In 2013, change loomed large on the horizon. With interventional radiology approved as a primary specialty in September 2012, plans were rapidly unfolding to create new educational pathways for interventional radiology training. At this time, even though insurance exchanges and coverage expansion from the Affordable Care Act would not begin for another year, efforts to revise the Physician Quality Reporting System (PQRS) were already underway; only in retrospect could one predict that the sustainable growth rate would be replaced by MACRA, further driving quality metrics into health care economics.
Fortunately, these changes were coming at a time of unprecedented strength for SIR and SIR Foundation. Membership, meeting registration, corporate engagement, impact factor of the Journal of Vascular and Interventional Radiology (JVIR), and other key metrics continued to be exceeded with each passing year. It was increasingly clear that the IR community and SIR and SIR Foundation worked together to not only meet the changes that were quickly approaching, but that the society and foundation were also in position to set a course to lead the specialty forward and thrive.
The 2013–2017 Strategic Plan set six bold goals to position the society, foundation and SIR members for success in uncertain times. The plan called on leadership to develop a strong infrastructure to support the collection of outcomes data; to communicate a fresh new story of interventional radiology to decision-makers, referring physicians and other key stakeholders; to ensure that all IRs receive the training and ongoing postgraduate education they need to remain a key part of the health care team and provide high-quality patient care; and to ensure that SIR and SIR Foundation grow their membership and remain in a strong financial position.
Looking back on the past several years, it is clear that the strategic plan not only set the right course, but that both the foundation and society achieved what they set out to accomplish. While the focus of this communication each year has been to outline our annual successes, we’ve chosen to dedicate this year’s SIR and SIR Foundation annual report to a wider lens and capture the significant accomplishments reached over the past four years.
Through the development of quality-based performance measures, advocating before Congress on behalf of the specialty, and working closely with other key organizations, SIR ensured that interventional radiology remained on the radar of policymakers and other key stakeholders.
A changing health care environment necessitates new approaches to long-standing challenges, from the burgeoning IR Residency education pathway to cutting-edge communications that meet the needs of members, wherever they are.
SIR’s quality experts have been laser-focused preparing interventional radiologists for the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), a radical change to how physicians will be paid in the future.
MACRA took effect Jan. 1, 2017, changing Medicare from a volume-based system (the sustainable growth rate or SGR) to a value-based system. MACRA includes a new Merit-based Incentive Payment System (MIPS) and provides incentives for physicians to participate in alternative payment models such as accountable care organizations and patient-centered medical homes.
SIR has developed several resources and programs that will help IRs maximize their reimbursement in the most efficient way possible. Taken together, these resources provide a pathway toward improved quality, value, research and patient care.
Developed in partnership with the American College of Radiology (ACR) and hosted by ACR, the Interventional Radiology Registry enables MIPS reporting and, as a Qualified Clinical Data Registry, allows the specification of non-MIPS performance measures. Beyond MIPS reporting, data collected in the IR Registry will be used to discover which IR procedures and systems are most effective and valuable for patients.
SIR has also created a new collection of structured reports that make it easier to collect performance data needed for MIPS and streamline the collection of data for the IR Registry, while supporting the specialty’s efforts to improve patient care. The reports can replace the narrative-based clinical reports IRs currently use. Seventeen reports have been tested and revised. Several other reports are under development. The reports are available for free to society members on the SIR website in XML and RTF formats for importing into voice recognition dictation systems.
“Structured reporting can help us tailor treatments to patients in the future and can help us determine whether standards are being met for certain outcome measures at different institutions,” said Rajesh Shah, MD, co-chair of the SIR Standardized Reporting Subcommittee.
In addition to powering MIPS reporting to CMS, the IR Registry will send quarterly reports regarding performance metrics to participating institutions and provide benchmark information on how they perform compared to other institutions.
“This allows individual sites to drive quality improvement projects to improve their performance,” said Jeremy D. Collins, MD, chair of the SIR Foundation Performance and Quality Improvement Division.
Listen to Jeremy Collins, MD, explain how hospitals can improve care through the Interventional Radiology Registry.
To make it easier for IRs to participate in the new performance-based payment system, SIR created and submitted 13 performance measures related to interventional radiology to the Centers for Medicare and Medicaid Services (CMS) in 2014. Five were accepted and are currently available and will carry over into the MACRA system. SIR drafted 22 measures for inclusion in the 2017 program and 13 for the 2018 program. These measures are currently under preliminary review by CMS.
CMS is revising its strategy for acceptance of new measures, aligning the measures development process with the reporting years under the MIPS program. SIR is tuned in to any developments but faces a new challenge to ongoing performance measure development: CMS no longer accepts claims-based measures, requiring outcomes-based measures instead. This makes the process of collecting data through the standardized reports and the IR Registry all the more important.
“You have to have reasonable measures that target outcomes, which are sometimes harder than process measures to develop and quantify,” Dr. Collins explained.
MACRA also requires that proposed measures include a literature review that makes the case for need and illustrates that the data can’t be collected through any existing measure, Dr. Collins said.
Under the system, CMS’s priority is to improve the quality of health care, which is “why we’re moving in the direction of outcome measures,” said Sophia Autrey, MPH, CHES, a social science research analyst at CMS. “More and more, we find that, while process measures are important for physicians, they do not contribute to improved quality health care.”
As CMS evaluates proposed performance measures, it looks for several elements: Whether the measure is relevant to the stakeholders (physicians and patients), whether there is a performance gap and whether the measure will lead to improved quality, Autrey said.
As specialty societies develop proposed measures, it is important that they collaborate with CMS from the start, as SIR did, Autrey said. “From our perspective, it’s very helpful, especially when we’re involved early in the process. We can go through their concept with them and help identify gaps … and help them tweak the measures.”
As SIR continues to advocate for the specialty through face-to-face meetings, action alerts, phone calls and other efforts, it is important that IRs get involved. Legislators appreciate hearing directly from IRs—their constituents in the trenches. As interventional radiologists meet their representatives and senators face to face, they forge relationships that are critical to building support for IR issues now and in the future.
“The challenge is to put a face on interventional radiology and educate our legislators on who we are and what we do,” said Meridith Englander, MD, vice chair of the SIR Government Affairs Committee and SIR’s delegate to the American Medical Association. When visiting with lawmakers, Dr. Englander highlights IR procedures and points out how they help patients: faster recovery times, cost savings, preventing or staving off major surgeries and hospital stays.
“We want people to know who we are so that when we do have something big to ask for, we’re not an anomaly and they are aware of the value we add to the health care system,” Dr. Englander said.
Congressional staff members attest to the success of SIR efforts: “SIR is uniquely equipped to lend its expertise to members of Congress who need to understand how various public policy decisions would impact interventional radiologists,” said Mark Chenoweth, former chief of staff to Rep. Mike Pompeo, R-Kan. “Without SIR’s insights, Congress might mistakenly support changes that would be detrimental to patients and providers.”
To get more IRs involved, SIR created the Grassroots Leadership Program, which celebrated its third class of participants in 2016. The program offers interested SIR members from across the country the opportunity to engage with their elected senators and representatives and key congressional staff about the policy issues that affect interventional radiologists.
Over two days in Washington, D.C., in May 2016, 15 SIR members met with lawmakers to share their expertise and put a human touch on decisions about interventional radiology. Beforehand, they took part in a four-hour advocacy boot camp to gain an overview of the advocacy process and understanding of key policy issues. They also participated in three SIRPAC events that hosted Rep. Gus Bilirakis, R-Fla., John Shimkus, R-Ill., and Chris Collins, R-N.Y., who serve on the House Energy and Commerce Committee.
“SIR’s federal affairs representatives, and the doctors whom they brought to town, were among the brightest, most straightforward people I met,” Chenoweth said. “And they were the most capable of explaining complex ideas in simple terms that I encountered on Capitol Hill.”
While government affairs staff is dedicated to working on these issues every day, it is essential for legislators to hear about issues, challenges and solutions directly from interventional radiologists.
“We’re a little-known specialty, albeit rapidly growing and one of the more popular in medicine today, and our interests need to be represented on Capitol Hill,” Dr. Alago said. “To continue to celebrate the advances that IR has achieved as a specialty is quite important—as important as informing the people who are shaping health care policy so they know what we’ve done and what we continue to do to advance the interests of our patients.”
In July 2016, when CMS published the proposed 2017 Medicare Physician Fee Schedule that governs Part B payments, the SIR Economics Committee, working closely with ACR, went into action to avert a proposed blanket 7 percent reduction to IR services.
After several weeks of analysis, SIR submitted comments to CMS, pointing out discrepancies in CMS's analysis, and gained back practice expense costs, as well as restore some of the physician work relative value units (RVUs) that had been cut. In response to SIR's comments, and coupled with new projected utilization data used by CMS, the final 2017 overall cut to IR was reduced to about 1 percent.
As the new IR Residency is launched, first hundreds, and eventually thousands, of new physicians will be focused solely on IR as its own specialty. To prepare for this new model, SIR has been collaborating with ACR to develop tools and resources that will promote the clinical practice of interventional radiology.
“Because each organization has a different approach and a different thrust, both can be useful in helping interventional radiologists build and enhance their practice,” said Kenneth W. Chin, MD, FSIR, a member of the ACR Interventional Radiology and Interventional Neuroradiology Task Force. Dr. Chin is an interventional radiologist and was a longtime liaison between the two organizations.
The task force was created in 2013 and completed its work in 2016, creating resources in three areas—education, clinical practice and communications. A part of ACR Imaging 3.0, these resources are co-branded and mutually beneficial to both organizations.
“With integration within the two specialties, it’s very helpful to have a high-powered diagnostic group affiliated with a high-powered interventional radiology group because one will often let the other know of issues or practices or opportunities,” said Philip S. Cook, MD, FSIR, chair of the task force and chair of the ACR Commission on Interventional and Cardiovascular Radiology. “We need to find ways to overcome any traditional or older boundaries between how diagnostic radiologists and interventional radiologists practiced in the past.”
On Match Day, March 18, 2016, four years after the American Board of Medical Specialties (ABMS) recognized interventional radiology as a distinct medical specialty, thousands of nervous and excited medical students across the United States were about to learn if they matched with their dream residency program, whether that was in pediatrics, dermatology, cardiology or, now, interventional radiology.
And, on that day, 15 students made history, becoming the first class of interventional radiology residents, matching at seven newly minted IR residency programs. In 2017, that number will increase significantly as 61 programs are now ABMS accredited with approximately 120 available positions.
“It’s been incredibly rewarding to see the IR education community step up in such a strong way to the challenges of radical change in training,” said M. Victoria (Vicki) Marx, MD, FSIR, SIR secretary, former chair of the IR Residency Task Force and associate director of the IR residency program at the University of Southern California (USC).
Students’ interest appears to be enormous. Dr. Marx said USC applications for its inaugural match year in 2017 have far exceeded the number of positions. At the Medical College of Wisconsin, approximately 275 applications had been received with six weeks still to go before the deadline—for only two available positions, said Parag J. Patel, MD, MS, FSIR, associate professor of radiology and councilor of the SIR Graduate Medical Education Division.
The popularity of the IR Residency in just its first year shows both the need for the specialty and the interest among future physicians. Thanks to SIR’s vigorous education and awareness campaigns aimed at medical students—as well as the creation of IR interest groups at medical schools and regional IR symposiums for med students—students have been developing an excitement for IR. They have become passionate about building a medical career that will allow them to become experts in imaging and perform image-guided procedures, all while providing ongoing care for their patients.
Instead of focusing four years on diagnostic radiology, followed by a one-year fellowship, integrated IR residents will now spend those five years integrating diagnostic and interventional radiology and clinical care. The number of procedures they were required to perform in fellowship—a minimum of 500—will double to 1,000. Another residency option, the “independent residency,” will allow a resident who completes a four-year diagnostic radiology residency to follow it up with two years of IR training. This is an option for those who don’t initially match into IR or DR residents who decide partway through residency they want to become interventional radiologists.
Beyond the longer IR program and the heightened focus on clinical care, the new residency allows for plenty of room for innovation, which can lead to better patient care, said Dr. Patel.
“Different training programs provide exposure to innovative therapies or research experiences at their institutions, and a trainee now has five years to commit to being involved in some of those efforts,” he said. “I think the opportunity to spend five years with a trainee, who can then be involved more meaningfully in research or problem-solving for patients, can only benefit our specialty.”
Listen to Dr. Vicki Marx explain how the heightened focus on clinical care in residency will streamline patient care.
SIR Connect, SIR’s rapidly growing online community, provides a private space for SIR’s 6,100 members to network, ask questions and share challenges and successes related both to career and clinical care.
In only its first two years, 85 percent of SIR members have logged in. This 24/7 community can be helpful for those working at smaller institutions where they are the sole IR, for younger IRs looking for career advice and for those seeking expert opinions from peers on a difficult or perplexing case or procedure.
As participants build discussions and share information, they help each other improve patient care and clinical practice at the ground level. Initial queries and advice have led to ongoing mentorships and new relationships among IRs.
This year, SIR Connect launched a volunteer module that allows SIR to host all volunteer opportunities in one place, making the volunteer process more flexible, efficient and effective. Volunteer opportunities will include not only roles on standing SIR committees and task forces, but also SIR and non-SIR as-needed roles such as reviewing materials, submitting comments to a federal rule or writing website content.
The online module provides a doorway to SIR members who have wanted to get more involved but didn’t know where to start. Recruiting new voices expands the diversity of ideas and solutions, benefitting the specialty from every angle.
Since its inception in 2012, the SIR Foundation Summer Medical Student Research Internship Program has offered medical students across the country valuable opportunities to learn more about interventional radiology research and medical device development. The program was born of the mission to promote and support interventional radiology research by investing in educating future interventional radiologists about fundamental and advanced research techniques. By offering a structured research environment and developing an educational curricula put forth by mentors and mentorship institutions (both corporate and academic), this program has fostered the development of physicians who will develop a lifelong interest in research and development.
Over the years, both academic and corporate organizations have helped evolve the program into what it is today. Some long-standing partners include Bard Peripheral Vascular, University of Texas MD Anderson Cancer Center, Yale-New Haven Hospital, and UCLA Medical Center.
According to Edward W. Lee, MD, PhD, program host at UCLA, “Our recent interns have been an important and crucial part of our IR team in both research and clinical work. All have been very successful in publishing their work and were able to learn IR and clinical medicine to decide what they want to do in their career.”
The interns have found the program incredibly valuable as well. “I would absolutely recommend this internship to my peers,” said Alicia Eubanks, an intern at UCLA. “The internship was a truly unique experience that allowed me to get a lot of one-on-one personal development as a researcher and clinician.” Jeremiah Stringham, an intern at Yale-New Haven, agrees: “I would recommend the opportunity to anybody considering a career in IR … it is an opportunity to cultivate an innovative spirit that I feel is essential for the field. For me it was life changing.”
The future of interventional radiology will combine data collection, registries and research to improve and develop new procedures and treatment options, said Raj Pyne, MD, secretary of SIR’s Early Career Section and an IR in private practice at Rochester General Hospital and medical director of The Vein Institute in Rochester, N.Y. “I think the only way you can do that is if you have collaboration, and the only way to have collaboration is if you are networked with other people,” he says.
That collaboration started in earnest two years ago with the creation of the Early Career Section, which is for interventional radiologists in their first eight years of practice out of fellowship. The section was a way to bridge the gap between the Resident, Fellow and Student Section (RFS) and more senior attendings.
Within one year, the Early Career Section already had more than 150 members, serving the unique career and practice needs of this group through peer-to-peer development. “For a lot of the young IRs, you learn how to do procedures,” Dr. Pyne says, “but you don’t learn the business.”
The section’s webinar series this year has been wildly successful: 100+ people registered for the inaugural webinar on legislative changes to payment reform. ECS leadership anticipates that the webinars will connect its members with the latest on clinical and practice management topics year round.
To ease the transition of fellows-in-training and early-career members, the section successfully advocated for the creation of a membership discount for early-career IRs. Previously, fellows-in-training received a 50 percent discount on membership dues as they moved into the first-year membership category. The new rate offers an additional 20 percent reduction for the first two years. This offer will be time limited to encourage early renewal.
The section will continue to implement and advocate for programs that allow new IRs to network and work together as they build their clinical practices.
Listen to Raj Pyne, MD, explain how the Early Career Section is building a better network of IRs.
SIR’s Diversity and Inclusion Committee has launched several new programs to recruit more minority and female medical students into the specialty, recognizing the need for increased diversity.
Although 13 percent of the people in the United States are black or African American, they make up only 4 percent of the physician workforce, according to the Association of American Medical Colleges (AAMC). In addition, only 4 percent of doctors are Hispanic, 12 percent are Asian and 49 percent are white. Furthermore, IR is among the medical specialties with the least amount of gender or ethnic diversity when compared to gender and ethnic percentages of AAMC-certified medical schools and all ACGME-certified residencies and medical fellowships.
It is important that the diversity of the physician workforce mirror the diverse patient population, in part, because studies show that patients are more comfortable with doctors who look like them and whose backgrounds and cultural experiences are similar, said Derek L. West, MD, co-chair of the Diversity and Inclusion Committee.
The two-year-old committee has three subcommittees focusing on new efforts to recruit women and underrepresented minorities into the specialty:
For the strategic plan period of 2013–2017 one of the goals that the society focused on was revenue growth, which was necessary to support the other major goals of the strategic plan. From the end of 2012, revenue for the society increased 19 percent, from $8.1M to $9.7M. This revenue growth can be attributed to changes in operational activities related to membership, corporate relations (CAP program), annual meeting and growth of advertising royalty programs related to JVIR and other publications. The revenue growth has been reinvested in SIR infrastructure and program services:
Fiscal 2016 led into the final year of the strategic plan with the strongest financial position during the past 10 years. SIR generated a positive operational bottom line with a total gain for the year of $636,729. Total revenues in 2016 were $9,707,541, which is $739,400 higher than they were in 2015. The increase stemmed from corporate support and promotional opportunities related to the CAP program, increased revenue related to JVIR advertising royalty and editorial support, and increased membership dues related to the 2015 dues increase. Total expenses in 2016 were $9,070,812 which is $562,347 higher than they were in 2015. Functional areas that drove this increase were investments in member engagement and website redesign, lobbying activities related to the graduate medical bill, activities related to MACRA payment reform, and the absorption of data outcomes and registry activities from the foundation.
The society’s long-term investment portfolio resulted in a net gain of 6.0 percent for the fiscal year 2016. As of Dec. 31, 2016, investments totaled $6,353,079. The portfolio is invested in a number of equity and fixed-income mutual funds, which is in line with the long-term objectives of capital appreciation for the portfolio.
SIR continues to maintain its strong financial position. As of Dec. 31, 2016, the society had assets of $10.3M and liabilities of $3.4M, with net assets of $6.9M. Net assets increased overall by $980k in fiscal year 2016 from the positive bottom line and investment returns.
Membership dues $3,136,091
Annual meeting $3,690,954
General programming (CAP unrestricted) $629,667
Other pubs & products $282,209
Annual meeting $2,348,508
Other pubs & products $306,503
Health policy & Econ $347,245
Quality & safety $325,203
Government relations $332,520
Other programs $433,738
Governance & admin $2,322,840
Member services $715,028
In fiscal 2016, SIR Foundation generated a positive bottom line with a total gain for the year of $15,714. Total revenues in 2016 were $1,086,866, which is $345,129 higher than they were in 2015. Annual Fund donations from companies and a one-time donor gift of $150k account for the majority of the increase. Total expenses in 2016 were $1,071,152, which is $527,887 lower than 2015. The decrease in yearly expenses can be attributed to awarding less in grants and moving the data outcomes, quality and registry activities into the SIR budget. The reorganization of the data outcomes, quality and registry division into the society was made to ensure there is cohesive coordination between the reimbursement activities of the society with IR Registry development and the development of structured reporting. With the passing of MACRA legislation, the use of registry data to support the evidence-based outcomes for reimbursement will be crucial for ensuring IRs are appropriately reimbursed for their procedures.
The foundation’s long-term investment portfolio resulted in a gain of 8.8 percent for the fiscal year 2016, and investments totaled $4,576,396 on Dec. 31, 2016. The foundation investment portfolio is more aggressive than the SIR portfolio because the foundation is using returns from income and dividends to fund potential cash-flow deficits as an alternative to starting a new extensive funding campaign such as Discovery.
The foundation also continues to maintain its strong financial position. As of Dec. 31 2016, the foundation had assets of $5.6M and liabilities of $991k, with net assets of $4.6M. Net assets increased overall by $450k in fiscal year 2016 from the positive bottom line.
Annual fund $704,246
Other revenue $24,280
Clinical research & registries $321,878
Foundation grants & awards $304,607
Quality & outcomes $52,048
Governance & admin $162,739
OH forgiveness from SIR ($250,000)
In fiscal 2016, the society continued work on the website redesign, which was funded from the long-term reserves. The redesign of the website was completed in January 2017. Along with the new website, over the last two years, the society has invested in infrastructure that enhances the member experience and increases member engagement through a new payment and donation portal, easier access to online educational activities and the SIR Connect community platform.
In order to provide for ongoing financial stability, the appropriate level of funding for infrastructure projects and resources for future initiatives, the society has a target level for long-term investments of 50 percent of annual expenditures. As of Dec. 31, 2016, this percentage was 66 percent.
The society’s independent auditors, RAFFA , are in the process of completing the audit of the fiscal year 2016 consolidated financial statement in March 2017. Their report will be reviewed by the SIR Audit Committee in April and will be on file at SIR headquarters in Fairfax, Virginia.
Charles E. Ray Jr., MD, PhD, FSIR Suresh Vedantham, MD, FSIR M. Victoria Marx, MD, FSIR Matthew S. Johnson, MD, FSIR Alan H. Matsumoto, MD, FSIR Filip Banovac, MD, FSIR Robert Lewandowski, MD, FSIR Stephen L. Ferrara, MD, FSIR Parag J. Patel, MD, MS, FSIR Daniel B. Brown, MD, FSIR
Immediate Past President
SIR Foundation Chair
Annual Scientific Meeting Division Councilor
Health Policy and Economics Division Councilor
Graduate Medical Education Division Councilor
Postgraduate Medical Education Division Councilor
Suresh Vedantham, MD, FSIR
M. Victoria Marx, MD, FSIR
Matthew S. Johnson, MD, FSIR
Alan H. Matsumoto, MD, FSIR
Filip Banovac, MD, FSIR
Robert Lewandowski, MD, FSIR
Stephen L. Ferrara, MD, FSIR
Parag J. Patel, MD, MS, FSIR
Daniel B. Brown, MD, FSIR
Sanjeeva Kalva, MD, FSIR
Member Services Division Councilor
Boris Nikolic, MD, MBA, FSIR
Standards Division Councilor
Brian F. Stainken, MD, FSIR
International Division Councilor
Sanjay Misra, MD, FSIR
Laura Findeiss, MD, FSIR
Michael D. Dake, MD, FSIR
Ziv J Haskal, MD, FSIR
Meridith J. Englander, MD, FSIR
AMA Delegate, ex-officio
Susan E. Sedory Holzer, MA, CAE
Executive Director, ex-officio
Filip Banovac, MD, FSIR
Jeremy C. Durack, MD, MS, FSIR
Stephen T. Kee, MD, MMM, FSIR
Immediate Past Chair
Matthew S. Johnson, MD, FSIR
SIR and SIR Foundation Treasurer
Jeremy D. Collins, MD
Performance and Quality Improvement Division Chair
R. Torrance Andrews, MD, FSIR
Development Division Chair
Erik N.K. Cressman, MD, PhD, FSIR
Research Grants and Education Division Chair
Sarah B. White, MD
Clinical Research and Registries Division Chair
Charles E. Ray Jr, MD, PhD, FSIR
Suresh Vedantham, MD, FSIR
Stephen L. Ferrara, MD, FSIR
SIR Health Policy and Economics Councilor
Daniel B. Brown, MD, FSIR
SIR Postgraduate Medical Education Division Councilor
Ziv J Haskal, MD, FSIR
Carolyn Strain, MA, MS
SIR Foundation Executive Director
Susan E. Sedory Holzer, MA, CAE
SIR Executive Director
The SIR Foundation Board of Directors extends its deepest appreciation to each donor who contributed to SIR Foundation through the Annual Fund, Pioneer Circle, Gala and the Corporate Ambassador Program (CAP). We recognize the individuals and companies below for their generosity and support of the specialty. Without their contributions, the foundation’s initiatives would not be possible. For more information on how to contribute, please visit our website.