The Royal
Australian and
New Zealand
College of
Radiologists
Detailed Review of
Funding for
Diagnostic Imaging
Services
RANZCR Submission
May 2010
Contents
Executive Summary .................................................................................................................. 3
Context of the DI Review.......................................................................................................... 6
Importance of Diagnostic Imaging ............................................................................................ 8
Appropriateness......................................................................................................................... 9
Health System Reforms and DI Services ................................................................................ 12
Current DI Service Delivery ............................................................................................... 14
Future DI Service Delivery ..................................................................................................... 16
Patient Access to Comprehensive DI Services.................................................................... 16
Improved Patient Access for Rural and Remote Communities ........................................... 16
Professional Supervision and Accountability...................................................................... 17
Integrated Patient Care ........................................................................................................ 17
Changes to Current DI Service Delivery Arrangements ..................................................... 18
Radiologist Training............................................................................................................ 19
Training Networks............................................................................................................... 20
Shortage of Interventional Radiologists .............................................................................. 20
DI Funding Arrangements....................................................................................................... 20
Public Sector Issues............................................................................................................. 21
DI Rebates ........................................................................................................................... 22
Indexation ............................................................................................................................ 24
Diagnostic Imaging Services Table (DIST) ........................................................................ 25
Access to Quality Assured MRI Services ............................................................................... 29
Clinical appropriateness ...................................................................................................... 29
Patient Access ..................................................................................................................... 29
Patient Billing Arrangements .............................................................................................. 30
MBS Rebates ....................................................................................................................... 31
Indexation ............................................................................................................................ 31
Improving Access to Quality Assured MRI Services ......................................................... 31
GP referral for MRI ............................................................................................................. 31
Substitution for Inappropriate CT ....................................................................................... 32
Strategies for Improving Access to Quality Assured MRI Services ................................... 32
Access to Quality Assured PET Services ................................................................................ 33
Restrictive Patient Access to MBS Approved Indications. ................................................. 34
Inequitable Patient Access to Funded PET Services ........................................................... 34
Under funding of MBS PET Services ................................................................................. 34
Future Developments .......................................................................................................... 35
PET Rebates ........................................................................................................................ 35
Indexation ............................................................................................................................ 35
Proposal to Restructure PET Item Descriptors.................................................................... 35
Improving Access to Quality Assured PET Services .......................................................... 36
Summary of Key Points .......................................................................................................... 38
Attachment 1 - Elements of a Comprehensive Diagnostic Imaging Practice ......................... 41
RANZCR Submission to DI Review, May 2010
Page 2
Executive Summary
This submission has been prepared by The Royal Australian and New Zealand College of
Radiologists (the College) in response to the Department of Health and Ageing’s Discussion
Paper on the Detailed Review of Funding for Diagnostic Imaging Services (DI Review).
Rather than attempting to respond to the specific questions raised in the Discussion Paper, the
College’s submission focuses on key areas the College believes the Government needs to take
into account in determining the future funding of diagnostic imaging (DI) services. The College
views this submission to the DI Review as just the first stage of a process to develop a
framework for the future delivery of DI services and the funding of those services. The College
will provide further input when the Department releases a second, more focused discussion
paper in mid-2010, outlining the results of the current information gathering phase and
identifying a range of possible options for further consideration by stakeholders.
Changes to the overall healthcare delivery system impact diagnostic imaging
DI is an integral component of 21st Century healthcare and must be factored in to the
development of broader healthcare reform policies. Given the potential for these broader health
reforms to impact on DI services, the College would like a commitment from the Government
to establish an overarching approach to diagnostic imaging that is informed by the advice of
experts working in the field. The College recommends a formal structure, such as a DI Advisory
Group, be established as the principal advisor to the Government on policy and service delivery
implications for DI of the broader health reforms as these evolve, and to manage associated
change.
Consideration needs to be given to how DI will fit into the delivery of acute services both in and
out of hospitals, how DI will be integrated into the management of patients with chronic illness,
how DI will help in prevention and how to optimise the integration of DI systems and other
information and communications technology (ICT) tools into Australia’s eHealth system.
Radiologists should have a greater role in overall patient management.
Radiologists have expertise to bring to clinical treatment and management but their clinical
expertise is not utilised to its full potential. With the wide range of complex imaging modalities
available today, radiologists should have a greater role in patient management as key members
of multi-disciplinary teams focused on patient treatment and care.
A multi-faceted approach is needed to ensure that imaging is appropriate and
clinically accountable.
Approaches that address the causes of clinically inappropriate or unnecessary imaging will be
required to achieve practical and sustainable improvement in the appropriate use of DI. These
approaches need to address the lack of basic medical training in diagnostic imaging, the
radiologist’s role, referrer education, greater access to MRI, more effective use of ICT for
decision support and eHealth and issues of reasonable rationing and priority setting.
The current MBS fee for service model has worked well to provide reasonable patient
access to high quality imaging services and healthy competition between providers.
Any proposal to shift to alternative funding mechanisms will need careful policy design to
ensure maintenance of quality DI services and appropriate patient access to services, as well as
to avoid instability, variations in performance and inequalities.
RANZCR Submission to DI Review, May 2010
Page 3
Patient access to comprehensive DI practices offers the most cost effective use of
resources for delivering quality assured imaging services to the majority of
Australians.
Australians already have very good access to “one stop” comprehensive DI services. Planning is
needed to avoid an unnecessary duplication of services. A viable network of professionally
supervised comprehensive practices, supported by increased funding for patient travel and
accommodation for people living in rural and more remote areas, is the most cost effective
model of delivering high quality DI services that are accessible to patients. With the networking
potential afforded by ICT systems, this is the most efficient model and the most effective use of
resources for responding to the emerging needs of a more patient centred approach. ICT also has
the potential to improve access to specialist supervision and opinions for people in rural and
remote communities.
A serious investment in training is required to provide the radiologist workforce
needed to meet the future demand for imaging services.
The College estimates that training positions in Radiology will need to increase to at least 450
by 2012, a 20% increase over 2010. There must be further expansion of training places in
private comprehensive practices where trainees can obtain the necessary range of experience. It
is untenable for the public sector to continue to carry the full burden of Radiologist training.
DI funding needs to support the viability of both the public and private DI sectors.
The College supports a complementary mix of public and private DI service providers. The
College would like to see changes to public sector funding aimed at achieving sustainable and
equitable funding for both public hospitals and private radiology practices.
Current DI rebates do not cover the cost of providing quality, affordable DI services. Rebates
should be closely aligned to the cost of providing services or at least a viable mechanism is
needed to encourage providers to provide services without charge to those in the community
who are genuinely not able to pay a patient co-payment (eg pensioners and concession card
holders).
The only way private practices can meet increasing costs and continue to provide quality
services is by charging patients a co-payment. Rebates need to be indexed for increasing costs,
especially wages.
The Diagnostic Imaging Services Table (DIST) is outmoded and needs to be
simplified and rewritten.
The College supports the establishment of a DIST Committee to provide advice on the
composition of the DIST and associated rules and regulations.
Priority should be given to improving patient access to quality assured MRI services.
Access to MRI is a fundamental component of medical services in the 21st Century. MRI
licensing and funding arrangements have created a range of inequities for both providers and
patients. A sustainable framework for equitable and improved access to MRI must be an
outcome of this review.
Priority should be given to improving access to and affordability of quality assured
PET services.
Patient access to PET services is restricted by the current MBS approved items and by the
unplanned evolution of PET services. The use of PET in Australia is lagging behind that of
other developed countries with modern cancer care.
RANZCR Submission to DI Review, May 2010
Page 4
A sustainable framework is needed for improving access to and the affordability of PET
services.
The treatment of the capital component for Medicare funded PET services needs to be brought
into line with the treatment of the capital component of other DI services.
Any patient with a histological proven cancer should have access to timely, life saving and life
modifying Medicare funded PET services. Further, arbitrary regulatory requirements should not
prevent services being delivered in outer metropolitan and regional areas.
RANZCR Submission to DI Review, May 2010
Page 5
Context of the DI Review
The Review of Funding for Diagnostic Imaging Services (DI Review) is being conducted in the
context of the broader health reform agenda including hospital and health reform, primary
health reform and preventative health. While the scope of these reforms has not yet been fully
disclosed, it is inevitable that they will impact health care delivery as well as the relationships
between providers and the locations in which people seek attention.
Any review of DI must therefore consider the
structure of health care delivery. The Government
seems to favour a greater role for general practice in
the management of chronic disease and prevention
with a different funding model, and a reduced role in
acute care with a migration to large acute care clinics
linked to major hospitals and emergency departments.
Such changes to the current primary health care
delivery model have the potential to change the
dynamics of referral for imaging and where investigations are performed. It is therefore
considered somewhat unrealistic to be attempting to develop different funding arrangements for
DI before the changes to primary health care delivery have been more clearly articulated and the
funding structure clarified.
Changes to the overall healthcare
delivery system impact diagnostic
imaging. Access and availability
of imaging are both change
management tools. Knowing the
destination is a critical first step
for the DI Review.
The DI review is also occurring after 10 years of capped MBS funding agreements for DI
services and cost shifting of public DI services to the MBS by state/territory governments
which, in combination, led to a freeze on most DI rebates and closure of many private practices.
Substantial productivity gains during the rebate freeze period allowed minimal out of pocket
expense increases to patients, however toward the end of the period, decreased practice
sustainability lead to pressure to raise patient gaps for DI services. Ten years of capped funding
delivered significant efficiency gains to the Government in the private sector.
This review is occurring at a time when there is a significant change occurring in the technology
and algorithms of practice which is creating further cost pressures. It is also occurring while
imaging providers are installing the most sophisticated data management systems in the country
and making a greater contribution towards effective e-health than any other medical group.
These investments have largely been driven by the need
to manage the increasing workloads in an environment
Technological change is
that is seriously under funded. It has not been
revolutionary and diagnostic
recognised by government that the platforms and
imaging is a leader. Technology
connectivity installed by DI practices are already
is changing what is possible
sustaining the system at a lower cost, higher
clinically. Government policy
effectiveness and greater efficiency.
must be adaptive and flexible and
not stifle innovation.
The College acknowledges the Government’s
imperative to ensure that total future health care spending is sustainable and that in the context
of the ageing Australian population it will be necessary to manage the increasing demand for DI
services as part of the overall effort to contain health spending within affordable limits. On the
other hand, the DI sector needs a stable and predictable fiscal environment to maintain
investment and deliver high quality imaging services.
Despite the introduction of the bulk billing incentive
Uneconomic rebates do not save
from 1 November 2009, current DI rebate levels are
money for Government. They
uneconomic and as a consequence the 28% of patients
result in secret taxes, reduced
who pay gaps are paying a “secret” tax on their health
investment and changes in health
care to cross-subsidize those who are bulk billed. If DI
care delivery which are
rebates are not adjusted to more closely align with the
unplanned.
RANZCR Submission to DI Review, May 2010
Page 6
cost of providing the services, and if indexation is not introduced to account for the increasing
costs of providing these expensive services, patients will face increasing gap payments.
We note the recent comments by the Professional Services Review (PSR) director, Dr Tony
Webber, that he was concerned about “the cavalier fashion” in which doctors are making CT
referrals for complaints of back ache 1. Further he
indicated that the PSR would be undertaking a
To be a gate keeper requires
crackdown on CT scans. If CT scans are found to be
delegated authority which for
inappropriate or if the investigation is deemed to be not
radiologists means substitutionclinically
relevant, the practitioner will be required to
of-test powers; this authority is
reimburse the Medicare benefits paid. This has serious
equivalent to that already
implications for the role of the radiologist as a gateentrusted to specialist clinicians.
keeper and adviser for the relevance and
appropriateness of imaging, yet radiologists are required to be a gatekeeper without powers of
test substitution and in a framework where relevance is established retrospectively and with the
use ofother data that are not known to the DI service provider at the time of doing the test.
The College is equally concerned that policy for the future funding and delivery of quality DI
services be determined not primarily by an imperative
Imaging is a benefit not just a
to cut spending, but strategically and recognising DI’s
cost. Cost effectiveness of
increasing role in modern medical management. In
imaging must be measured in the
particular DI determines the need for and specificity of
broad context of improved patient
surgical intervention, and is improving patient
outcomes. This means a new
outcomes and decreasing costs associated with
approach to rebates. Thwarting
exploratory and extensive surgery. In addressing the
expenditure at the DIST level
challenges of escalating health costs and increasing
may create a greater cost burden
demand for DI services, it is important to acknowledge
elsewhere.
that every policy and reform strategy will confront the
need to reconcile benefit, access and affordability. It is
also unreasonable to expect that costs can be contained while the benefits in terms of patient
outcomes are improving, patient expectations are rising, and medico-legal pressures persist in a
system that has created a large number of referrers who have little training in the
appropriateness of imaging.
All countries are dealing with the increasing costs of health and a variety of different funding
and policy approaches are being considered, but there are very few funding alternatives that
increase the pressure on clinicians to reduce imaging
requests and on patients to reduce their expectations.
The College wants to work with
the Government for sustainable
The College views its submission to the DI Review as
change as long as the goals are
the
first stage of a process to develop a framework for
defined in the broad context of
the future delivery of diagnostic imaging (DI) services
access, affordability,
and
the funding of those services. The College will
sustainability, quality services
provide
further input when the Department releases a
and patient outcomes. This will
second,
more
focused discussion paper in mid-2010,
take time. What is needed is a DI
outlining
the
results
of the current information
policy committee that seeks and
gathering
phase
and
identifying a range of possible
respects advice that is focussed
options for further consideration by stakeholders.
and measured against these yard
sticks and that acts on such
Given the potential for the broader health reform
advice. Frequent policy changes
agenda to impact on DI services, the College would
are disruptive to investment,
like a commitment from the Government to establish
orderliness and sustainability.
an overarching approach to diagnostic imaging that is
1
Doctors ‘cavalier’ on use of CT scans, Adam Creswell, Health Editor, Australian. Aug 7,2009
RANZCR Submission to DI Review, May 2010
Page 7
informed by the advice of experts working in the field. The College recommends a formal
structure, such as a DI Advisory Group, be established as the principal advisor to the
Government on policy and service delivery implications for DI of the broader health reforms as
these evolve, and to manage associated change. It is important to build on the positive aspect of
DI management to date and the collaborative input of the profession under the previous MOUs
is viewed by the College as one of its major achievements.
Importance of Diagnostic Imaging
Diagnostic imaging has expanded dramatically in recent years as has its sophistication. This has
been matched by increasing complexity in medical practice and increasing reliance on imaging
to manage patients. Today, in 2010, diagnostic imaging is perceived by both clinicians and
consumers as an integral part of medical care. DI services are a critical part of all aspects of
healthcare delivery: prevention, diagnosis, treatment and monitoring.
The advent of sophisticated computers has allowed development over the past thirty years of
several types of body scanning, utilising x-rays (CT scans), ultrasound, radioisotopes (nuclear
medicine scans), and magnetic and radio waves (MRI scans). Conventional x-ray has also
become digital, no longer requiring film to capture the image. The ability to image any part of
the body, and the increasing expectations of timely and accurate diagnosis, have placed
diagnostic imaging at the forefront of patient care. Diagnostic imaging is now requested by
practitioners and their patients to confirm, exclude, stage, or monitor almost all serious illness.
Figure 1: Medicare Funded DI Services, 10 year trend to 2009
Medicare funded DI Services ('000)
1999/2000-2008/09
20,000
18,000
No Services ('000)
16,000
CAGR (10yrs) - 4.3%
CAGR (5yrs) - 5.2%
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
Source: Medicare Australia, MBS Statistics
Figure 1 shows the steady growth in Medicare funded DI services over the past 10 years, with
17.3 million services provided in 2008/09. This equates to approximately four services for every
five persons in the population.
RANZCR Submission to DI Review, May 2010
Page 8
DI services accounted for approximately 14% of all MBS outlays in 2008/09. As a funder of
medical services, the Government must recognise that by investing in DI, it is purchasing a key
component of 21st century healthcare.
Radiologists are highly trained medical specialists who have expertise to bring to clinical and
treatment decision making across all disciplines but their clinical expertise is not utilized to its
full potential. With the wide range of complex imaging modalities available today, the College
considers diagnostic Radiologists as central and indispensable specialist consultants who should
have an increasing role in overall patient management. The clinical model in which diagnostic
and interventional radiologists are key members of
Radiologists are doctors’ doctors.
multi-disciplinary teams focused on patient treatment
Their educational role, their disease
and care, is how modern day radiologists should act.
management and staging role and
In addition, the time that diagnostic and
their teaching role are often over
interventional radiologists spend on such activities as
looked. Radiologists are integral to
multi-disciplinary care meetings, providing second
all these components of every
opinions and providing before and after clinical care
examination. They create
to patients should be remunerated in the same way as
accountability for clinicians.
other clinicians. A key focus of the College’s new
diagnostic radiology curriculum is directed to this
clinical role and the importance of collaboration and supporting other medical practitioners in
the multi-disciplinary care team.
Developments in the Internet and image storage have led to full digital imaging, where images
are captured and stored in digital format, and distributed electronically to the radiologist for
reporting and the requesting practitioner for viewing. In the future these images, together with
the radiologist’s report, will become part of the patient’s eHealth record.
Appropriateness
One of the first challenges in addressing imaging
Appropriateness requires
growth is to ensure that imaging is appropriate and
experience and training by
clinically accountable. If changes are to be made to
referrers. That young doctors do
health care delivery, the re-distribution of
not have sufficient training in
responsibilities must be aligned with outlay
anatomy, pathology and the use
expectations. There is no point in suggesting that there
of diagnostic imaging is a cause
should be nurse practitioners with rights to request
for concern but increasing access
imaging and then expecting specialist radiologists to
to less well trained people is
accept responsibility for the appropriateness of these
likely to create higher referrals.
requests. The College is very concerned that best
practice and evidence based criteria are linked to
imaging services and yet chiropractic referrals and other non –evidence based referrals are
funded in an unregulated environment that is neither without risk to patients nor medico-legal
risk to providers.
More than 90% of DI services are arms length referred services, about 60% of these deriving
from requests by GPs and the rate of GP referral for imaging has been increasing (BEACH
data 2). It is generally acknowledged that a proportion of these imaging requests are clinically
inappropriate or unnecessary. However, a multifaceted approach that addresses the causes of
clinically inappropriate or unnecessary imaging will be required to achieve practical and
sustainable improvement in the appropriateness of DI requests:
2
Australian Institute of Health and Welfare. General Practice Series No.26, General Practice Activity in
Australia 1999-00 to 2008-09: 10 year data tables, BEACH, December 2009
RANZCR Submission to DI Review, May 2010
Page 9
Medical Student Training: a significant cause of inappropriate referral is related to the lack of
basic training of medical students and junior doctors in anatomy and pathology and the use of
diagnostic imaging. This failure of training is a weakness of academic medicine and in part the
result of problem oriented learning and in part a product of current clinical systems which make
decisions based on imaging and other investigations before relying on clinical judgement.
The College shares the concerns of other specialist colleges about the variation in anatomical
training across Australia’s medical schools. In this
There has been a failure of academia
regard, the RANZCR has made representations to
and medical curricula to teach
“Medical Deans Australia and New Zealand”, the
clinical diagnosis and decision
peak body for the Deans of eighteen Australian and
making, which has resulted in a
two New Zealand medical schools and faculties; and
greater reliance on imaging as a
to the “Confederation of Postgraduate Medical
substitute for diagnostic reasoning.
Education Councils” which through its member
councils is responsible for developing and implementing the education and training of junior
doctors during their prevocational (PGY 1 and 2) years. In each case the College has
emphasised that diagnostic imaging has been significantly under represented in medical school
training and in the prevocational years, resulting in young doctors developing habits of
unnecessary and inappropriate imaging and, in some cases reluctance to seek the advice of
radiologists in determining what the most appropriate approach to imaging their patients is. The
value add to patient care from imaging studies is also severely reduced and compromised as a
consequence, because even radiology reports need to be explained in simpler terminology when
new graduates do not understand the anatomical or pathological abnormality being diagnosed.
The College has offered to work with medical schools and postgraduate medical councils to
address these educational deficiencies, so far with very limited response.
It is important to emphasise that with the trend towards shorter medical courses, there is a move
away from didactic anatomy education, which forms the basis of radiology. In the current
medical school environment it is therefore crucial that undergraduates are educated on how to
utilise DI appropriately. This should not be confused
RANZCR wants to migrate away
with teaching medical graduates how to perform
from modality expertise to a
detailed radiological interpretation, which is beyond
greater training emphasis on
the scope of their courses.
disease specificity. This is very
hard to achieve when the
Radiologist Role: Radiologists have an in depth
dependence on general imaging
knowledge of anatomy, pathology, clinical medicine
has increased because of the
and diagnostic imaging that comes from many years of
issues of medico-legal liability
experience and training, firstly as doctors and then as a
and referral uncertainty.
doctors specializing in imaging and image guided
intervention. More direct involvement of radiologists in
the clinical decision making process would reduce unnecessary and inappropriate requests for
imaging, but with current workload pressures there is less and less time to review requests and
to educate referrers and the concept of requiring radiologists to ring referrers and ask questions
to define appropriateness of each request is simply unrealistic and costly.
Referrer Education: current referrers need education and better information and the College is
looking to work closely with the National Prescribing Service (NPS) to develop appropriate
strategies to deliver more evidence based requesting.
Greater Access to MRI: MRI is the modality of
choice in an increasing number of clinical conditions
and does not use ionising radiation. The current
licensing arrangements and related policy settings for
MRI, particularly specialist only referral and the lack of
powers for test substitution by specialist radiologists,
contribute to inappropriate imaging. These artificial
RANZCR Submission to DI Review, May 2010
RANZCR considers appropriate
access state-of-the-art imaging to
be a fundamental component of
medical services in the 21st
Century, and that MRI access
issues must be resolved in the
current review.
Page 10
restrictions result in exposure of patients to unnecessary radiation from CT procedures
requested as a substitute for MRI when MRI would be a safer and better procedure.
Clinical Decision Guidelines and ICT: At the same time, ensuring the right patient receives
the right service at the right time will not be significantly enhanced without more effective use
of information and communications technology (ICT) tools such as decision support and
eHealth. Clinical decision guidelines or appropriateness criteria would assist referring
practitioners to decide if imaging is medically justified. The College welcomes the
Government’s efforts to introduce a national, integrated eHealth system by 2012. The DI sector
already has a strong base to enable the sharing of images and other relevant information,
through its significant investment in Radiological Information Systems/Picture Archiving and
Communication Systems (RIS/PACS) systems as a means of managing increased workloads
arising from the rapid expansion of digital imaging. The linking of such systems to decision
support at the point of DI request has the greatest potential to result in significant reduction in
unnecessary or inappropriate imaging in addition to
It is Government’s role to inform
streamlining patient care.
the public that it will only fund
certain imaging in certain
Reasonable Rationing and Priority Setting: Overall
circumstances. Evolution to
healthcare policy needs to consider issues of prioritisation of
rationing based on proven benefit
services. As DI plays such a fundamental role is healthcare,
is also the responsibility of the
any such policies should also be applied to it. Rationing of
Government. It must be
care is currently ad hoc, variable and based on little
articulated openly and not turned
systematic cost effectiveness analysis. DIST item descriptors
into a blame game between
may need to be used to a greater extent to restrict access and
doctors and patients.
reduce unnecessary imaging or even be removed if publicly
funded services need to be rationed. The College is
expecting that this will be addressed under the new MBS Quality Framework’s process for
systematic monitoring and review of all MBS items on an ongoing basis to ensure that:
• all items are effective and safe, likely to lead to improved health outcomes for patients,
and represent value of money; and
• item descriptors, fees or usage that are not consistent with best practice or contemporary
evidence are identified and either removed or appropriately amended.
Processes need to be established to monitor, review and evaluate the outcomes of initiatives
adopted to address inappropriate and unnecessary imaging.
RANZCR Submission to DI Review, May 2010
Page 11
Health System Reforms and DI Services
The Government’s desire to restructure the health
system around a more patient centred delivery of health
care services through greater integration of health care
services, a multi-disciplinary approach to patient
management and a shift from managing illness to
preventing illness requires a clear vision for the future
delivery of diagnostic imaging services.
Changes in health care delivery
and types of services impact
demand for DI, not the reverse.
Consequently these drivers of
demand will not be influenced by
changes to the schedule or to
controls on DI services. The DI
schedule is a schedule for
sickness not for health and
prevention. If this is a new
direction it will need new
funding.
Some of the proposed reforms under consideration have
the potential to be disruptive and produce fragmentation
of what is an efficient, well integrated, comprehensive
DI service in Australia (see current DI service delivery
below). The installed base of comprehensive imaging
practices represents a huge investment; it is fixed in
The role of Government is to
location and has very limited re-location potential.
facilitate connectivity and patient
Change must factor this in. It would be a wilful waste
confidentiality. The capability
of expensive resources to start reproducing this
already exists to deliver service
installed base in acute care centres or other health
integration in decision making
facilities in order to offer patients co-ordinated and coand ought not to be reproduced in
located care for specific conditions when there are
any way that makes existing
adjacent, or nearby, appropriate facilities. Determining
facilities obsolete.
how this integration would occur cannot take place
until there is more precise detail as to how such clinics
will operate and how they will be linked to major hospitals and emergency departments.
A recent OECD report 3 examined the use of market mechanisms in health care. It considered
that the perils associated with competition are likely to be relatively immaterial for some acute
aspects of care with homogenous patient groups, for which there are good outcome measures
and well understood technologies. However it was considered difficult to envisage
circumstances in which a truly competitive market could be created for many common (and
costly) chronic conditions with heterogeneous patient groups for which there are few if any
measures of outcome and complex patient pathways.
Any proposals to shift to alternative funding mechanisms will therefore need careful policy
design to ensure the maintenance of quality DI services and appropriate access to services as
well as to avoid instability, variations in performance and inequalities. For example, in theory,
there may be some scope for DI services to be included in
The current MBS fee-for-service
an episode based payment approach for certain conditions,
model is an efficient and effective
eg a hip replacement, but a number of issues would need to
means of funding DI services. It
be addressed in developing such payments: Inclusion of DI
has worked well to provide
in bundled payments has been successful in private
reasonable patient access to high
hospitals where the bundled payments have served to
quality imaging services and
create known gaps, have shifted the debate about charges
healthy competition between
to the private hospital management and the doctor so that
providers.
there is a mutual responsibility to have facilities available,
to have personnel available and to limit bed stays. But this
is not without difficulties, for example with coronary angiography, which is just an imaging test
in a hospital environment and has defined costs, its complexity and difficulty changes with comorbidities such as immobility, other vascular disease, diabetes etc. these and other issues
3
Achieving Better Value for Money in Health Care. OECD 2009
RANZCR Submission to DI Review, May 2010
Page 12
would need to be dissected for DI if bundled payment models are to be pursued. The key issues
identified are:
• Defining the episodes of care
• Establishing episode based payment rates
• Identifying providers to receive episode based payments, and how DI providers are
remunerated within the episodic payment
• Compatibility with other payment mechanisms
• Staging implementation, eg to focus on a narrow set of priority conditions, patients and
providers, and addressing potential legal barriers.
Such alternative funding mechanisms seek to transfer, or at least share, responsibility for how
money is spent with clinicians and to make clinicians more accountable. Clinicians however
often have their commitment thwarted by lack of beds, delays in theatre access, staff shortages
etc . They will quickly see their contribution to this new cost containment as spiralling out of
control and out of their control. To ensure high quality but more efficient DI services, Specialist
Radiologists will need to be more directly involved in the patient management team. It would be
critically important for the profession to be engaged in the development of such a payment
mechanism.
A clearer understanding of the current system might help in developing strategies to meet the DI
review and broader health service reform objectives. DI is an over arching layer that provides
certainty of diagnosis, defines intervention parameters, reduces unnecessary surgery, and stages
disease accurately so that unnecessary and expensive
therapies are not embarked upon. It is one of the pillars
DI is an integral component of
of efficient medicine, not a liability. However, the
21st Century healthcare and must
College recognises that there is a need to optimise the
be factored into the development
use of DI, particularly the tests that involve ionising
of broader health reform policies.
radiation, and a more prominent role for Radiologists is
Change needs a plan, one that
needed to achieve this.
looks at investment efficiency
and avoids duplication and
Going forward, it is imperative that consideration be
instability.
given to how:
•
•
•
•
DI will fit into the delivery of acute services both in and out of hospital;
DI will be integrated into the management of chronic illness;
DI will help in prevention;
to realise and optimise the potential productivity gains and quality improvements from
the integration of DI systems and other ICT tools into Australia’s E-health system.
A shift to delivering care along “service” lines or within discrete episodes of care may have a
significant effect on radiology training programs, which would be expected to train sub
specialists for other organisations’ service lines, while such training requires deep sub-specialty
silos.
Radiology needs to be integrated with clinical disease-specific teams. It would be unfortunate if
other specialists started competing for services, doing the areas of greater intellectual and
financial reward in-hours and expecting a depleted radiological service to provide the services at
other times. The College is mindful of the need to achieve greater respect for, and integration of,
radiologist services and has introduced a new curriculum which will shift the focus to integrate
appropriate services in a wider clinical context. This already occurs in large tertiary centres, but
this is not where the majority of services occur.
There are many ways this can be achieved and
Radiologists should have an
without this discussion the viability of an under
increasing role in overall patient
management.
RANZCR Submission to DI Review, May 2010
Page 13
funded DI service meeting the expectations of expertise and quality will not survive.
Current DI Service Delivery
Diagnostic imaging (DI) services in Australia are currently provided by public hospitals (3540% of total services) and private imaging practices (60-65%). It is estimated that
approximately 70% of DI services are now funded through Medicare and this is rising at least in
part due to public outpatient services being increasingly billed to Medicare.
Table 1 shows that almost three quarters of MBS DI services in 2009 were provided to the
Australian people in comprehensive practices with some 64% being provided by private
specialist radiologist providers in community based practices and 9 % being provided within
public hospital settings. In some of the larger private practice groups, a hub and spoke model
enables greater penetration into smaller communities with larger central sites serviced by
smaller feeder sites, while most after hours services are provided 24/7 in public or private
hospital emergency departments. This model of complementary public and private sectors has
ensured the widespread availability of quality and timely services to the Australian population.
Table 1: Providers of Medicare Funded DI Services, 2009
Provider
Type of Practice
No Practices
Private
Specialist
Radiologists
Public
Hospitals
Comprehensive practices with at least 3
modalities (eg x-ray, ultrasound, CT)
Smaller non comprehensive practices
Comprehensive imaging departments
with at least 3 modalities
Non-comprehensive or specialist clinics
Specialist, GP and other practices
575
% MBS
DI services
Jan-Jun 2009
64%
775
113
14%
9%
424
1,677
3%
10%
Non
Radiologist
Providers
Source: Unpublished data, Department of Health and Ageing.
Public and private radiology providers also provide services to Veterans’ Affairs, workers
compensation, third-party, public hospital and private patients, although collectively these
services represent a small proportion of total services provided.
Map 1 shows the distribution of comprehensive practices across Australia, distinguishing
private specialist radiologist and public hospital practices.
Australians are extremely well
served in terms of access to DI
Map 2 shows the location of comprehensive practices,
services - 90% live less than
distinguishing basic comprehensive services and those
25km from a “one stop”
that provide further services such as MRI or Nuclear
comprehensive DI practice.
Medicine overlayed on population areas up to 100,000
persons. The map shows that the current geographic
dispersion of comprehensive practices, by their very need to be accessible to patients, already
supports the broader trend now occurring in patient care to a more patient centred approach.
Further analysis reveals that almost 90% of the population (2006 Census) live within 25km of a
comprehensive practice, increasing to 94.5% living within 50km and 97.5% living within
100km.
RANZCR Submission to DI Review, May 2010
Page 14
Diagnostic imaging is a large industry in Australia. Organisations providing DI services are
expected to generate revenue of approximately $2.5bn from providing DI services under
Medicare in 2009-10.
RANZCR Submission to DI Review, May 2010
Page 15
In population terms there are about 65 Radiologists per million of population in Australia. This
figure is significantly lower than the USA (100 per million) and some European nations (the
highest being 120 per million). In order to increase this figure by just 10 per million, Australia
would require another 220 Radiologists more than the estimated 1,380 practicing radiologists 4
In addition to the Radiologist workforce, the DI sector employs more than 10,000 medical
imaging workers. In population terms in 2006, the latest data available from the Australian
Institute of Health and Welfare 5, there were 510 medical imaging workers per million of
population and they were the second fastest growing health occupation group, increasing by
28.2% over five years.
Future DI Service Delivery
A range of forces including the digital revolution, globalisation, consumerism and pressure to
contain the escalating healthcare costs is causing radiologists to reflect on how they can most
effectively contribute to the future health care system.
Patient Access to Comprehensive DI Services
From a business perspective, the time, effort and skill required in managing large scale imaging
operations (high cost, high maintenance and high operating costs) that face rapid technology
changes, continues to favour at least some clustering of imaging equipment. An outline of the
many elements of a Radiology practice is at Attachment 1.
A viable network of comprehensive practices,
supported by increased funding for patient travel and
accommodation for people living in rural and more
remote areas, is the most cost effective model for
delivering high quality DI services that are
accessible to patients. With a radiologist on site to
professionally supervise the imaging services and
personally attend the patient when required, together
with the networking potential afforded by information and communications technology and
RIS/PACS systems for image transmission to specialists, to hospitals and to GPs, the
geographically centralised “one stop” comprehensive practice model, is the most efficient model
and the most effective use of resources for responding to the emerging requirements of a more
patient centred approach.
Professionally supervised
comprehensive practices with
their high level information and
communications technologies offer
the most effective use of resources
for delivering imaging services.
Improved Patient Access for Rural and Remote Communities
The College supports the range of recommendations of the National Health and Hospital
Reform Commission 6 to improve health care access for people living in rural and remote areas,
including:
• calls for increased funding for patient travel and accommodation to enable better and
more cost effective access for patients in remote and rural areas to comprehensive DI
practices;
• development of mechanisms to support a range of initiatives including expansion of
specialist networks, telehealth services including teleradiology, on-call 24 hour
telephone and internet consultations and advice; and
• strategies to improve health workforce supply and clinical training opportunities in
remote and rural areas.
4
AMPCo August 2008
Health and Community Services Labour Force 2006. AIHW
6
Chapter 3, A Healthier Future for All Australians, Final Report June 2009.
5
RANZCR Submission to DI Review, May 2010
Page 16
Innovative teleradiology
strategies can improve access to
specialist supervision and
opinions for people in rural and
remote communities.
Information and communications technologies have
enormous potential to provide real time access to
specialist clinical opinions. Despite the challenges of
scarce resources and the high costs of diagnostic
imaging equipment, these technologies are already
being used in some rural and remote parts of Australia to provide innovative teleradiology
access to specialist radiologists to the people of those communities. For example, in the
Goldfields region of Western Australia, the X-Ray West practice operated by Imaging the South
(ITS) has made an active contribution to the betterment of indigenous health care and its work
has been recognised internationally in a presentation of research studies centred on cardiac and
renal disease management innovations for remote communities 7. Funding and incentives are
needed for further development and implementation of such strategies to better meet the
imaging needs of rural and remote communities.
Professional Supervision and Accountability
The College’s Standards of Practice have established the Radiologist as the single point of
accountability for each imaging examination with each component of a diagnostic imaging
service required to be carried out under the professional supervision of a Radiologist. This is
also required by radiation regulations across Australia for those examinations involving the use
of ionizing radiation. There are specific ‘rules’ in the Standards, determined on a clinical risk
management basis, around what tasks can be
Provision of images without a
delegated, and under what circumstances. Where there
report removes the single point of
are not specific rules set out in the Standards, it is up
accountability for the total
to the individual Radiologist to ensure that appropriate
service, including the
protocols are in place for delegation of tasks to
interpretation of the images.
individual imaging team members with the required
professional expertise to undertake these tasks
independently, but still under the radiologist's professional supervision.
Integrated Patient Care
The interpretation of visual data is a core competency of specialist radiologists but for imaging
data to be useful for clinical decision making and patient management today requires the
imaging data to be provided in a broad array of imaging formats and to be combined with an
increasingly broad range of knowledge relevant to the management of the patient’s overall
health. More direct involvement in patient care and clinical decision making will also enable
radiologists to acquire and integrate additional knowledge during the image interpretation
phase.
Radiologists have invested heavily in digital technologies, including RIS/PACS and are well
placed to integrate imaging studies with other relevant information and to provide accurate,
accessible, fast and timely information, including after hours. The introduction of eHealth, with
electronic referral and transfer of test results and the sharing of patient records will provide the
platform for Specialist Radiologists to become vital members of the patient’s diagnostic and
treatment team. The infrastructure is already being developed to support eHealth in a large
proportion of Radiology practices and the potential efficiencies and benefits to the broader
health care system should not be underestimated. These
eHealth will enable a quantum
include productivity improvements, increased remote
leap towards integrated patient
access and better reporting together with reductions in
care and enable better use of the
duplicate tests, lost results, communication errors.
clinical expertise of radiologists.
eHealth will also provide the platform for electronic
decision support tools which have the potential to
7
http://www.imagingthesouth.com.au/index.php?option=com_content&task=view&id=15&Itemid=100
RANZCR Submission to DI Review, May 2010
Page 17
reduce inappropriate and unnecessary requests for imaging.
Changes to Current DI Service Delivery Arrangements
As outlined above the current installed base of comprehensive imaging practices provides very
cost effective access to services for the vast majority of the Australian population. It is fixed in
location and has very limited re-location potential. Change must factor this in. It would be a
wilful waste of expensive resources to start reproducing this installed base in acute care centres
or other health facilities in order to offer patients co-ordinated and co-located care for specific
conditions when there are adjacent, or nearby, appropriate facilities. Comprehensive practices
would be/are of sufficient size and workload to require the presence of an on-site radiologist,
enhancing the quality of the service with on-site clinical supervision and providing appropriate
clinical input to coordinate imaging and clinical parameters, by being able to interview and
clinically assess the patient and provide the integrated imaging required to answer the clinical
question. This would avoid the current situation where patients are referred for imaging that the
radiologist knows is inappropriate for the clinical condition and in the report recommends
another test, necessitating another patient attendance with associated wasted time and resources
and possibly increased radiation exposure.
The establishment of 37 GP Superclinics and the concept of “one stop” shops require an
assessment of;
• the current accessibility of imaging services for patients that will use these clinics; and
• the need for and cost effectiveness of additional imaging services, possibly co-located
with the superclinic, in order to meet the community expectations for the delivery of
imaging services to the local community.
By way of illustration only, the first GP superclinic to
open was at Ballan, a small town about 80km from
Changes to primary health care
Melbourne and 34km from Ballarat. It has a population
delivery may impact the delivery
of less than 2000 and is in the Shire of Moorabool
of diagnostic imaging services which has a population of around 27,000 people. Map
planning is needed to avoid
3 shows the diagnostic imaging services, including
unnecessary duplication of
comprehensive practices (red dots), accessible by
services.
driving from Ballan: comprehensive practices are
located within 30 minutes drive in Ballarat and within 45 minutes drive in Melton. There is a
chiropractic clinic providing limited x-ray services in Ballan.
In the case of Ballan, the existing comprehensive services are considered to be reasonably
accessible for patients and the population base does not support the investment in a co-located
comprehensive DI service. As the population expands, a feeder practice providing US and x-ray
services may be a viable consideration.
RANZCR Submission to DI Review, May 2010
Page 18
Radiologist Training
The Radiology profession and industry recognize the need for a substantial increase in the
number of training positions in order to provide the workforce required to meet the future
demand for DI services. If access to training opportunities in Radiology is to be maintained
relative to the number of medical graduates forecast, the College estimates that training
positions in Radiology will need to increase significantly to at least 450 by 2012, a 20%
increase over 2010.
There are currently approx 335 training positions in Radiology in Australia of which around
94% are in the public sector. Even though approx 70% of trainees, on completion of training,
will work primarily in the private sector, the opportunities for the private sector to contribute to
training in Radiology have been fairly limited and there have been few financial incentives other
than the longer term one of investment in its future workforce. This is in part because the
requirements for accreditation of training sites (particularly with regard to workloads which
permit protected time for trainees and supervisors, provision of teaching resources etc) have
been more geared to larger public sector sites where training has been regarded as an important
part of service provision. The College has welcomed the $100,000 per trainee contribution by
the Federal Government as an incentive for private practices to invest in training. There must be
further expansion of training places in private comprehensive practices where trainees can
obtain the necessary range of experience. It is untenable for the public sector to continue to
carry the full burden of Radiologist training.
Specialist training typically requires five years and a long term funding commitment is needed
for Radiologist training overall and to promote training beyond the traditional tertiary training
hospital setting so that trainees can gain valuable
experience in areas of radiology that are more
A serious investment in training
commonly practised in the private sector.
is required to provide the
Radiologist workforce needed to
It should be noted that as a consequence of the shift in
meet the future demand for
many types of elective surgery to the private sector and
imaging services.
RANZCR Submission to DI Review, May 2010
Page 19
the increased performance of endoscopic procedures by a wide range of specialists in public
hospitals, many kinds of previously routine diagnostic imaging tests are no longer (or very
rarely) performed in public teaching hospitals, whereas they are still widely and frequently
performed in private practice. The continued value of these studies is not in doubt, but the
casemix environment in public hospitals means that most trainees today will get very little
exposure to studies they will be expected to perform and interpret if they work in the private
sector.
Training Networks
Increases in private sector training places must not be at the expense of the public sector. The
establishment of training networks based on major public hospitals, but with structured rotations
to outer metropolitan, regional and private sector hospitals/practices recognizes the important
role of registrars in public sector service provision and the importance of public sector teaching
sites in delivering high quality training and at the same time significantly increases potential
participation of the private sector in training by managing the risks over the lengthy training
period. Training networks have been established for some time in South Australia and Western
Australia and similar arrangements are being developed in Queensland and NSW. There are
several other examples in Australia and New Zealand where ad hoc arrangements have been
established between individual hospitals and private sector sites.
It is also desirable for radiology training to expand into BreastScreen and other sites that are
neither private sector nor public tertiary teaching hospitals, in order to provide the required
range of training opportunities. This expansion will not be possible without government
support.
Shortage of Interventional Radiologists
Interventional radiology has critical and direct links to patient care and the importance of image
guided therapy is increasing. In recent years MBS under funding of interventional procedures
and different funding arrangements between the public and private sectors has lead to a decline
in the performance of many interventional procedures in the private sector. This situation has
resulted in a reduction in the number of radiologists seeking and gaining post graduate
fellowship in interventional radiology. This has contributed to a skills shortage and reduced
access to services particularly in outer and regional centres.
DI Funding Arrangements
Two of the stated objectives of the DI review are to:
• establish appropriate fee relativities for MBS items across and within different
diagnostic imaging modalities; and
• develop alternatives to fee-for-service and establish whether there are areas of
diagnostic imaging that would be more appropriately funded through a different
mechanism.
The College has already commented on the difficulties associated with considering different
funding mechanisms for DI services while it is unclear how these services will be impacted by
broader healthcare and hospital reforms. While
The objectives of the review
consideration of fee relativities might be more sensibly
suggest the Government believes
done following a streamlining of the current DIST (see
that current DI relativities are
below), there are a number of more general comments
inappropriate and that fee-forthat the College would like to make about the current
service funding should be replaced
funding arrangements and DI rebates.
by a different funding mechanism.
RANZCR Submission to DI Review, May 2010
Page 20
Public Sector Issues
The College supports a complementary mix of public and private DI service providers. The
College strongly supports the concept of properly funded academic departments which have a
vital role in training at all levels and in supporting research. However, as a consequence of
chronic under funding in the public sector, there has been a decline in the ability of academic
departments to provide properly funded research facilities, to engage in research and to cope
with teaching demands.
Despite the development of professorial departments the funding is such that there is a serious
focus on service work and the need to have co-located private practices to augment salary levels
in order to retain staff. The under funding of public hospitals over many years has created a
number of issues for public sector radiologists as public hospital administrators have sought to
obtain additional revenue by shifting as many services to Medicare as they could. This under
funding and the consequent efforts to shift costs to Medicare has:
• Created a two tier public system through the perverse incentive to prioritise Medicare
eligible patients over those who are not eligible for Medicare;
• Detrimentally impacted the viability of many private providers operating in the same
community to maintain a high quality service, or in some cases any service, when
confronted with an expansion of bulk billing capacity by public hospitals who have a
dual source of funding for equipment and other competitive advantages compared to
private sector practices;
• been detrimental to their academic teaching role;
• severely limited capacity to provide adequate training positions for new radiologists;
• impacted negatively on the quality of services to
patients accessing their services, particularly
Funding needs to support the
public patients; and
viability of both the public and
• increased the level and complexity of
private DI sectors. Current
administrative and billing processes in radiology
distortions in public sector DI
departments and exposed individual public
funding need to be addressed.
hospital radiologists to the risk of being in
breach of Medicare billing regulations.
It is not clear how the public hospital reforms recently announced by the Government 8 will
impact both the Commonwealth funding through Medicare of DI services provided by public
hospitals to private patients and funding for radiology training delivery. However, the College
would like to see a package of changes to the funding of public sector DI aimed at achieving a
sustainable, equitable and uniform high-level regime of funding for both state-funded hospitals
and community radiology practices. The College recommends that:
1. That all patients be eligible for Medicare rebates for DI services provided by public
hospitals. In effect, this means the Commonwealth takes over funding responsibility for
all DI services in public hospitals, both public and private patients.
2. The capital component of the DI rebates for services provided by State funded public
hospitals (or their controlled or related entities, such as business units) should be
addressed as part of the hospital reform process whereby the Commonwealth will make
a funding contribution towards the costs of operating capital (such as equipment
essential for delivery of services to patients) as part of the independent assessment of
the efficient price to be paid for each service. The College also notes that the
Commonwealth announced it will commit to fund 60 per cent of planned new capital
investment through a mechanism to be negotiated with states. The Government has
been silent on the funding arrangements for private patients in public hospitals currently
8
A National Health And Hospitals Network For Australia’s Future, Australian Government, March 2010
RANZCR Submission to DI Review, May 2010
Page 21
funded through Medicare. Whatever capital arrangements apply, it is expected that the
proposed new funding arrangements will impact on the Medicare reimbursement rates
for DI services provided by public hospitals and funded through Medicare.
3. Additional funding for training is provided to recompense appropriate trainee teaching
and supervision and to align financial incentives with quality of training. This
arrangement should also be extended to private practices as an incentive to undertake
radiologist training, since all studies performed or reported by a trainee need to be
supervised to the same quality and medicolegal standard as performed or reported by
the consultant radiologist. Such funding should be conditional upon provision of
tangible evidence of trainee supervision.
DI Rebates
From 1998 to 2008 total funding for DI services under Medicare was capped at around 5%
through two five-year funding agreements (MoUs) with the Commonwealth Government.
Because growth in demand for DI services exceeded 5%, patient rebates generally decreased
over that period and as a consequence bulk billing became unsustainable and there were
significant increases in gaps paid by patients. This situation was partially redressed by a 10%
increase in rebates for bulk billed services from 1 November 2009 but data are not yet available
to assess the impact of that initiative on bulk billing rates and gaps.
The following chart shows that DI rebates decreased by up to 40% in real terms over the past 10
years.
Figure 2: Real (CPI adj) decline in DI Rebates over past 10 years
Source: Medicare Australia, MBS Statistics and ABS
Ninety three per cent of all DI services are provided to patients who are not in-patient in a
hospital. Table 2 shows that overall bulk billing rates for out of hospital services range from
around 60% for Ultrasound and MRI to 80% for Diagnostic Radiology services while average
RANZCR Submission to DI Review, May 2010
Page 22
patient gaps for those patients who are not bulk billed range from .$42.50 for Diagnostic
Radiology to $143.75 for MRI services.
Bulk billing rates for DI services are lower than those
for GPs (79%) and for Pathology (85%) services and
the average patient gaps are more than three times the
gaps charged for GP ($23) and Pathology ($20)
services.
Gaps being paid by patients that are
not bulk billed increased by 27%
between 2006 and 2009 while bulk
billing rates increased by 10%.
Both bulk billing rates and patient gaps however vary considerably between types of services
and between practices. They are also impacted by the patient’s socio-economic circumstances
with more than 5 million concession card holders and 2 million listed dependants in 20099.
Concession card holders represent approximately 24% of the population and their numbers are
increasing. Public hospitals do not have the capacity to provide the services to meet the
imaging requirements of these card holders and there is an expectation that private practices will
bulk bill these patients.
If the Government wants
concession card holders to be
bulk billed, the reimbursement
rate for these patients needs to be
adequate to meet the cost of
providing the service. Patients
who can afford to pay a gap
should not be subsidising the cost
of bulk billing such patients.
The Government seems to support the principle that
those with greater capacity to pay for
their health care should do so. Rebates should be
closely aligned to the cost of providing services or a
viable alternative funding mechanism is needed to
encourage providers to provide services without charge
to those in the community who are genuinely not able
to pay a co-payment (i.e pensioners, children, health
card holders, etc). For example, the Government could
pay 100% of the fee as an incentive to bulk bill such
patients. Alternatively if rebates cannot be more closely aligned with the cost of providing
services then a compulsory co-payment could be introduced, with a one off increase in the
welfare payments of concession card holders.
Table 2: Patient Billing - Out of Hospital Services, 2009
Service
Group
US
CT
DR
NM
MRI
Total DI
Private Comprehensive
Practices
%
% of
Average
Services
Total
Patient
Bulk
Group Gap (excl
Billed
Services EMSN)
65%
76%
77%
64%
41%
72%
61%
90%
67%
38%
62%
66%
$80.01
$118.48
$44.30
$121.87
$144.25
$74.92
Private Non-Comprehensive
Total Practices incl
Practices
Public Hospitals
%
% of
Average
%
Average
Services
Total
Patient
Services Patient
Bulk
Group Gap
Bulk
Gap
Billed
Services (excl
Billed
(excl
EMSN)
EMSN)
45%
31%
$89.56
60%
$83.12
66%
1%
$93.81
78%
$116.83
84%
23%
$39.67
80%
$42.48
78%
31%
$100.56
76%
$104.24
59%
$143.77
65%
23%
$79.16
72%
$74.93
Source: Unpublished MBS data, Department of Health and Ageing
Note: Bulk billing rates have increased by approx 2% since 1 Nov 2009 following a 10% increase in
rebates for bulk billed patients.
Almost two thirds of all out of hospital DI services are provided in comprehensive practices and
overall comprehensive practices provide services more efficiently in terms of bulk billing rates
9
Department of Families, Housing, Community Services and Indigenous Affairs Annual Reports
RANZCR Submission to DI Review, May 2010
Page 23
and average gaps to patients than non-comprehensive practices which include services provided
by specialists and other non radiologist providers.
However, cost modelling undertaken by the College is confirming claims by practices that
current DI rebate levels do not cover the cost of providing services and as such bulk billing is
not sustainable. Accounting for radiology practice costs is complex and there is scope for
significant variation between practices across a range of input variables, including equipment
costs, salary costs, occupancy costs, throughputs, etc. The College’s cost model is assumption
driven and demonstrates both the complexity of costing DI services and the sensitivity of the
results to the assumptions made.
The College’s cost model provides valuable insight into the difficulties of trying to establish the
cost of individual services within a comprehensive practice setting. Further, consideration of
rebate and cost relativities needs to take account of the range of input variables and the impact
of assumptions made, and this cannot be properly addressed until the Government has
established an appropriate funding framework for the delivery of quality assured DI services.
Indexation
While bulk billing rates have been increasing slowly,
patient gaps have been increasing more rapidly. This
reflects increasing costs and the failure to index rebates
for these increases for more than 10 years. During that
period, there have been significant efficiencies achieved
through increased productivity and investment in digital
information systems.
DI providers cannot absorb
increasing costs. No indexation of
rebates can only lead to
increasing out of pocket expenses
for patients.
The only way practices can meet increasing costs and continue to provide quality services is by
charging patients a co-payment. A mechanism is required to adjust for cost variations,
particularly increasing wage costs. An annual indexation rate is applied to MBS fees in all areas
except DI and Pathology.
Capital Component
The College is willing to explore fair and efficient mechanisms for adjusting for depreciation of
the capital component. However:
• It is difficult to make adjustments for the capital component when the current rebates do
not cover the cost of providing services;
• The capital component of the cost of providing services is relatively small and much
smaller than the 50% level proposed in the proposed capital sensitivity measure;
• Issues identified in relation to equipment life, effective life, upgrades and compliance
costs have not been resolved; and
• Funding of the capital component in the public sector has always been contentious and
as the volume of Medicare funded services provided by the public sector has increased,
this dual source of capital funding in the public sector has heightened calls to address
competitive neutrality issues with the private sector. It is unclear how the Government’s
indication10 that the Commonwealth will make a funding contribution towards the costs
of operating capital (such as equipment essential for delivery of services to patients) as
part of the independent assessment of the efficient price to be paid for each service will
impact on DI services provided in public hospitals and funded by Medicare. In addition,
the Commonwealth announced it will commit to fund 60 per cent of planned new
capital investment through a mechanism to be negotiated with states.
10
A National Health And Hospitals Network For Australia’s Future, Australian Government, March 2010
RANZCR Submission to DI Review, May 2010
Page 24
Diagnostic Imaging Services Table (DIST)
The College supports the proposal to establish a Diagnostic Imaging Services Table Committee
(DISTC) to provide advice to the Government on the composition of the DIST, including the
listing of new items, as well as on appropriate criteria for referral, patient access and quality
service delivery. Such a committee could work with the Quality Framework process to expedite
a restructuring of the current DIST.
Without expanding the scope of the existing items, many of the item descriptors could be
rewritten to better reflect the evidence base or current clinical practice and to promote more
appropriate requesting by referring doctors. There are also a number of other issues that the
College would like to see addressed in a restructure of the current DIST including radiologist
substitution, after hours services, the multiple services rules and interventional items and these
are discussed briefly in this section.
Outmoded Schedule
The DIST has more than 500 items (including PET).
Approximately half (242) of these items came onto the
DIST between 1991 and 1998. Since 1998 there have
been around 130 new items added, including MRI (in
1998/99) and PET (in 2001/02). A further 126 items
were the result of item restructuring under the first DI agreement (1998-2003), some of which
involved the addition of new items to enable more detailed monitoring of the demand for
particular services.
The DIST is outmoded and needs
to be simplified and rewritten to
better reflect the evidence base
and current clinical practice.
Analysis of the utilisation of the 468 DIST items (excl PET items) reveals that just 62 items
accounted for 85% of all DI services in 2008/09 and 100 items accounted for 94%. Less than
half (213 items) had utilisation of more than 2500 items (ie about 10 per day nationally).
Test Substitution by Radiologists
The current test substitution rules do not recognise radiologists as highly trained specialists,
whose expertise could be better utilised in the clinical
Specialist radiologists do not
decision making process to reduce unnecessary and
have the same authority as other
inappropriate requests for imaging.
clinical specialists to determine
which imaging procedure is the
It is difficult for many practitioners to know the most
most appropriate.
appropriate test for many clinical indications but at the
same time most requests for imaging do not contain
sufficient information for the Radiologist to decide the appropriateness of the request without
discussion with the patient. In these circumstances, the concept of requiring radiologists to ring
referrers and ask questions to define the appropriateness of an imaging request before they can
substitute a more appropriate test is both unrealistic and costly. The restrictions on Radiologist
substitution of MRI and certain US services reflects the view that specialist radiologists should
not have the same authority as other clinical specialists.
eHealth will provide the platform for electronic order entry and decision support tools which
have the potential to enable greater Radiologist vetting of imaging requests, in conjunction with
the patient’s clinical record, to determine the appropriateness of the test requested. The College
would like to see Radiologists taking a greater role in overall patient management and the rules
around the rights of test substitution amended to delegate greater authority to Radiologists to
substitute more appropriate tests.
RANZCR Submission to DI Review, May 2010
Page 25
After hours services
Medicare provides a single level rebate for each type of diagnostic imaging service, irrespective
of the time of service delivery. In other parts of the MBS however, higher fees are paid for
after-hours general practice, anaesthetic and miscellaneous services (GP Table - Group A2,
A11, A16, A22, A23, Anaesthetic Table - Group T7, T10, subgroup 24, Miscellaneous Services
Table - Group A2, Group A16), in recognition of the increased costs involved in supplying
urgent after-hours services.
There have been significant increases in Emergency Department and after-hours GP attendances
in the past decade, which have flowed on to a substantial and growing requirement for afterhours radiology services. Higher utilisation of after-hours imaging services has also been
fuelled in some states by recently introduced Emergency Department policies such as the “4hour rule” whereby there is a requirement for at least 98 per cent of patients arriving at
emergency departments to be seen and admitted, transferred or discharged within a four-hour
timeframe 11. This requires that patients are fully investigated as soon as they present to an
Emergency Department, irrespective of their arrival time. Patients who may previously have
been observed overnight, and if necessary, undergone diagnostic imaging investigations the
following day, are now referred for urgent after-hours CT and ultrasound examinations in order
to expedite their diagnosis and management in the Emergency Department. New treatment
pathways for acute conditions including thrombolytic therapy for stroke have also resulted in
higher utilization of after-hours imaging.
Most after-hours radiology services are rendered in radiology departments attached to private or
public hospital emergency departments or after-hours GP clinics. After-hours radiology services
are also provided to private and public hospital
inpatients and there are some private practices
The DIST does not include any
items that recognise the
operating limited after-hours services for modalities
such as ultrasound and MRI.
significant additional costs of
providing services after hours.
Radiology is a labour intensive industry where wages
account for approximately 40-50% of the cost of service provision. Radiographer staffing for a
radiology department providing a 24-hour service to a hospital with an Emergency Department
is approximately 50% higher than for a private practice operating five and a half days during
regular business hours. The additional staff covering the after-hours service are paid at penalty
rates (shift-work loading and Saturday, Sunday and Public Holiday loading) and receive
generous on-call allowances, call back payments and overtime payments. The Health
Professionals and Support Services Award 2010 introduced in January has recently resulted in
higher staff costs for many radiology service providers.
Under the current award, radiographers and sonographers called back from home to provide an
urgent after-hours service receive a minimum payment of 2 hours pay at the appropriate
overtime rate. In view of the difficulty in recruiting sonographers and radiographers to cover
after-hours services, payment for call-back is usually more generous than required by the award
(e.g. typically three hours at twice or two and a half times the normal hourly rate). Using
average salaries of $40-$55/hour for sonographers and $30-$50/hour for radiographers, the cost
for a sonographer or radiographer call-back to perform a single urgent after-hours examination
is between $180 to $385.
11
Government of Western Australia Department of Health:
http://www.health.wa.gov.au/fourhourrule/home/
RANZCR Submission to DI Review, May 2010
Page 26
The following table highlights the inadequacy of the fees for common after hours DI studies.
MBS Fees for common after-hours diagnostic imaging studies
Abdominal Ultrasound (55036)
$111.30
Duplex Ultrasound leg veins (55244)
$169.50
CT Head non-contrast (56001)
$195.05
CT Cervical Spine (56220)
$240.00
CT Abdomen and Pelvis (56507)
$480.05
CT Chest CTPA (57351)
$510.00
Multiple Services Rules
The multiple services rules, first introduced in November 1996, discount Medicare schedule
fees when an imaging service is provided with other imaging, consultation or procedural
services. They were implemented with the intention to bring diagnostic imaging in line with
other areas of the Medicare Benefits Schedule (MBS),
The multiple services rules
where fees are discounted to better reflect the resources
promote inefficient and delivery
used, and efficiencies gained, in providing more than one
of services and a variety of
service during the same episode of patient care.
behaviours designed to work
around them (eg splitting services
The College has received many requests from providers
over multiple days).
to take up the cause for patients inconvenienced by
application of the multiple services rules and has
undertaken a detailed review of these rules. The rules are considered complex to follow and are
poorly articulated in the DIST. The substantially reduced rebates produced by application of the
rules are considered unrealistic with regard to the minor efficiencies gained in providing
multiple diagnostic imaging services on the same day.
Interventional Procedures
There are over one hundred and fifty items in the MBS that can be construed as being imaged
guided interventions. Since the original interventional items were added to the MBS there has
been little, if any, review of item rebates relative to the cost of provision, changing technology,
consequent ease or difficulty in performing the procedures and the reduction in non image
guided procedures performed as a result of newer IR techniques. Many procedures previously
performed surgically are now performed as imaging guided interventions.
IR has been particularly sensitive to the adhoc rebate
changes that occurred under the MoUs, due to the cost
of consumables involved in performing an
interventional procedure. For example, the rebates for
pleuracentesis and ascites drainage are $59.00 and
$40.10 respectively, however the pigtail or drainage catheters alone can cost $100 before
factoring in the radiologists time, radiographer time, nursing staff time, equipment and
occupancy costs. Reimbursement should include the direct cost of consumables.
In some cases the consumables
involved in interventional
procedures cost more than the
relevant rebate.
On the other hand there is a significant difference in the rebates for digital subtraction
angiography depending on the number of runs, which is not as relevant with today's advanced
digital imaging equipment. There is a strong argument for reviewing the rebates for multiple
runs.
The viability of providing interventional procedures in private practice has been impacted by
under funding of these procedures in the MBS and by differing funding arrangements between
RANZCR Submission to DI Review, May 2010
Page 27
public and private providers resulting from the dual source of funding for equipment and other
competitive advantages in the public sector.
Inadequate remuneration for fluoroscopic and ultrasound guided injection item numbers has
driven the use of CT for many simple joint injections and reduced willingness of providers to
purchase fluoroscopy machines.
RANZCR Submission to DI Review, May 2010
Page 28
Access to Quality Assured MRI Services
Medical Resonance Imaging (MRI) is a state-of-the-art modality and patient access to MRI is a
fundamental plank of medical services in the 21st Century. In Australia, the licensing and other
policy settings that have been applied over the past 12 years since the listing of MRI services
onto the MBS have hindered proper transfer to this technology (especially from CT).
By contrast with access to comprehensive practices generally, less than 80% of the population
lives within 25km of an MRI unit (licensed or unlicensed).
Clinical appropriateness
Greater access for patients to MRI is clinically both necessary and appropriate.While CT is
entirely more appropriate, and more effective, than
A sustainable framework for
MRI in many situations including assessment of
equitable and improved access to
renal stones and their complications, multi-trauma
MRI is long overdue.
accidents, facial fractures including 3D
visualisation, and studies of the lungs and abdomen,
MRI is generally more appropriate for conditions relating to the brain, musculo-skeletal joint
imaging (knees, shoulders, wrists), several spinal conditions, oncology staging (incl. bones) and
a long list of more unusual conditions such as transient osteoporosis of the hip.
In view of the higher risk to children of cancer occurring later in life from exposure to CT, MRI
should be the imaging of choice for children under 20 years of age, unless a CT is clinically
indicated, for example in trauma cases. The risk of a CT scan-triggered fatal malignancy
developing later in life has been estimated by some authors to be up to one in 500 for children
under the age of one, one in 1,250 for children up to ten years and one in 1,600 for those up to
20. 12
Patient Access
At January 2010 there were 125 Medicare eligible units, servicing 128 sites with a further 2
sites yet to come online. There are an estimated further 50 unlicensed units providing services to
meet the unmet demand for provision of MRI services, for example for indications not included
on the MBS, compensable cases, sports medicine cases and GP requests.
Australia has one of the lowest levels of access to MRI amongst OECD countries with 5.7
licensed units per million in 2009. Even the inclusion of unlicensed units, bringing access to
about 7.9 total units per million, is still well below the OECD average of 11.0 MRI units per
million population in 2007.
Restricted access to MRI, through licensing and specialist only referral, has resulted in less than
80% of the population living within 25km of an MRI unit (licensed or unlicensed). Limited
access to both specialists and to licensed MRI units combine to make access more difficult for
patients in regional and rural areas.
The policy of “controlled expansion” of MRI through site specific licenses to encourage
providers to take up licenses in certain areas has also been shown to have been discriminatory to
providers. For example, where there are insufficient specialists to support a viable MRI service
in some rural areas throughputs are about 25% below the average throughputs in metropolitan
areas that have an appropriate specialist referral base.
12
Brenner DJ, Elliston CD, Hall EJ, Berdon WE.Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J
Roentgenol 2001;176: 289-296.
RANZCR Submission to DI Review, May 2010
Page 29
Specialist referral restrictions have skewed GP choice of imaging modality towards CT, and in
combination with the restriction on the rights of radiologists to substitute an MRI when an
inappropriate CT has been requested, are potentially compromising clinically optimal imaging
and patient welfare. By contrast with MRI, Australia has one of the highest levels of access to
CT amongst OECD countries with an estimated 38.4 CT scanners per million populations in
2009 compared to the OECD average of 20.2 per million in 2007.
Specialist referral to MRI is also being circumvented by GPs and sports medicine physicians
referring their patients to unlicensed units where patients
are generally able to access MRI without delay and for a
Licensing and other policy
cost that is competitive with the combined gaps they
settings are hindering appropriate
would be likely to incur through the specialist referral
use of MRI services.
arrangements and having a scan on a licensed unit. The
current licensing arrangements are inequitable for both patients and providers. The recent
expansions of MRI indications following MSAC assessment for Breast MRI and MRI for Rectal
Cancer have further aggravated the existing inequities by only allowing these indications to be
provided on licensed units. Patient access to quality MRI services should be through
appropriately accredited comprehensive practices and clinical indications, not equipment and
locations. Patients and clinical priorities should be the basis for determining the most effective
allocation/ rationing of scarce funding resources. Rationing on clinical grounds for cost control
is not considered effective, but this is a matter for Government.
Patient Billing Arrangements
Despite increasing efforts to control the costs through tendering for licenses since 2001, MRI
licensing has driven up costs for patients. Private sector units that are not bound by contracts
with the Government that require them to bulk bill most patients, can charge higher patient gaps
in order to compete with the gaps charged by their unlicensed competitors. Bulk billing for
services on these units in 2009 was 34% compared with 95% for those with more restrictive
bulk billing contracts. Average gaps charged by the unregulated private units were $147.70,
with some charging almost all patients and some having average patient gaps in excess of $200.
RANZCR Submission to DI Review, May 2010
Page 30
The inequitable MRI licensing arrangements between
providers have translated into inequitable billing
arrangements for patients and these arrangements need to
be standardised.
MRI licensing and funding
arrangements have created a
range of inequities for both
providers and patients.
MBS Rebates
A new schedule of MBS rebates for MRI services, based on relative complexity of different
services, was introduced in August 2004, along with an arbitrary 15% cut in the average rebate
to fund further expansion of MRI licenses. There have been no increases in rebates since and
average MRI rebates are now about 40% lower in real terms than they were 10 years ago. The
low levels of bulk billing and the high gaps charged by those providers who are not bound by
contracts with the Government suggest that MRI rebates are seriously under funded. It follows
that the viability of those practices that are bound by contacts with the Government requiring
services to be bulk billed is impacted by their inability to charge patients in order to recover any
shortfall in the cost of providing these services.
As with other modalities, MRI rebates should be closely aligned to the cost of providing
services or a viable alternative funding mechanism is needed to encourage providers to provide
services without charge to those in the community who are genuinely not able to pay a copayment (i.e pensioners, children, health card holders, etc). As suggested above, the
Government could pay 100% of the fee as an incentive to bulk bill such patients. Alternatively
if rebates cannot be more closely aligned with the cost of providing services then a compulsory
co-payment could be introduced, with a one off increase in the welfare payments of concession
card holders.
Indexation
As with other DI services, rebates for MRI need to be adjusted periodically for cost variations.
An annual indexation rate is currently applied to the MBS fees in all areas except DI and
Pathology.
Improving Access to Quality Assured MRI Services
The College considers that priority needs to be given to improving patient access to quality
assured MRI services and that options for minimising inappropriate requests for MRI, and if
necessary options to manage demand, need to be developed around other policy levers such as
referral restrictions and professional supervision.
GP referral for MRI
The AMA has been promoting GP referral for MRI for some time. In principle, the College
supports expanded access for GPs to MRI referral for certain conditions that present commonly
in general practice:
• where the evidence supports the use of MRI as the most appropriate test to exclude or
confirm the condition;
• where the result of the MRI could prevent a referral to a specialist or exposure to
ionising radiation that will not contribute to subsequent diagnosis or management;
• where the result of the MRI may lead to earlier treatment and where this earlier
treatment prevents long term costs to the patient and/or the health care system (eg
through prevention of disability)
• in conditions where MRI has been shown to be cost effective in reducing some other
outcome, eg surgery or disability , due to earlier or less invasive diagnosis
• where it is possible to define patient characteristics that a GP could reasonably be
expected to identify with a high level of reliability that would allow selection of a
subset of patients most likely to benefit in the above ways from having an MRI.
RANZCR Submission to DI Review, May 2010
Page 31
To ensure high quality referrals for MRI by GPs however, the College considers that GPs will
require some education and training, or decision support to assist them to understand:
• Where MRI fits into diagnostic imaging options
• which patients are appropriate and how to identify them,
• the risks/dangers of MRI,
• which patients are not likely to benefit from MRI
• false positive diagnosis/non specificity of MRI;
• which potentially serious conditions may not be detected by MRI
• what MRI findings mean in the context of the overall criteria needed for diagnosis
• determining the need for further tests or specialist referral.
In the short term, education and training via an online CPD module would enable early
implementation of GP referral for MRI. In the longer term, the College considers that decision
support at the point of DI request has the greatest potential to minimise unnecessary or
inappropriate imaging.
Substitution for Inappropriate CT
Radiologists are best placed to oversee requests from GPs accredited to refer for MRI, to ensure
the appropriate use of MRI. Radiologists need, however, to
be able to substitute an MRI procedure in cases where a GP
To be a gate keeper requires
has inappropriately requested a CT procedure.
delegated authority which means
Strategies for Improving Access to Quality
Assured MRI Services
substitution powers; authority
equivalent to specialist clinicians.
The College recommends the following strategies for improving patient access to quality
assured and affordable MRI services:
1. uniform eligibility arrangements for all Radiology providers determined through
new quality based professional practice standards, including requirements for
appropriate clinical expertise where deemed necessary;
2. appropriate clinical indications;
3. referral for MRI by GPs who have undertaken appropriate education and training in
referral for MRI (eg via online CPD Program) in the short term;
a. Option 1: No restrictions on clinical indications
b. Option 2: No restrictions on clinical indications in non-metropolitan areas and
restricted to certain clinical indications where MRI is considered a more
appropriate test than CT in metropolitan areas
4. extension of the right of substitution for radiologists for certain clinical indications
where MRI is considered a more appropriate test than an ionising CT test;
5. standardised billing arrangements for all providers of MRI;
6. development of GP decision support for imaging requests including MRI, in the
longer term;
7. Monitoring and evaluation of GP referral for MRI;
8. Medicare Australia auditing of use of CT for those indications where MRI is
considered a more appropriate test.
These strategies should also result in improved patient outcomes through:
• Reduction in specialist referrals;
• Reduction in ionising radiation as CT is replaced by MRI for some clinical indications’
• Reduced time to treatment for certain conditions by allowing patients to be more
effectively triaged for specialist referral as a
result of the MRI result being available to the
Priority should be given to
GP.
strategies for improving patient
access to quality assured MRI
services.
RANZCR Submission to DI Review, May 2010
Page 32
Access to Quality Assured PET Services
In 2009, there were just 20 sites providing Medicare funded PET services in Australia and with
the exception of 2 sites, these are all located in capital cities.
Patient access to PET is limited through both site restrictions and limited access to the full suite
of rebatable items in some sites. PET is currently funded through various arrangements which
expire in June 2010 including;
i.
MBS funding for a limited number of sites who have contracts with the Australian
Government (Health Insurance (Positron Emission Tomography) Facilities
Determination 2008);
ii.
MBS funding for nine specific indications for those sites that meet a specified set of
criteria (Health Insurance (Positron Emission Tomography) Determination 2008 No.2).
A sustainable framework is needed
Restricted access to timely PET services has resulted
for improving access to and the
from both the unplanned evolution of PET services in
affordability of PET services.
Australia and the restrictiveness of the current MBS
approved items. The current mechanism for
recommending new PET indications for MBS funding is via the Medical Services Advisory
Committee (MSAC). The MSAC process is slow and restrictive, and its recommendations are
frequently at odds with current world practice, as was the case with the recent MSAC decision
on funding of PET in lymphoma.
PET CT is underutilised in cancer care in Australia and its use is lagging behind that of other
developed countries with modern cancer care. For example, the following table shows the list of
PET funding in the United States.
Source: National Comprehensive Cancer Network Task Force: Clinical Utility of PET in a variety of
Tumour Types. DA Podoloff et al. Journal of the National Comprehensive Cancer Network. Volume 7,
Supplement 2, 2009
RANZCR Submission to DI Review, May 2010
Page 33
Restrictive Patient Access to MBS Approved Indications.
Cancer patients with those cancers supported by MBS can access PET, yet cancer patients with
those cancers not supported by MBS are denied access to MBS benefits. In many cases, the
cancers are biologically identical, and differ only in their organ of origin. For example,
metastatic squamous cell carcinoma originating in the head and neck (usually from cigarette
smoking) is fully supported by MBS, yet metastatic squamous cell carcinoma originating in the
skin (from sun exposure) is not. The biology of the two cancers is the same, and the
effectiveness of PET in demonstrating the cancers and driving clinical care is the same. It is
inequitable from the vantage point of the patient who has metastatic skin cancer as a result of an
outdoor occupation that his treatment is valued less than that of a patient who has metastatic
cancer from smoking.
Cancer patients whose cancers are supported by MBS but only for some indications can access
PET when their clinical situation fits the MBS item descriptor, yet face an access block when it
does not. For example, a patient with a colorectal cancer with suspected metastatic spread is
supported by MBS only after the primary cancer has been resected. The biology of the cancer is
the same before and after resection of the primary cancer and it is both clinically sound and cost
effective to identify metastatic disease before treatment so that futile curative treatment is not
commenced.
Inequitable Patient Access to Funded PET Services
Two PET centres in Australia receive block funding in addition to funding under MBS. As a
result, these two centres have been able to offer PET scanning to patients who would otherwise
not be eligible for financial support as a result of their
cancers not being MBS eligible. Such patients often
Any patient with a histological
travel very long distances (and often past the PET
proven cancer should have access
centres in their own catchment) to reach these two
to timely, life saving and life
hospitals. The capacity of these two hospitals is finite.
modifying, Medicare funded PET
A few public hospitals also provide PET scans for
services.
MBS ineligible malignancies through State
Government funding. For cancer patients to access such PET services they need to be accepted
as public hospital patients in these hospitals.
Under funding of MBS PET Services
Unlike other DI services, the current MBS rebates for PET do not include a capital component.
This needs to be taken into account in any review of fee relativities with other DI modalities.
PET should also be excluded from the 2009 budget initiative to introduce capital sensitivity
provisions. PET services should be integrated into the DIST with fees structured in a manner
consistent with those established for other DI services.
The capital cost of PET scanning is in the order of $2-3 million per unit (including the scanner,
hot lab and associated equipment) with further comparable outlays at new sites for major
building works including radiation shielding. State government funded hospitals have used
their major infrastructure funding arrangements to purchase and install their PET scanners and
use the MBS rebates to fund their operating costs. The most recent public sector PET
installation was at the Royal Hobart Hospital with the Commonwealth and the Tasmanian State
Government each contributing $3.5m to the $7m cost.
RANZCR Submission to DI Review, May 2010
Page 34
Private providers of diagnostic imaging services are
The treatment of the capital
required to fund the capital cost themselves. The need
component for Medicare funded
to recover the cost of capital, over the ten to fifteen
PET services needs to be brought
year lifetime of the equipment, through patient gaps
into line with the treatment of the
makes the viability of privately funded PET services
capital component for other DI
under the current PET funding arrangements marginal.
services in the MBS.
For this reason the availability of PET services in
Australia is limited, with only three private DI practices providing PET services.
Future Developments
The next major development in PET technology will come from new fluorinated
radiopharmaceuticals. As more PET radiotracers are developed, trialled and become available
for commercial production and clinical use in Australia, there needs to be a mechanism to fund
their clinical use. Newer radiotracers (such as FLT, FET, FCholine, Festradiol, etc) will cost
considerably more than FDG.
PET Rebates
There are a number of factors impacting on the cost of providing PET services that should be
considered in any review of the relative costs of PET indications:
•
•
•
•
•
The fee for lower limb melanoma and lower limb sarcoma examinations should be
higher relative to other oncology PET-CT procedures as these take significantly longer
to acquire.
Currently each MBS PET item is duplicated, with the second item being for same
service but with bladder catheterisation. The fee differential between the two
duplicated items is small. In oncologic PET practice, bladder catheterisation is
undertaken very infrequently but its real cost is much higher than the MBS differential.
The MBS fee structure promotes separate CT and PET reporting. Concurrent
interpretation of diagnostic CT and diagnostic PET by a dual trained radiologist bestpractice. It takes longer and more professional input toaccurately report both a PET and
a diagnostic CT and the fee structure should reflect this.
Rebates need to reflect the additional professional input required to undertake
comparisons ith previous scans.
The current PET rebates reflect reporting times and complexities related to the use of
FDG PET. Once new and different radiotracers are introduced to clinical practice, the
time to report PET studies will not necessarily stay the same.
Indexation
As with other DI services, rebates for PET need to be adjusted regularly to account for cost
variations. An annual indexation rate is currently applied to the MBS fees in all areas except DI
and Pathology.
Proposal to Restructure PET Item Descriptors.
It is proposed that the schedule of PET item descriptors could be restructured and simplified to
optimise patient access and remove unfairness inherent in the current system. The major patient
eligibility criterion for MBS funding support should be histologically proven malignancy (see
below). There should also be a method of reimbursing the capital cost component which is
applicable to providers who fund their own cost of capital.
Further simplification of the PET schedule could be achieved by:
• Replacing all items that include bladder catheterisation by a single item for bladder
catheterisation in conjunction with a PET study. Fourteen of the 39 items reflect just the
addition of $22 where the services include catheterization of the bladder.
RANZCR Submission to DI Review, May 2010
Page 35
•
•
•
•
Replacing multiple items which differ only by ‘for staging', or ‘for restaging', or 'for
biopsy guidance' with a single item 'for evaluation'.
PET procedures requiring longer medical specialist input (specifically comparison with
previous images, and simultaneous reporting of diagnostic CT with diagnostic PET) be
funded differentially to reflect the greater time and effort required.
PET items for myocardial and brain scanning be balanced against the oncology PET
items to reflect the savings in camera and reader time relative to oncologic PET
scanning.
there be a PET item covering the additional cost of providing PET services where the
primary is a lower limb melanoma or lower limb sarcoma (item reflecting greater cost
of camera time).
Improving Access to Quality Assured PET Services
The College considers that priority should be given to improving access to and affordability of
quality assured PET services. A range of measures is needed:
1. Allow patient access to PET procedures where there is histological proof of
malignancy.
Oncology PET is only relevant to a very specific population (namely cancer patients)
and this proposal would eliminate current inequities faced by those cancer patients who
do not have access to PET because of inequitable and ad-hoc Medicare item wording.
PET currently has 39 approved different indications incompletely covering a small
range of cancers and there are a number of other indications in the MSAC process. The
indications are fragmented, confusing to referrers and providers, and disadvantage
oncology patients who are unable to access PET because of lack of Medicare support.
2. Provide a mechanism to support the capital cost of PET services for those
providers who fund their own cost of capital.
Providers whose PET facilities are not funded by state governments (or their business
units) and who are not block-funded by the Commonwealth or State governments
should be eligible for reimbursement of the capital cost of their PET equipment.
3. Modify the site restrictions
The current arrangements require services to be provided in a facility where each of the
following services is provided (whether or not other services are also provided):
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
PET;
computed tomography;
x-ray;
diagnostic ultrasound;
medical oncology;
surgical oncology;
radiation oncology; and
neurology.
The College shares the views of ANZAPNM that the physical co-location of all these
services is not critical to the delivery of high quality PET services, so long as there are
appropriate links to oncology services (medical, surgical and radiation). PET use for
neurology is a small proportion of all PET use Australia-wide, and is undertaken in
centres specialising in neurology.
RANZCR Submission to DI Review, May 2010
Page 36
Arbitrary regulatory requirements
Access to quality assured PET services for
that may not reflect current best
patients outside of major metropolitan areas
practice should not prevent
should be available to support the oncology
services being delivered in outer
treatment centres that exist in many nonmetropolitan and regional areas.
metropolitan areas. Access to PET in outer
metropolitan and larger regional areas would give cancer patients in these areas access
to staging and treatment assessment without the need for them to travel long distances.
The requirements for PET services to be integrated into multidisciplinary care and other
technical requirements should be incorporated into the practice accreditation process.
RANZCR Submission to DI Review, May 2010
Page 37
Summary of Key Points
Broader Health Care Reforms
•
•
•
•
•
Changes to the overall healthcare delivery system impact diagnostic imaging. DI is an
integral component of 21st Century healthcare and must be factored into the development
of broader health reform policies.
A DI policy committee is needed to advise the Government on changes to imaging
services within the broader healthcare reform context as well as the achievement of
access, affordability, sustainability, quality DI services and patient outcomes.
Technological change is revolutionary and diagnostic imaging is a leader. Government
policy must be adaptive and flexible and not stifle innovation.
The role of Government is to facilitate connectivity and patient confidentiality. The
capability already exists to deliver service integration in decision making and ought not to
be reproduced in any way that makes existing facilities obsolete.
Access and availability of imaging are both change management tools. Change needs a
plan, one that looks at investment efficiency and avoids duplication and instability.
Importance of Diagnostic Imaging
•
•
•
Diagnostic imaging is an integral part of medical care.
Radiologists have expertise to bring to clinical and treatment decision making and they
should have a greater role in overall patient management.
Radiologists are doctors’ doctors. Their educational role, their disease management and
staging role and their teaching role are often over looked. Radiologists are integral to all
these components of every examination. They create accountability for clinicians.
Appropriate Imaging
•
•
•
•
•
A multi-faceted approach that addresses the causes of clinically inappropriate or
unnecessary imaging requests will be needed to achieve practical and sustainable
improvement towards ensuring that imaging is appropriate and clinically accountable.
Appropriate DI requests require experience and training by referrers. That young doctors
do not have sufficient training in anatomy, pathology and diagnostic imaging is a cause
for concern but increasing access to less well trained people is likely to create a higher
volume of clinically inappropriate or unnecessary referrals.
There has been a failure of academia and medical curricula to teach clinical diagnosis and
decision making which has resulted in a greater reliance on imaging as a substitute for
diagnostic reasoning.
The current licensing arrangements and policy settings for MRI contribute to
inappropriate imaging. MRI access issues must be resolved.
It is Government’s role to inform the public that it will only fund certain imaging in
certain circumstances. Evolution to rationing based on proven benefit is also the
responsibility of Government.
Current and Future DI Service Delivery
•
Australians have very good, cost effective access to diagnostic imaging services - 90%
live less than 25km from a “one stop” comprehensive DI practice.
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Page 38
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•
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A viable network of professionally supervised comprehensive practices offers the most
effective use of resources for delivering quality assured imaging services to the vast
majority of Australians.
Increased funding for patient travel and accommodation is the most cost effective way of
providing access to these services for patients in rural and remote areas.
Innovative teleradiology solutions are needed to improve access to specialist supervision
and opinions for people in rural and remote communities.
The College standards have established the radiologists as the single point of
accountability for each imaging service.
Provision of images without a report removes the single point of accountability for the
total service including the interpretation of the images.
eHealth will enable a quantum leap towards integrated patient care and enable better use
of the clinical expertise of radiologists.
Training
•
A serious investment in training is required to provide the Radiologist workforce to meet
the future demand for services.
Funding Considerations
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•
Imaging is a benefit not just a cost. Cost effectiveness of imaging must be measured in the
broad context of improved patient outcomes. This means a new approach to rebates.
Thwarting expenditure at the DIST level may create a greater cost burden elsewhere.
The current MBS fee-for-service model is an efficient and effective means of funding DI
services. It has worked well to provide reasonable patient access to high quality imaging
services and healthy competition between providers.
Funding needs to support the viability of both the public and private DI sectors. Current
distortions in public sector DI funding need to be addressed.
If the Government wants concession card holders to be bulk billed, the reimbursement rate
for these patients needs to be adequate to meet the cost of providing the service. Patients
who can afford to pay a gap should not be subsidising the cost of bulk billing such
patients.
Uneconomic rebates do not save money for Government. They result in secret taxes,
reduced investment and changes in health care delivery which are unplanned.
Rebates must be indexed to account for cost variations.
DI providers cannot absorb increasing costs. No indexation of rebates can only lead to
increasing out of pocket expenses for patients.
The DIST is outmoded and needs to be simplified and rewritten to better reflect the
evidence base and current clinical practice:
o The DIST does not recognise the significant additional costs of providing services
after hours.
o The current test substitution rules do not recognise radiologists as highly trained
specialists, whose expertise could be better utilised in the clinical decision making
process to reduce unnecessary and inappropriate requests for imaging.
o The multiple services rules promote inefficient and inconvenient delivery of
services to patients and a variety of behaviours designed to work around them.
o In some cases the consumables involved in interventional procedures cost more
than the relevant rebate.
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Access to Quality Assured MRI Services
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Appropriate access to MRI is a fundamental component of medical services in the 21st
Century and improved access is needed to this state of the art modality
A sustainable framework for equitable and improved access to MRI is long overdue.
MRI licensing and other policy settings are hindering appropriate use of MRI.
MRI licensing and funding arrangements have created a range of inequities for both
providers and patients.
Priority should be given to strategies aimed at improving patient access to quality assured
MRI services.
To be a gate keeper requires delegated authority which for radiologists means substitutionof-test powers for Radiologists; this is authority equivalent to that already entrusted to
specialist clinicians
Access to Quality Assured PET Services
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•
•
Restricted access to timely PET services has resulted from both the unplanned evolution of
PET services in Australia and the restrictiveness of the current MBS approved items. A
sustainable framework is needed for improving access to and the affordability of PET
services
The treatment of the capital component of PET needs to be brought into line with the
treatment of this component of other DI services.
Any patient with a histological proven cancer should have access to timely, life saving and
life modifying, Medicare funded PET services.
Arbitrary regulatory requirements that may not reflect current best practice should not
prevent services being delivered in outer metropolitan and regional areas.
RANZCR Submission to DI Review, May 2010
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Attachment 1 - Elements of a Comprehensive Diagnostic Imaging
Practice
A diagnostic imaging practice contains the following elements:
• a radiologist(s) or other diagnostic imaging provider
• technical staff
• clerical staff
• premises
• diagnostic imaging equipment
• computers and network equipment
• ancillary equipment.
Each of these elements is described below.
The radiologist
The radiologist is a medical practitioner who has completed specialist training in diagnostic
radiology. A new diagnostic imaging training curriculum cam into force in January 2010, and is
available from http://www.ranzcr.edu.au/educationandtraining/curr.cfm. This rewriting has
occurred following comprehensive review of the skill set that is generally regarded as being
required to perform to the standard required of a diagnostic radiologist. As well as the
knowledge base outlined in the curriculum, a radiologist needs to be able to perform a large
number of procedures for which adequate training and experience is required. The knowledge
base required to practice as a specialist radiologist is encapsulated by the recently released set of
textbooks entitled "Radiology". This multi-volume multi-author set illustrated in Figure 1 is
written in a concise point format which summarises the anatomy pathology and diagnostic
imaging findings of abnormalities. They are not discursive texts which cover subjects "from A
to Z", but are an aide-memoire for knowledge radiologists need to have in their heads, or know
exists, to which one refers when reporting. A comprehensive understanding of the subject
matter of these texts requires much wider reading. These texts do not cover procedural services.
Figure 1. Recently released set of textbooks entitled "Radiology"
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What the radiologist does
The radiologist is the single point of accountability for all aspects of the quality of the medical
service provided to each patient by the practice. The radiologist oversees all aspects of the
diagnostic imaging service. This includes the following:
• Providing training to clerical and technical staff to ensure high standards, and the
introduction of new skills and technologies as they occur.
• Providing clinical information to requesting practitioners as required, about the
appropriateness of diagnostic imaging in a particular clinical setting, and the diagnostic
imaging service most likely to be useful. (The explosion in the choice in diagnostic
imaging has meant it is almost impossible for requesting practitioners to know the best
test for many clinical indications, except for the common clinical settings. For example
the multitude of techniques in CT or MRI available to assess a single organ or system
depending on the abnormality being assessed, is beyond the knowledge base of most
requesting practitioners.)
• Reviewing each request for clinical appropriateness as required, and prescribing the
exam technique, particularly for CT and MRI scans, or substituting an appropriate test
where required. This may require consultation with the patient to get further
information about the clinical problem.
• Personally performing any of the examinations or procedures listed in the DI Services
Table, including imaging guided biopsies and treatment (See DI Procedures List at
Attachment 1.1). The interventional radiologists who provide procedures such as
interventional neuroradiology, interventional oncology and other subspecialty
procedures often act as the patient’s primary physician, not only performing the primary
treatment (procedures) for the patient but also providing before and after clinical care.
• Providing advice on all matters relating to the patient and the service raised by the
technical or clerical staff during the procedure.
• Reviewing the images obtained when the examination is completed to confirm that a
satisfactory examination has been obtained and the clinical question addressed.
Unexpected findings may require further additional imaging including a change in
examination technique.
• Comparing images from the current examination with images from previous
examinations of the same area, and comparing with the findings of any previous
imaging examinations.
• Reporting the examination.
• Contacting the requesting practitioner as required to notify them of urgent or
unexpected findings.
• Discussing the findings with a patient as required particularly to organise immediate
care for unexpected or significant findings or to arrange any further imaging that may
be required to clarify findings, such as a CT scan to characterise a liver or renal mass
found on ultrasound, or a CT body scan when a chest x-ray has shown multiple lung
metastases.
The reporting process
To be effective and efficient, the reporting process needs to be undertaken by a highly trained
medical specialist in an appropriately equipped environment. A diagnostic imaging examination
produces between one and several thousand images. A written report is the only way to convey
the findings to all the medical practitioners who may be involved in a patient's episode of care,
as well as creating the medical record. Further episodes of care for any individual patient
necessitate correlation with previous diagnostic imaging findings. It is not practical to
reinterpret all the images on each occasion when the findings need to be known, and the
findings of any previous imaging can only be accessible via the written report. Therefore the
findings of each examination must be converted to writing, following expert assessment of the
images obtained in the study.
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A diagnostic imaging examination has images of multiple organ systems. Accurate
interpretation requires examination of all organ systems demonstrated within the diagnostic
imaging study. Only a general radiologist has the breadth of knowledge to accurately assess
every organ system within a diagnostic imaging study. Sub specialist radiologists usually only
report that organ system within their subspecialty, and a comprehensive assessment requires the
input from other sub specialist radiologists, or a general radiologist. Specialist referrers have
particular knowledge about the organ system(s) of their specialty, but not all the other organ
systems demonstrated within a study. A neurosurgeon for example may recognise a brain
tumour, but not sinusitis. A gastroenterologist may have a reasonable understanding of
pancreatic or liver tumours, but not the adjacent spine or lung bases. An emergency medicine
specialist or general surgeon may recognise a perforation of an abdominal organ, but may not
recognise a renal tumour. Many pathologies cross organ systems, for example tumours
commonly spread to bones or lungs, and therefore image interpretation requires knowledge of
all organ systems. Examinations performed for one clinical indication frequently reveal an
incidental finding such as an unexpected renal or lung tumour, which will require recognition
and accurate reporting.
If the diagnostic imaging study is to be interpreted from films, a large number of film viewers
are required to simultaneously display the relevant images particularly in CT or MRI scans.
Multiple x-ray viewers are generally not available outside a radiology reporting room. If a
diagnostic imaging study is to be interpreted from a reporting workstation, this requires a
radiology reporting workstation containing the radiology information software, and image
viewing software, and high-resolution monitors to demonstrate images particularly x-rays and
mammography in high-resolution. The workstation must be linked to the Radiology Information
System and the Picture Archiving System (RIS/PACS system). It must contain dictation
software or voice recognition software to create the report which will be sent to the RIS. The
radiologist must be able to review the hundreds or thousands of images created by an
examination in a timely fashion, dictate the report and review and sign it off when it has been
transcribed. In unusual pathology the radiologist may need to refer to a standard text, but must
first be able to recognise the nature of the abnormality, know where to access relevant
information about the differential diagnosis, and interpret images in the light of it.
Comparison with any previous examinations of the same area is an essential part of image
interpretation. This may facilitate the recognition of subtle abnormalities. It allows assessment
of disease progression, for example heart failure, pneumonia, and cancer. It may confirm that an
abnormality is not significant. For example a lung nodule might be a significant finding such as
infection or tumour, if new, but benign and non-significant if present for some years.
Unnecessary further investigation will often be avoided by comparing current and previous
imaging. This requires that the images are available, can be satisfactorily viewed on a sufficient
number of viewing boxes, or are available for comparison in the PAC system. Satisfactory
access and viewing conditions for previous examinations is only generally available in
radiology reporting rooms. It also adds to the time taken to report a study.
Diagnostic imaging interpretations are subject to errors of detection and interpretation which are
categorised as sensitivity and specificity. Sensitivity is the ability of a diagnostic imaging test to
find the abnormality. Specificity is the ability of the diagnostic imaging test to find all the
normals. No diagnostic imaging test is 100% sensitive and specific. A good example of this is
screening mammography and its ability to detect breast cancer, and differentiate other
abnormalities which are not cancer. Figure 2 is a graph of sensitivity and specificity for
screening mammography for a group of 69 readers who were tested with 50 screening
mammograms showing a variety of findings including a number with subtle cancers. A small
proportion (17/69) of readers scored over 80% for sensitivity and specificity. Only one reader
scored 100% for both. Many readers scored either over 80% for sensitivity or over 80% for
specificity.
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Screening Mammography test scores
120
100
80
60
Series
1
40
20
0
0
50
100
150
Specificity
Figure 2. Specificity and Sensitivity of Breast Cancer Detection in 50 test cases read by 69
readers.
This highlights the difficulty of interpretation of subtle findings, which may or may not indicate
the presence of disease. If the pre-test probability of an abnormality being present is low, subtle
findings are more likely to not indicate the presence of disease, and therefore be interpreted as
not significant. If the pre-test probability of an abnormality being present is high, subtle findings
have a higher probability of being due to the presence of disease, and therefore would be
interpreted as abnormal. The reader therefore has to know what the pre-test probability of an
abnormality is in the patient or group who are having the imaging test, and interpret the imaging
in the light of that pre-test probability. What this highlights is that image interpretation is
difficult, requires a large degree of experience, skill and knowledge, otherwise an imaging test
is of no value, or harmful to the patient.
Inter-observer variability is another measure of the difficulty in image interpretation. For
example, a number of observers may all agree on the presence of a large pulmonary embolus in
the right pulmonary artery. There may be significant disagreement between observers on
whether there is a small pulmonary embolus in one of the distal pulmonary artery branches.
Figure 3 illustrates this issue. Again the issue of inter-observer variability highlights that image
interpretation is difficult and requires a large degree of experience, skill and knowledge,
otherwise an imaging test is of no value, or harmful to the patient.
RANZCR Submission to DI Review, May 2010
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Rotator Cuff Disorders: Interobserver and Intraobserver Variation in
Diagnosis with MR Imaging. P L Robertson, M E Schweitzer, D G
Mitchell, F Schlesinger, R E Epstein, B G Frieman and J M Fenlin
PURPOSE: To determine interobserver and intraobserver variation in the
interpretation of magnetic resonance (MR) images in rotator cuff disorders.
MATERIALS AND METHODS: MR images of the shoulder in 97 patients
were retrospectively reviewed twice, with a 3-week interval. Surgical
findings indicated a full-thickness tear in 29 patients, grade 1 impingement
in 19 (tendinitis), and grade 2 impingement (partial tear) in 26. The control
population comprised 23 asymptomatic volunteers or patients. RESULTS:
All observers were accurate in the diagnosis of a full-thickness tear (89%98%), with good intraobserver (kappa = 0.67-0.84) and interobserver
agreement (kappa = 0.74-0.92). In diagnoses of tendinitis, partial tear, and
normal cuff, there were wide ranges of sensitivity (13%-74%) and
specificity (72%-93%), as well as poor interobserver (kappa = 0.12-0.60)
and intraobserver agreement (kappa = 0.35-0.78).
CONCLUSION: Full-thickness tears of the rotator cuff can be accurately
identified at MR imaging with little observer variation. Consistent
differentiation of normal rotator cuff, tendinitis, and partial thickness tears
is more difficult.
March 1995 Radiology, 194, 831-835.
Figure 3. Inter and Intra observer variation in Image Interpretation
The reporting process therefore must take account of the knowledge base required to be able to
interpret a particular study, the issues of the study accuracy and inter observer variability, and
the facilities needed to create the written record in an efficient manner. Because of their
specialist knowledge, experience, organisation, and application to the task, radiologists will
generally achieve this much more efficiently than anyone else.
The technical staff
The technical staff are university graduates, most with a degree in radiography. Sonographers
have a postgraduate qualification, which requires a further two-three years study under
supervision, and while working in a diagnostic imaging practice. Further training is also usually
undertaken for advanced CT and MRI recognition. The cost of further training in ultrasound CT
and MRI represents a significant cost burden, which is borne by the diagnostic imaging
practices in which a staff member works.
What the radiographer does
The radiographer performs a diagnostic imaging examination. The steps to achieve this are:
• Discussing a request with the radiologist as required prior to the examination being
performed
• Identification of the patient named in the request.
• Escorting the patient to the examination room.
• Explaining the examination procedure to the patient.
• Establishing whether there are any contraindications to the examination such as
pregnancy, allergy, metal implants (in the case of MRI), claustrophobia.
• Obtaining any consent required for example for the administration of contrast.
• Positioning the patient appropriately for the examination required.
• Cannulating if required for the administration of intravenous contrast.
• Operating the imaging equipment to produce the images.
• Viewing the images obtained for technical quality.
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Discussing the images obtained with the radiologist if there is any question about the
adequacy of the study, or the need for additional views, or a further examination based
on the findings, before the patient leaves the practice.
Producing hardcopy images if required.
Despatching the images and any documents into the RIS/PACS.
Returning the patient to the waiting room.
What the sonographer does
In addition to the requirements of a radiographer, since ultrasound does not produce a standard
set of images as x-ray CT and MRI do, the sonographer must produce the images of the subject
of the examination. This requires that they can recognise anatomy and many pathologies, in
order to be able to find and properly demonstrate the abnormalities that are to be confirmed,
staged, or excluded. Sonographers are therefore able to contribute to the diagnosis, and this
reduces the time a radiologist would otherwise need to spend to ensure the quality and accuracy
of the study. However it requires that the sonographer is able to recognise pathology and
demonstrate it optimally on the images produced.
In addition, the technical staff have the following duties:
• Maintain the organisation of the imaging rooms.
• Keeping the imaging equipment clean.
• Conducting any quality assurance tests required on the imaging equipment.
• Restock the examination rooms with disposable items as required.
The clerical staff
The clerical staff may be unqualified or have TAFE qualifications for example in bookkeeping
or typing.
What the clerical staff do
The clerical staff manage all administrative aspects of a patient attendance at the practice and
the diagnostic imaging examination. The steps to achieve this are:
• Making patient appointments either over the telephone or if the patient attends in
person.
• Obtaining all relevant information from a patient to enable an appropriate booking, for
example obtaining gestational age information in order to book scans at the appropriate
time during pregnancy.
• Obtaining any medical information which may contraindicate a particular requested
procedure, for example determining if a patient booking for a biopsy or injection
procedure is on anticoagulants.
• Obtaining any medical information which needs to be considered in the patient
preparation, for example diabetes and how this needs to be managed if tests require
fasting.
• Explaining the preparation required for the examination to be performed.
• Explaining the billing policy and procedures in the practice, and advising a patient if
they will have any out of pocket charges.
• Identifying the patient when they present for the examination.
• Entering the patient data in the RIS/PACS.
• Advising the technical staff that the patient has arrived.
• Providing the patient with any questionnaires required to be completed prior to an
examination, such as a history of relevant contraindications if intravenous contrast is to
be given, or metal implants if an MRI scan is to be performed.
• Transcribing the dictated report.
• Providing the patient with a copy of the report and images.
• Ensuring the requesting practitioner receives a copy of the report.
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Providing the patient with an account if the service is billed to the patient, or providing
a patient with an assignment form to sign if the service is to be bulk bill.
Arranging delivery of films to the requesting practitioner if required.
Sending an account rendered for unpaid accounts.
In addition there are administrative functions which are required. These include:
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Payroll.
Banking.
Bill payment.
Practice accounts.
Staff training and recruitment.
Establishing and maintaining policies and procedures manuals.
Establishing and maintaining quality assurance procedures.
Establishing and maintaining accreditation requirements.
Identifying and complying with regulatory requirements.
Complying with occupational health and safety requirements.
Checking all practice deliveries against invoices and arranging payment
Handling all general enquiries relating to the practice
The imaging practice
The imaging practice has the following components:
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Waiting areas.
Corridors.
Technical work areas.
Filming equipment
Storage rooms.
Reception areas.
Clerical function areas.
Radiologist reporting room.
Change cubicles.
Communications rooms.
Imaging suites.
Imaging equipment.
RIS/PACS computer equipment and networking.
Practice operating costs can be divided into the following:
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Rent.
Salaries.
Capital equipment.
Premises fit out costs.
Equipment and premises maintenance costs.
Consumables.
Overheads.
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Attachment 1.1
List of DI Procedures
DI PROCEDURES
ANGIOSUITE
A.DRENAL VEIN SAMPLING
ANG I OGRAM - Non Selective
ANGIOGRAM - Selective (eg Renal, Carotid)
ANGIOGRAPHY/ANGIOPLASTY
ARTERIAL EMBOLIZATION
BILARY WALL STENT INSERTION
CERVICAL FACET JOINT INJ
CHYMOPAPAIN INJECTIONS
COELIAC PLEXUS BLOCK
CORE BIOPSY LUNG ONLY
DISCOGRAM (Lumbar or Cervical)
FISTULOGRAMS (For A.V Fistula)
INSERTION ARTERIAL STENTS
INSERTION HICKMAN'S CATHETER
INSERTION NEPHROSTOMY CATH
INSERTION PICC LINE
IVC FILTERS
JJ STENT INSERTION
NEPHROSTOMY
OESAPHAGEAL DILATATION
PORTA CATH INSERTION & REMOVALS
RENAL ARTERY STENTING
UTERINE ARTERY EMBOLIZATION
VARICOCELE EMBOLIZATION
VENOGRAPHY
VERTEBROPLASTY
CT2
CHEST
KIDNEY
LIVER
LUNG
LYMPHNODES
PANCREAS
BLOOD PATCHES FOR C.S.F LEA
CYST ASPIRATION (eg renal)
DRAINAGE
EPIDURAL INJECTION
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DI PROCEDURES
FACET JOINT INJECTIONS -Lumbar
FINE NEEDLE ASPIRATION & BIOPSY
FORAMINAL INJECTlONS - Cervical
FORAMINAL INJECTIONS - Lumbar
LUMBAR PUNCTURE
LUMBAR SYMPATHETIC BLOCK
SACRO-ILIAC INJECTIONS
MAMMOGRAPHY
DUCTOGRAM
MAMMOGRAPHY - Cyst
MAMMOGRAPHY - Hookwire
MAMMOGRAPHY - FNAB
STEREOTACT1C BREAST BIOPSY
SCREENING
ANTEGRADE PYELOGRAM
ARTHROGRAM - Ankle
ARTHROGRAM - Elbow
ARTHROGRAM - Hip
ARTHROGRAM - Shoulder
ARTHROGRAM - Wrist
BARIUM ENEMA
BARIUM SWALLOW/MEAL
DACROCYSTOGRAM
GADOLINIUM INJECTIONS
HSG (Hysterosalpingogram)
INJECTION INTO JOINT
IVP (Intravenous Pyelogram)
LAP BAND ADJUSTMENT
LUMBER PUNCTURE
MCU (Micturating Cystourethrogram)
MYELOGRAMS - Cervical
MYELOGRAMS - Lumbar
PAEDIATRIC BARIUM ENEMA
PAEDIATRIC MICTURATING CYSTOGRAM
PAEDIATRIC SWALLOW/MEAL
SIALOGRAPHY
SINOGRAM/FISTULOGRAM
SMALL BOWEL ENEMA (Enteroclysis)
SMALL BOWEL SERIES
T-TUBE CHOLANGIOGRAM
URETHROGRAPHY - Adult
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DI PROCEDURES
WATER SOLUBLE CONTRAST ENEMA
ULTRASOUND
BIOPSY - BREAST
BIOPSY - LIVER
BIOPSY - LYMPH NODE
BIOPSY - THYROID
BIOPSY - TRANSRECTAL PROSTATE
BIOPSY
BREAST LOCALISATION/HOOKWIRE
CYST ASPIRATION (eg Renal)
DRAINAGE - CHEST/ABDO (ascites)
DRAINAGE - PLEURAL (effusion)
DRAINAGE - ABCESS
INJECTION INTO SHOULDER
INJECTION INTO ALL OTHER MSK
PAEDIATRIC ABDOMEN/RENAL
PAEDIATRIC HEAD U/S
PAEDIATRIC HIP UlS
PAEDIATRIC SPINE
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