As interventional radiology continues its evolution to a clinical specialty, the responsibilities of the IR service also continue to change. Preprocedure consultation, patient education, inpatient rounding and postprocedural follow-up are no longer beyond the scope of practice; in fact, they are an imperative. At the same time, changes in health care finance are creating a tremendous incentive in hospitals to shorten length of stay and improve the quality of care—both of which goals rely heavily on the IR service.
As a result of these pressures, many IR groups are turning to physician extenders (also referred to as midlevel providers or clinical associates) to keep the wheels turning. A recent survey of the five hospitals in Seattle, Wash. (excluding the Puget Sound VA) found at least one IR physician extender at each, with two facilities each employing two of these individuals. A single practice group in Spokane, Wash., employs four.
Depending on the needs of the practice and the laws of the state in which they reside, physician extenders can dramatically increase the efficiency of an IR service. Physician extenders can see patients in clinic before and after treatment; review medical records and study results; provide patient education; dictate letters, reports and insurance appeals; coordinate longitudinal care and referrals to other providers; consult and round on inpatients (yours and others’); and, in many facilities, independently perform IR procedures.
For IR practices that are already performing the evaluation and management (E&M) services listed above, shifting that responsibility to a physician extender gives the physicians more time for their procedures, which can improve throughput and increase both case volume and the quality of procedural care. Practices that do not currently perform and bill for E&M service can, with the addition of a physician extender, recognize an incremental increase in billing revenue while at the same time improving the quality of patient care and satisfaction among both patients and their referring providers. Furthermore, having dedicated clinical management can result in the capture of procedural and imaging studies that might otherwise be overlooked or forgotten (such as filter retrieval or follow-up MRI after UFE).
Very busy practices may opt to use physician extenders as proceduralists for certain routine cases, such as vascular access or drainage. Doing so can improve departmental throughput, allow the physicians to focus on more complex cases, or allow the physicians to dictate imaging procedures while the physician extender handles cases that would generate lower RVUs than those imaging studies. The specific nature of procedural work available to a physician extender is subject to each institution’s credentialing body as well as state practice law, as further discussed below.
Physician extender types
Three groups of physician extender lend themselves to an IR practice: nurse practitioners (NPs), physician assistants (PAs) and radiology assistants (RAs). These groups vary greatly in their background, training pathways and practice paradigms, and there are still further variations within each practitioner group by state of licensure. (See table on p. 24.)
Nurse practitioners
The first formal training program for clinical NPs was launched in 1965. There are now more than 350 NP programs in the United States offering master’s and doctoral degrees, with approximately 150,000 NPs practicing in this country. Enrollment requires a registered nurse (RN) degree and most programs also require a period of clinical experience prior to matriculation. Since their students have already had exposure to a broad range of clinical issues, NP programs are specialty-specific and weighted toward classroom didactics. The national average of clinical (e.g., bedside) training hours for a master’s level NP program is reported to be 686 (17 weeks), whereas the minimum number required for accreditation is 500 (13 weeks). This clinical exposure, like the training itself, is specialty-specific and is distributed over the entire period of training.
NPs are independently licensed and have prescriptive authority in all 50 states and the District of Columbia, though many states require a “collaborative relationship” or physician supervision for prescriptions to be honored. NPs have the ability to prescribe controlled substances under the same restrictions in all states but Alabama and Florida, where they have no such ability. In 17 states, NPs can operate independent practices without physician oversight; the others require varying degrees of physician supervision. An interactive summary of NP scope of practice by state is available at bartonassociates.com.
NPs qualify for National Practitioner Identification (NPI) numbers and bill CMS under their own numbers for their work. When doing so, their Medicare reimbursement rate is fixed at 85 percent of that of a physician.
Physician assistants
The first group of PAs, which coincidentally also began training in 1965, was made up of former navy corpsmen. This pathway from military medic to PA continued for many years and initially a large number of PAs were former medics or corpsmen. PA training programs—of which there are currently more than 150 conferring either bachelor’s or master’s degrees—are modeled on the training of physicians and consist of a year of preclinical classroom education followed by a year of broad-based formal clinical rotations much like those of medical students. The number of clinical (e.g., bedside) training hours for a PA is approximately 2,000. There are approximately 90,000 PAs in practice in the United States.
PAs are licensed to practice and to prescribe medications in all 50 states and the District of Columbia, as well as all offshore territories but Puerto Rico. They can prescribe controlled substances in all states but Kentucky and Florida. Unlike NPs, who offer fully independent services in some states, PAs in all states require oversight by a physician. The specific obligations of that oversight vary by state, but direct, on-site supervision and cosignature of notes and orders are not required. Rather, there is an expectation that the PA and physician will have a shared approach to management and will regularly confer and that complex or unusual cases will be managed with direct interaction. This arrangement may require a formal written practice plan in some states. Some states also specify an “on-site” requirement under which the supervising physician must be physically present at the PA’s practice location for a minimum fixed percentage of time. A summary of state law regarding PA practice is available at aapa.org.
Like NPs, PAs have unique NPI numbers and bill CMS at 85 percent of the rate of a physician for the
same work.
Radiology assistants
Radiology assistant is the generalized phrase used to describe an advanced practice radiologic technologist whose additional training allows him or her to operate semi-autonomously within a radiology environment. More specifically, these individuals are either radiology practitioner assistants (RPAs, not to be confused with “registered physician assistants,” who are also sometimes called RPAs) or registered radiology assistants (RRAs), a designation that reflects some variations in their training paradigms and prerequisites that are beyond the scope of this article. RAs in either group complete a two-year program that culminates in a bachelor’s or master’s degree. There are at present 10 RPA or RRA programs in the United States, with approximately 700 graduates
in practice.
Although the RA training paradigm requires “clinical preceptorships,” these are rotations through different areas of the imaging department rather than medical/surgical rotations as experienced by the other trainee groups. The RPA curriculum includes two courses in which students are presented with patient histories, lab values, images and other clinical information and are required to predict imaging findings and the likely clinical pathway. However, in general, RAs have no specific training in clinical management beyond that which occurs in the radiology department. Therefore, while an RA may interview a patient and aggregate data regarding that patient’s history, he or she would not be expected to generate or document billable history and physical examinations (H&Ps), consult notes or rounding notes. Similarly, while an RA might maintain a database of patients requiring follow-up imaging, lab studies or clinic visits, he or she would not order those studies or visits. Because they do not have prescriptive authority, RAs cannot supervise or administer medications and are therefore unable to independently perform any procedures that require sedation. However, they can, within a given institution, be credentialed to perform other invasive procedures that do not require sedation (joint injections, lumbar punctures, catheter checks, PICC line placements, etc.).
RPAs, but not RRAs, are able to obtain NPI numbers. However, neither category of RA is recognized by CMS for billing purposes. In some very specific situations the work of an RA can be billed under the physician’s NPI, but his or her work is otherwise not billable. A very detailed discussion of these issues is available at cbrpa.org
One unique characteristic of the radiology assistant approach is the opportunity for on-site training. Some RA programs offer distance learning pathways that allow the candidate to obtain his or her practical training at the institution in which he or she already works. It is therefore possible for a highly qualified and motivated technologist to advance his or her training and career without having to leave the job site that has nurtured that motivation. As long as certain criteria are met (such as the number of specific procedures that must be performed), training can be tailored to meet the needs of the practice group rather than conforming to a national standard that might not be entirely relevant. And because the training covers all aspects of a radiology practice, rather than just IR, an RA might be utilized more broadly in the department than would an NP or PA. This might be advantageous in a smaller radiology department with limited subspecialization.
Financial considerations
According to the Medical Group Management Association’s “Physician Compensation and Production Survey 2009 Report Based on 2008 Data,” the median salary for a full-time NP or PA in 2008 was between $80,000 and $88,000 (current salary levels are higher; see table at right). Median collections by those individuals were between $200,000 and $250,000, for a compensation-to-collections ratio of 0.35–0.38. Thus, the addition of an NP or PA could reasonably be expected to be revenue-neutral or better even if his or her work is limited solely to E&M billing. However, since a physician extender is likely to generate additional imaging and procedural studies, his or her contribution to the revenue stream of an imaging practice is likely to be much greater.
As previously noted, RAs cannot bill independently, so their value lies in allowing the physician to focus upon activities that do generate revenue. Unpublished data from the cbrpa.org link cited previously report that use of an RA produced a time savings for the typical diagnostic radiologist of 3.5 hours/day, which the authors correlated to a total of $2,548.74 per day and $637,185.00 per year in increased revenue.
Conclusions
As the landscape of medical care in the United States changes, ever more is expected of the IR service. Yet, at the same time, the increasing visibility of IR and its growing recognition as a clinical specialty present new opportunities. Physician extenders can help in both areas by being “the face” of the IR service in the clinic and on the hospital wards, by improving the flow of patients through their IR experience and by ensuring that the IR physicians meet their longitudinal care obligations and also realize the follow-up imaging and procedural opportunities that might otherwise be missed. Far from representing an additional cost to the IR service, these individuals can not only cover their own salaries but also generate incremental new revenue. Local needs and state regulations will play a significant role in determining which physician extender group will fit best into any given practice.
Additional information
American Association of Nurse Practitioners: www.aanp.org
American Academy of Physician Assistants: www.aapa.org
Certification Board of Radiology Practitioner Assistants: www.cbrpa.org
American Registry of Radiologic Technologists: www.arrt.org
American Society of Radiologic Technologists: www.asrt.org.
The author thanks the following individuals for their assistance in the preparation of this article: Kathy Taylor, MS, FNP-C, chair, SIR Clinical Associates Committee; Ann Davis, PA-C, MS; and Jane Van Valkenburg, PhD, RPA.
