identifying the above information, task force members collaborated to identify four challenges faced by IR practices in S/R communities.

“The ability to provide 24/7/365 access to image-guided procedures is limited by the availability of physicians, technologists, and nursing staff members with the necessary skill set.”

 

“The availability of emergency coverage of level 1 and most level 2 services, in the analyzed group of practices, is linked to at least a 300-bed hospital to support three interventional radiologists, the minimum number needed for 24/7/365 coverage.”

 

“The presence of certain subspecialties, such as urology, nephrology, gastroenterology, wound care, oncology, and obstetrics and gynecology, often dictates the types and complexity of procedures that are performed.”

 

“Division of labor, practice financial issues, and after-hours coverage for both diagnostic and IR services often cause friction between diagnostic and interventional radiologists in the same group.”

 

The research authors and the task force members suggest that both hospitals and radiology groups must be flexible and realistic about their return on investment. The authors remind both parties, “Existing payment models generate significant hospital technical revenue from IR services. The relatively low hospital costs for IR services and the decreased inpatient length of stay improve hospital margins.

“Professional revenues from IR services are relatively low compared with diagnostic radiologic services, with lower work relative value units per unit of time. Therefore, hospitals and radiology groups may not be aligned on the financial benefits of interventional radiology.”

Negotiations must be sensitive to local considerations — variations in expenses and revenue and other variables involving payer contracts and case mix.

The task force’s takeaway is two-fold:

1. Level 1 procedures are those that most diagnostic radiologists, regardless of their subspecialty training, should feel comfortable performing.
2. Data suggests that diagnostic radiology residency programs may not provide adequate training for performing level 1 procedures.