Ezequiel “Zeke” Silva III, MD, FSIR, is chair of the American Medical Association (AMA) Specialty Society Relative Value Scale Update Committee (RUC). The RUC influences payments within the Medicare program, which accounts for roughly $660 billion in healthcare spending annually. He is also the immediate past co-chair of the AMA Digital Payment Advisory Group (DMPAG). The DMPAG is a group of 15 national thought leaders on digital health, including artificial intelligence, which help shape the payment and regulatory landscape in this field.
Dr. Silva will be giving the Dr. Charles T. Dotter Lecture at SIR 2024. The Dotter Lecture was initiated in 1984 as an annual invited lecture to honor Dr. Dotter as one of the founding fathers of interventional radiology.
SIR Today: Can you tell us about your career?
Zeke Silva, MD, FSIR: I completed my interventional radiology fellowship at the Massachusetts General Hospital in 2002 and then joined the South Texas Radiology Group. We are a high-quality subspecialized private practice in San Antonio, Texas, and I have been with them for more than 20 years. With this group, I do mostly interventional and some diagnostic radiology.
SIR Today: Do you have a specific area of interest?
ZS: I started my career at our 1,500-bed tertiary care hospital doing the full gamut of IR, including considerable oncology interventions. As I’ve gained more administrative responsibility within my practice, I still do IR every day. I love diagnostic radiology and when I’m not doing a case, I read imaging. I have a particular interest in digital health and its role across healthcare, including telehealth, remote patient monitoring, digital therapeutics and AI.
SIR Today: What was your reaction when you were asked to be this year’s Charles T. Dotter lecturer?
ZS: I knew immediately how significant the invitation and opportunity were. I had some imposter syndrome because I know the quality of Dotter lecturers in the past. I know the history of Charles Dotter well and have so much respect for this specialty. This opportunity is a tremendous honor for me and I’m excited, thrilled and a bit nervous to do it.
SIR Today: Can you share a preview of your lecture’s focus?
ZS: When you think about the Dotter lecturers—the individuals, the interventional radiologists—who have given this lecture, every one of them has a reason why they’re on that stage. Some of them are simply great physicians and most of them are innovators. Some have been very successful in the academic space or even within SIR in an advocacy-type role. I think it’s relevant to ask the question: what’s my differentiator? I’m proud of my interventional radiology skills and what I’ve done for organized medicine, but I think my differentiator is my ability to contribute at the national policy level—to help formulate, craft and push forward policy that is favorable to interventional radiology as a specialty. With that in mind, I found my topic: innovation in interventional radiology from a public-policy perspective.
SIR Today: What drives your passion for IR?
ZS: What I love about IR is how, as a specialty, we’re so young. Our youth allows us to, in a condensed fashion, look at decision points that took our specialty from being an idea to being irreplaceable. Dr. Dotter was likely not innovating his therapies while thinking, “This is going to someday become a medical specialty,” or in our case, a medical society. He was just doing the right thing. He was an innovator trying to move technology forward in a way that impacted patient care positively. You would like to think in the grand scheme of things that doing the right thing is enough—you work hard to ensure high-quality outcomes for your patients and hope that your innovations and work will grow, spread and be recognized. You hope it’ll allow young physicians to do the same work and expound upon it, but it’s just not that simple. When you look at specialties that have been around for 100 years or more, such as general surgery or radiology, what they’ve been able to accomplish is significant, but the timeline is much longer than IR’s. But for us, because we’re so young, we can find very recent time points, decisions, challenges and opportunities that we’ve been able to overcome in recent memory. During many of our careers, we’ve seen our specialty evolve to where it is today—which is known for innovation, high-quality patient care and favorable outcomes.
SIR Today: How will your lecture address the opportunities offered by IR’s relatively young history?
ZS: I plan to focus on three time points. I will look at the past because the past informs the future. I believe lessons, successes and failures from the past help inform what we presently do and what we’ll do in the future. I plan on highlighting some remarkable policy successes of interventional radiology. I’m going to look at where we are in the present universe, what challenges—from a policy perspective—are affecting interventional radiology today, and then I’m going to speculate where I think we will be in the future. Obviously, the future for interventional radiology will be critical to our members, physicians, leaders and those who engage in public policy. We have to formulate the right strategies and decisions so we can continue to grow and provide high-quality care.
SIR Today: What would you consider one of the major policy successes that you mentioned?
ZS: I would say the fact that interventional radiology is recognized as a single-standing specialty is notable.
When we were a young specialty and establishing ourselves as credible, not just within our local medical staffs, hospitals or communities, but trying to take a national presence on advancing what we do, we believed in the innovation that interventional radiologists brought forward. However, there’s a joke that a lot of us tell: “I’m super proud of my job, but even my mom doesn’t know what I do.” Interventional radiology early on was this innovative, almost niche, specialty—but from a policy perspective, we had to establish our identity. There were very practical considerations; for example, we needed to be separately identified by policymakers as interventional radiologists. We wanted to be able to bill for our services and have procedural codes that not only described what we did, but also reimbursed fairly for what we did. We wanted to have consistent procedural codes for health-policy research. When billing for services, we wanted to say, “This is our specialty identifier: interventional radiology.” It was a very important step for our specialty. It took a lot of involvement and engagement—both at a specialty society level, but also getting out there in the trenches and working with regulators such as Medicare, as well as lawmakers, to have ourselves identified within statute and law. It took a sort of public relations campaign to get our name and recognition out there. These efforts aren’t old—we were working on this in the early ’80s, and we’re still working on it in a different way today.
SIR Today: How did you get involved in public policy and find that passion?
ZS: Honestly, it was SIR. When I was a resident, I was on my interventional radiology rotation. One of my attendings, Cliff Whigham, DO, mandated that when we performed an IR case, we had to indicate all the CPT codes we did for a charge master, or super bill.
Back then, I was at a trauma center, so we did a lot of arch aortograms, which have since been replaced with CTs. We would have trauma patients come in and we’d get in the aorta with a catheter. We’d do the aortogram and see if there was deceleration or traumatic injury. If we had to select vessels, we would do that, then leave the procedure room, go to a piece of paper and indicate all the CPT codes that we did.
I found it interesting that medicine had created a system to describe what physicians do. We created this complex system where you have five-digit codes to describe not just what interventional radiologists did, but what surgeons or primary care physicians did. So, I decided very early on that I was going to learn as much as I could about that system. When I joined my practice in San Antonio, I managed all of the interventional radiology coding. I would read every IR report and add the proper codes for billing. Around that time, I got involved with SIR and joined our Economics Committee, which I later chaired. Eventually I became involved with the SIR coding and nomenclature activities and presented several codes to the CPT editorial panel. I also began attending the RUC meetings. I was doing this for SIR, but then I began doing it for the American College of Radiology around the time we were restructuring and revaluing much of the CT and MR families. At the same time, many of IR’s component codes were being reviewed. Along the way, I assumed more and more responsibility in payment policy. I’m now chair of the AMA’s RVS Update Committee. I’m the first interventional radiologist to be in that role. It’s a significant credit to not just me as a professional, but also the specialty I represent and SIR in general.
SIR Today: Why do you think it’s crucial for other IRs to pay attention to this area?
ZS: I firmly believe, and I say this as chair of the RUC, that physicians know best what it takes to do what we do. That may seem obvious, but the reality is that there are policymakers who believe they can help inform the resources necessary to do our jobs. I’ve been in many meetings where I’m at a table full of policymakers and I’m the only physician—and definitely the only interventional radiologist. I’m the only member of the medical community present. We’ll be talking and engaging in policy decisions and then I find I’m the one who raises my hand and says, “Let’s think about this at the patient-care level. What does this mean for physician–patient interaction? What does this mean for patient experience? What does this mean for physician well-being?” Policymakers and administrators can’t do this without physicians. They think they might be able to, but if they’re going to create a policy that affects interventional radiologists, it would be beneficial to have the interventional radiologists on board. The only way we can be at the table is if we engage and participate.
I’m a big believer in associations. I say that not just for interventional radiologists, radiologists or even physicians. I believe that every member of our society has the responsibility and obligation to contribute to associations that are striving to improve conditions within our sphere of influence. Our ability to contribute to SIR, even as a member and attending meetings, is crucial for our specialty. Having several of us that are willing to roll up our sleeves and get into the policy space, work with our lobbyists and government relations leads, go to the meetings and take time away from our practices is mission critical to what we do. It sounds trite, but if we don’t do it, someone else will, and they’re not going to do it better than we as interventional radiologists can.
SIR Today: If somebody walks away from your lecture wanting to get more involved in this area and contribute, what would you recommend? How can they do that?
ZS: I think: 1) be involved with SIR and 2) engage in what SIR produces. One example is IRQ’s monthly coding and nomenclature and reimbursement columns. There’s a couple of organizations that I think do a very good job of these types of issues within the radiology space, including interventional radiology. The ACR and Radiology Business Managers Association both do a very good job, but it’s really important to understand that when we think about public policy, we think about the ability of a doctor to contribute. Some of us have MBAs and some have done policy fellowships. I love that. Don’t get me wrong—there is nothing wrong with being a physician and doing the Robert Wood Johnson fellowship or doing a fellowship with some government agency. But for practical reasons, not all of us can do that. We just don’t have the ability to take that much time off from our practices. For those who can’t commit that time, you can still get involved and get educated. Read as much as you’re able. It takes time—you can’t flip the switch and know everything about code valuation, coverage policy around IR or even what we do in the academic setting. Effectively advocating for ourselves requires a very real long-term commitment, but it is fulfilling.
SIR Today: What message would you like members to take away from your lecture?
ZS: Currently, IR is in a transformative period because now we have an independent training pathway for interventional radiologists. We’re becoming independent from diagnostic radiology and beginning to function more as a clinically based specialty. We’re thinking about the best way for our practice models to evolve, so as we look to the future, we should think about our successes in the past. It’s remarkable that we have taken the innovations of someone like Dr. Dotter, such as doing the first angioplasty to save a patient’s extremity. We have built on that innovation to create more complex and meaningful therapies ever since.
I think we should ask ourselves, “What and who are we going to be in the future? How are we going to effectively continue to advocate for what we do?” Because there’s a lot of changes around us. Think about how rapidly we’re seeing digital health technologies evolve—we’re quickly seeing the emergence of telemedicine, telehealth, remote patient monitoring, hospital-at-home care, digital therapeutics, large language models and artificial intelligence. Think about how quickly that digital space is changing. It’s a fair question to ask what interventional radiology’s role is in that. You can’t do an interventional radiology procedure by telemedicine or telehealth, but you might receive a referral and evaluate patients via telemedicine and telehealth. I think we’re seeing a move away from traditional fee for service—what we think of as component coding—to more value-based care. We’re seeing that not just at the public, government-payer level, but also at the private-payer level. We should ask ourselves, “How are our services going to be recognized and valued within evolving payment models?” I think those ideas are on top of what is our normal baseline level of activity, which is creating very real opportunities for us to continue to make a difference.
Don’t miss Dr. Silva’s Dotter Lecture on Sunday, March 24 at SIR 2024 in Salt Lake City.
