Interventional radiology is a victim of its own success. The widespread application of minimally invasive, image-directed, endovascular techniques-undeniably beneficial to both patients and interventional radiologists-has taken its toll on the traditional surgical management of vascular disease. Vascular surgeons, frustrated by the loss of turf to interventional radiologists, are on the offensive to reclaim their role in the treatment of vascular disease and revitalize their bottom line. A number of "mini-fellowships" are currently available to practicing surgeons to teach them interventional skills, and vascular surgery fellowship training programs will soon mandate instruction in image-directed endovascular techniques. In many circumstances, interventional radiologists and vascular surgeons are competing for the same patients, and with control of the referral pathway, surgeons are in an excellent position to displace radiologists as the predominant provider of endovascular therapy.

At Inland Imaging, interventional radiology is a central element of the practice, with more than 7,000 interventional cases performed in the year 2000, accounting for 12% of our professional revenues. That year, approximately 20% of the diagnostic and vascular interventions performed at Inland Imaging were referred by a single group of four vascular surgeons. That surgical practice, on the other hand, had experienced declining procedural volume during the preceding years, and the surgeons felt compelled to embrace endovascular interventions to secure their futures. As we began discussions with the surgeons in 2000, one of them had completed postfellowship training at a respected interventional program that would qualify him for privileges in our hospital's interventional radiology laboratory, and there were plans to send a second surgeon.

Radiologists feel vulnerable, and appropriately so, to the growing ranks of nonradiologists who have, or plan to, assimilate imaging into their repertoire. The threats to radiology are both financial and intellectual. Radiologists are in no position to compete for patients with clinicians who perform their own imaging, and the loss of patient referrals is likely to have significant and immediate consequences for a radiology practice. An analysis of simple referral and procedural statistics can provide an estimate of the revenues at risk and is the basis from which radiologists should begin to evaluate the cost of various responses.

A factor that is not easily quantified, however, is the risk to the intellectual vigor of an interventional radiology program drained of its patients. A significant loss of patient referrals may result in an oversupply of interventional radiologists, a real decline in their professional satisfaction, and the migration of one or more interventional partners from the practice. In the worst of cases, an interventional radiologist may join the vascular surgery practice, resulting in an immediate transfer of expertise and credibility to the competition.

Preserving the Whole

The risk to interventional radiology is, of course, only one of the challenges aimed at the broader body of radiology by nonradiologists seeking to perform imaging. In virtually all full-service radiology practices, highly reimbursed modalities-typically interventional radiology, MR, and CT-subsidize professional income from modalities with lower rates of reimbursement and practice activities that do not generate revenue (eg, administration, equipment capitalization, PACS development, radiology research, and radiology education). This dilemma is due, in large part, to the distortion of reimbursement built into the Medicare fee schedule, and used in some form by most insurance payors. Imaging procedures at the lucrative end of the reimbursement spectrum are an attractive source of new income for nonradiologists, anxious to offset income lost to declining reimbursement or to expand their businesses. Equipment vendors and entrepreneurial teaching centers are, for their own reasons, eager to assist nonradiologists in their quest to learn the techniques and business of imaging. As the profitable elements of radiology are cherry picked by nonradiologists, the integrated practice of radiology is at risk.

When radiology turf is threatened, our instinctive response is to circle the wagons. But defensive strategies that have served us in the past are unlikely to preserve imaging as the special domain of radiologists in the future. Exclusive hospital reading contracts may slow the foray of nonradiologists into the department, but hospital administrators are unwilling to antagonize physicians who admit patients and fill operating rooms. Hospital credentialing criteria, traditionally an obstacle to nonradiologists, will be useless when vascular surgeons and cardiologists demonstrate suitable training and experience to enable them to perform procedures in the radiology department. We hope to reassure ourselves that our clinical colleagues will become easily discouraged with the complexity of our jobs, and exit imaging as quickly as they embraced it. However, the financial incentives of self-referral are too compelling to ignore, and given enough time, nonradiologists have developed and will continue to develop successful imaging programs.

Consider the Options

Radiologists challenged by threats to their business have options, and thoughtful consideration of the alternatives is preferable to resigned indignation. In our environment, the relationship between the vascular surgeons and radiologists had historically been collaborative and the groups wanted to craft a solution that could be mutually beneficial. Foremost was the desire of both the interventional radiologists and vascular surgeons to create a system where decisions about patient management would not be colored by issues of turf. We believed that full and equal partnership of the radiologists and vascular surgeons was the best arrangement to align the incentives of both parties to cooperate on shared objectives. Our financial analysis projected a net loss of radiology revenues, but also exposed an enlightening consideration: the cost to the radiology practice would be similar whether the surgeons struck out on their own, or if the groups merged and radiology revenues were used to supplement surgical incomes. It is our near-term expectation that efficiencies gained from the merged practices will offset the income differential.

An option to full partnership is a physician co-employment arrangement that permits radiologists to work on a contractual, case-by-case basis for nonradiologists. Under this arrangement, interventional procedures referred by a vascular surgeon are billed by the surgical practice, which in turn pays the interventional radiologist a salary defined by an employment contract. The radiologist, who remains primarily employed by the radiology practice, performs the procedures and retains control of the imaging. The radiology practice may thwart piecemeal fragmentation and preserve its valuable intellectual capital.

As with all new ventures, we have encountered hurdles, some anticipated and some not. Disparities of cultures, practice style, and practice revenues have been the subject of continued discussion and tuning since the merger of our groups. At this time, our efforts are directed at improving the efficiency of the integrated practices by eliminating redundancy, utilizing information technology to improve the flow of patients and their records, and optimizing physician productivity.

The threats to radiology are significant. If we do not seek and implement creative strategies to address these challenges, radiology is at risk of being carved into small pieces, and controlled by a host of clinical specialists. Partnerships, joint ventures, creative contracting, and yet-to-be-devised alternatives will be necessary to preserve an integrated radiology practice while accommodating the interests of would-be imagers.

Don Cubberley, MD, is president, Inland Imaging Associates, PS, a group practice of 38 radiologists and five vascular surgeons in Spokane, Wash.