Quebec radiologists billing $3M annually for obsolete task

Quebec radiologists are routinely billing RAMQ for analyzing coronary angiograms, sometimes years after procedures were carried out. The practice, deemed unnecessary by some, is costing taxpayers about $3 million a year, found Radio-Canada's Enquête.

Radiologists at Montreal Heart Institute stopped analyzing coronary angiograms in 2012, deeming them unneeded

The practice of radiologists analyzing a coronary angiogram like the one seen here after the procedure is considered obsolete by the Montreal Heart Institute, because digital imaging and real-time diagnoses mean cardiologists usually perform an intervention at the same time that the angiogram is done. (Radio-Canada)

Quebec radiologists are routinely billing the provincial health insurance agency (RAMQ) for analyzing coronary angiograms, sometimes years after the procedures were carried out, Radio-Canada's Enquête has learned.

The interpretation of coronary angiograms was long ago made unnecessary by technological advances, according to Dr. Gilles Hudon, a radiologist at the Montreal Heart Institute for 40 years.

Yet radiologists at many Quebec hospitals are still doing the analyses — and billing RAMQ about $3 million annually for that work.

Last year, Health Minister Gaétan Barrette, himself a radiologist with 30 years' experience, proposed abolishing the practice — a proposal that was rejected by the Quebec Association of Radiologists which he used to head.   

Enquête has learned some radiologists have been on a blitz of catch-up work, filing reports on their analysis of coronary angiograms months and even years after a cardiologist has done the procedure — and billing RAMQ $84 for each one.

To perform a coronary angiogram, a cardiologist injects dye into a major artery, looking for a blockage or narrowing of the blood vessels. Usually an intervention such as an angioplasty is performed on the spot, as soon as the diagnosis is made. (Radio-Canada)

What is a coronary angiogram?

A coronary angiogram is a procedure in which a dye is injected into a major artery and tracked through X-ray imaging to look for a blockage or narrowing of the blood vessels leading to the heart.

The procedure is carried out by a specially trained cardiologist, who usually performs an intervention to enlarge the artery at the same time, if coronary artery disease is diagnosed.

The whole procedure generally takes no more than an hour or two, and once it's done, the patient is usually home again within a couple of days.

Until the 1990s, a coronary angiogram and the follow-up procedure — an angioplasty or the placing of a stent — never happened at the same time.

"The images were recorded on film, and that had to be developed," recalls Hudon. The radiologist then had to be called in to interpret the finding.
A retired radiologist, Dr. Gilles Hudon worked at the Montreal Heart Institute for 40 years. It abandoned the practice of having radiologists analyze coronary angiograms in 2012. (Radio-Canada)

But digital imaging and real-time results changed that work flow.

Hudon said 20 years ago, the Heart Institute stopped having radiologists analyze angiograms in cases in which angioplasties or other procedures had already been done.

In 2012, it abandoned the practice entirely.

Still useful for catching errors?

Asked why radiologists continue to analyze coronary angiograms at other Quebec hospitals, Dr. Vincent Oliva, president of the Quebec Radiologists Association, said sometimes errors can be caught by radiologists after the fact.

"If it's done the same afternoon or the next day, or even within the week [of the procedure]," Oliva said, he'd consider a radiologist's analysis of an angiogram "a reasonable delay."

Dr. Vincent Oliva, the president of the Quebec Association of Radiologists, said the question of whether to abolish the practice of having radiologists interpret coronary angiograms is now under consideration by the association. (Radio-Canada)

However, Enquête examined data obtained from the Centre hospitalier universitaire de Sherbrooke (CHUS), where cardiologists perform some 3,000 angiograms a year.

It chose at random 200 coronary angiograms done between 2014 and 2016 and discovered that CHUS radiologists had filed reports on them 110 to 879 days after the procedures were performed.

A delay of that length — nearly four months to more than two years —  "does nothing to provide a safety net," Oliva acknowledged when presented with those findings. "We don't agree with that kind of practice."

More surprising still: Enquête found that one CHUS cardiologist billed for 49 reports on coronary angiograms in a single session, all of them procedures dating back more than 110 days.

The radiologist spent an average of less than four minutes on each patient file.

At $84 billed to RAMQ for each report, that works out to $1,300 for an hour's work.

"I think that comes within a hair's breadth of immorality," said Health Minister Gaétan Barrette when presented with Enquête's findings. 
Health Minister Gaétan Barrette said there's been a 'blitz of interpretation' of coronary angiograms by radiologists. Last year, he proposed abolishing the practice of having radiologists read them at all. (Radio-Canada)

The health minister says CHUS radiologists aren't the only ones to have been billing for reports on their analyses of coronary angiograms months after the procedures were done.

"It's been in the air," Barrette said. "There are people in the network who looked at the exams left unread since such and such a time, up to two years or more."

"There was an interpretation blitz."

As for how the CHUS radiologist could have worked through so many coronary angiogram reports so quickly, Hudon — the retired Heart Institute radiologist — said he would like to know how that was done too.

"My recollection is that it could take us between 20 and 30 to 40 minutes to interpret one coronary angiogram," Hudon said.

The radiology service at CHUS told Enquête in a statement that the work could have been done so quickly because the doctors had simply dictated reports on analyses that had been done at an earlier date — something Hudon said he has never seen in all his years of practice.

Enquête chose five reports on coronary angiograms done at the Centre hospitalier universitaire de Sherbrooke at random, and found that in each case, the cardiologist’s and radiologist’s reports were nearly identical. (Radio-Canada)

However, a confidential source at CHUS said the quick pace of work might be explained by the fact that some radiologists' reports are almost word-for-word what the cardiologists who performed the angiograms months before had already reported.

As for the many-months-long delays in filing reports on their analyses of angiograms, CHUS's radiology service told Enquête in an emailed statement that that had been a problem for the past 20 years "due to staffing problems and the absence of a system of prioritization by the department of those exams over others."

From a report for Radio-Canada's Enquête