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Summit, Studies Conclude Major Work Changes Needed
By Julie Crawshaw
In south carolina’s burgeoning upstate area, a woman may need to wait as long as six months for a mammogram. Tommy E. Cupples, MD, radiologist and assistant clinical professor of radiology at the University of South Carolina School of Medicine in Columbia, says the specialty of radiological technology is in real trouble if there aren’t some significant changes made during the next few years.
Judy H. Speer, mammography coordinator at Greenville Technical College in Greenville, S.C., says the shortage is expected to hit critical proportions in the area next spring when Greenville Hospital System opens its Eastside Center for Women with nine mammography units on site. The hospital system hopes to reduce the wait from six months to one month by performing another 12,000-14,000 mammograms a year at its Eastside Center.
The hospital system is aggressively recruiting technologists, but the problem is there aren’t many available. The American Society of Radiologic Technologists (ASRT) predicts 55,000 more technologists will be needed by the year 2008 to fill the projected need. Nationwide, more than 300 million radiologic procedures, including X-rays, CT scans and MRIs, are performed each year, and 8% of those are mammograms. That demand will only grow, since over the next three years a million women a year will celebrate their 40th birthday, a time when annual mammography screening typically begins. (For a look at the declining numbers of technologists, see Tables on page 134.)
|Table 1-Number of First-Time Candidates Taking Certification Examinations
in Radiography and Radiation Therapy
|(Certification exams administered by the American Registry of Radiological Technologists)|
|Table 2-Number of Educational Programs in Radiography and Radiation Therapy|
|(Educational programs accredited by the Joint Review Committee on Education in Radiological Technology)|
Add to all that a financial crunch caused by low mammography reimbursement levels, and the results reach crisis proportions.
Leaders at a recent summit on Radiological Sciences and Sonography attempted to develop strategies to combat the shrinking numbers of radiological technologists, radiation therapists, and sonographers. The meeting, facilitated by the Society of Nuclear Medicine Technologist Section, focused on solutions for the personnel shortage.
"The outcome of this meeting is that we all agree that there must be major changes in the profession to ensure the personnel shortage does not threaten the delivery and quality of patient care," says Lynn May, chief executive officer of the ASRT. "We agreed on three basic tenets of work force development and workplace enhancement—increased recruitment, upgraded education, and advancement potential and improved working conditions to ensure a better rate of retention."
Participants at the Summit agreed to develop a recruitment video or videos that can target a wide audience of potential candidates, from kindergarten through high school, minority populations, and returning students seeking a second or third career. They also set the goal of adding a Research Center for Excellence in the Radiologic Sciences to the ASRT Website to encourage technologists to perform original research and provide them with updates on research projects.
However, just improving recruiting techniques won’t solve the shortage problem, says ASRT Chairman Michael D. Ward, PhD, RT(R), FASRT, Director of Allied Health at the Jewish Hospital College of Nursing and Allied Health. He says the shortage has been exacerbated in part by the fact that nine-to-five jobs aren’t the norm in radiology anymore.
"People have to take calls and work weekends. That’s always been true to some extent, but it’s gotten rougher because there are fewer people on the job."
Ward points out that even as the radiological technologist population has shrunk the variety of technological work in the job market at large has greatly increased, giving entry-level candidates more career choices.
"Many of those do have nine-to-five hours and are better paid," Ward says. He adds, "We should develop programs that meet the needs of today’s students, including evening programs, weekend programs and distance-learning programs."
Salary Increases May Reduce Burnout Costs
Comparatively low pay is also a major issue in radiological sciences. Radiological technologists earn $12-$14 an hour, less than bartenders, wait staff, and others who often work on more flexible schedules and are in equally high demand. As more than two-thirds of U.S. hospitals are in the red and federal money does not appear to be forthcoming, finding the money to attract and keep a high-quality staff is a tough order.
An ASRT study mailed last December to 3,668 radiation oncology centers indicates that it takes an average of nearly four months to fill positions for radiation therapy and dosimetry. One center reported a position unfilled for two years.
The study drew 439 responses with one conclusion: Recent graduates can’t begin to fill available radiology positions. Centers that responded reported 299 radiation therapist vacancies within the six months prior to receiving the survey, and 55 positions were reported as having been vacant for more than six months. There were 354 current vacancies—13 % of available positions—for radiation therapists. There were 533 full time equivalent positions for medical dosimetrists, with 84 current vacancies. Seventy-seven vacancies were reported within six months of the survey date.
The survey asked centers to report measures used to recruit applicants to fill vacancies. More than 25% said they increased salaries or benefits; 21.6% offered sign-on bonuses that averaged $2,000- $3,000, but one center reported a $10,000 sign-on bonus. Only 3.9% reported adjusting salaries and benefits for all staff.
According to a study published in the fall issue of Radiation Therapist, radiation therapists experience significantly higher levels of emotional exhaustion and depersonalization than do nurses. The article pointed to recent studies of burnout in both jobs, and the nursing practice settings referred to included nursing homes and hospital AIDS units. The article points out that high levels of employee stress and associated burnout have been estimated to cost the United States in excess of $200 billion per year in absenteeism, reduced productivity, medical expenses, and compensation claims. The authors conclude, "real progress will be made when health care organizations realize the importance of providing a climate that promotes employee retention."1
Shortages and Smart Machines
While some may argue that proficiency standards for therapists can be lowered because the machines are getting smarter, Lynn May observes that technologists who are less capable than their predecessors isn’t the answer. "There probably has been a dumbing-down in medical imaging because the system only allows paying people at marginal levels. But any industry that bases its future on recruiting the lowest level is doomed," he says.
May points out that information technology is quickly permeating medical imaging and radiation therapy. Typically, when this happens situations change quickly because quantitative and qualitative data are available for analyzing and improving outcomes. It also causes rejection of hierarchical structures in favor of knowledge cultures in which self-directed professionals share expertise to solve problems and improve productivity. "When that happens," he says, "the human resource solution is not to hire a lot of semi-skilled workers, but to hire fewer, more competent/better trained individuals who can meet many needs."
Legislation for Practice Standards in Works
Proposed legislation now before Congress, and supported by ASRT, would establish an inducement to states to establish mechanisms for licensing or registering all personnel performing medical imaging or radiation therapy, except for sonographers. Non-compliant states would lose Medicaid waivers
"The requirements of the bill are simple," May says. "If a technologist or other personnel is trained in an educational program, a competent authority must accredit that program. If a technologist or other personnel is practicing, a competent authority must credential them."
If the bill becomes law, the Secretary of Health and Human Services would develop regulations establishing minimum standards for both accreditation and credentialing. The regulations would provide time and opportunity for technologists and other personnel who do not meet minimum standards to achieve compliance.
The bill is actively promoted by the Alliance of Quality Medical Imaging and Radiation Therapy, a coalition of 14 organizations representing professional societies, accrediting agencies, and certifying bodies in the radiological sciences, other allied health professions and physicists.
Mammography Centers are Impacted
The shortage of technologists adds another troubling dimension to the difficulties many women already have getting a mammogram. According to a report by the Dow Jones news service, mammography centers are closing their doors because they can’t afford to keep them open due to low reimbursement for the tests from managed-care insurers.
Radiologists complain that money they receive for mammograms is less than they need to keep their clinic doors open. They point the blame at managed care companies, which now have captured a large share of the health insurance market. Managed care companies, however, contend that reimbursement levels are appropriate and blame the problem on inefficient doctors and clinics.
Charles M. Cutler, MD, chief medical officer of the American Association of Health Plans, a Washington, DC-based HMO trade group, says that if women are having problems getting access to mammography centers, the problem lies in scheduling. As for radiologists who complain about reimbursement rates, Cutler adds, "presumably they negotiate fees that will be adequate for them to do their work."
That’s easier said than done, says Richard J. Bagby, medical director at Boston Diagnostic Imaging in Orlando, FL, which performed 20,000 mammograms last year. Bagby says that many health plans negotiate a master radiology contract that requires clinics to take lower payments on high-volume tests such as mammograms in order to get favorable rates on more-lucrative procedures such as CT scans and magnetic resonance imaging. Sometimes, clinics just have to hope they can make up the difference, he says. And, he adds, mammograms serve a community need that many doctors don’t want to abandon.
Medicare’s reimbursement rates are mandated by Congress and serve as a benchmark for many insurers. Last year, the agency paid for more than four million cancer-screening mammograms, reimbursing radiology offices, clinics, and other health centers an average of $46.11 for a cancer-screening mammogram, plus $21.70 to cover the radiologist’s fee.
However, last summer Medicare began paying hospitals an average of $33.94 for so-called diagnostic mammograms, the more intensive examinations radiologists use to follow up any breast abnormality.
The new Medicare reimbursement rate for diagnostic mammograms performed at hospital outpatient clinics is 33% less than the amount the federal program pays a freestanding clinic for the same procedure. Physicians at both types of facilities receive an additional $33.68 for their professional services. That means hospitals’ outpatient imaging centers now get 36% more for conducting a simple screening exam than they do for a more comprehensive and time-consuming diagnostic follow-up test. Although the disparity doesn’t affect most mammography patients directly, hospitals say it creates a financial bind for many radiology facilities that offer mammograms.
Even high-volume mammography providers that can operate on lower profit margins are having problems. Radiologix Inc., a Dallas-based company that operates 124 radiology centers across the nation, says it earns a nominal profit on mammograms. The company pointed to its Baltimore facility as an example of a center that is significantly underpaid. The company reports that health plans in Baltimore pay an average of 83% of Medicare’s fee and that one insurer there pays Radiologix just $23 for each test, 34% of the Medicare rate.
According to ASRT, about 1,800 student specialists took the national mammography exam in 1999, less than half the number who took the test in 1997. The American Cancer Society estimates that one million additional American women each year reach their 40th birthday, the age at which women are advised to begin having annual mammograms. This society says that this year about 182,800 new breast-cancer cases will be diagnosed and about 40,800 women will die from the disease.
1. Akroyd D, Adams R. The cost of caring: A national study of burnout in radiation therapists. Radiation Therapist2000;9:123-130.