So my talk today, health policy agenda or radiology at the table, patient steerage and pediatric radiology. So the picture you're looking at right now on the left, patient's right, you're left, is my older son when he was 9 years old. And the image on the other side is both of my boys when my older son was 10. And if I'm thinking back in time, the only real difference between when he was 9 and when he was 10 was that when he was 10, he liked to talk about how he met Duff, the bass player for Guns and Roses. Who you see pictured here, by the way. Now, in case you're thinking, oh, that was me who pointed out Duff and made my kid, no, no, no, no. We were at brunch, and he goes, dad, that's Duff. That's Duff, because he's a big Guns and Roses fan. Don't judge. I am, too, actually. And he's like, can we meet him? Can we meet him? No, he's having brunch. Afterwards, he went up to him, and he got a picture with Duff, the bass player for Guns and Roses. But I bring this up for a reason. So we're going to talk about steerage. So what is steerage? So steerage is when an insurance company, a payer, directs patients, directs their beneficiaries from getting care at one type of facility, like a hospital, to go to a different type of facility, like an outpatient center. That's what steerage is. It's directing patients where to get care, where not to get care, and instead of getting care here, go over here to get your care. That's what steerage is. So in 2017, Anthem, which is one of the largest health insurance companies in the country, unveiled a steerage policy with respect to radiology. What it said is that for beneficiaries of these plans with Anthem, if you need to get advanced outpatient imaging, CTNMR, you can't go to the hospital. You have to go to an imaging center unless it's medically necessary. And by the way, through their subsidiary, they'll tell you what medical necessity means. You don't get to decide. They'll tell you what medical necessity means. Here was their criteria. I've highlighted one thing which is of concern to us in pediatric radiology. It said that children that were nine and under, they're medically excluded. They're considered children. But once you're 10, in their eyes, you're an adult. And the adult rules apply. So I'm not sure why they chose nine or 10, but that was their rule. What they said was once you're 10, you're like an adult. You can't go to the children's hospital or any hospital. You have to go to an imaging center unless you can meet one of their other criteria. So let me explain how this impacted them with my children. So let's say my son, who didn't, but what if he had? When he was nine years old, if he had a seizure and needed to get a brain MR? Well, I live in Chicago. I could have taken him to a children's hospital here and made sure it was done with a pediatric protocol. It was read by a pediatric neuroradiologist. I could have done all that. But what happens if he had just turned 10? Nothing much had changed other than he met Duff from Guns and Roses. But if he'd had a seizure from meeting Duff from Guns and Roses, I wouldn't have been able to take him to a children's hospital. He would be considered an adult in the eyes of Anthem and I would have had to go to an outpatient imaging center unless I could find some other medical criteria to direct him back to a children's hospital. And they would have sent him here regardless if the imaging center has pediatric neuroradiologists. That would be regardless. So why is Anthem doing this? Well, these are their words. There's clinical research that shows the safety of these imaging centers, and their primary concern is access to quality and safe healthcare for their members. Now, they did go on to mention cost. Now, admit away, I put the word cost in bold letters. That's me. But everything else is just them. So I think if we're being honest with ourselves, that's what this policy is motivated by. This is economically motivated patient steerage, sending patients to the imaging centers for that reason. Now, they do mention they've got research on the safety. Now, I will not go through all the research that they cited, but I'll give you a flavor of it. This is an example of the evidence they cited about the safety of sending children to these outpatient imaging centers. It was the guidelines for diagnostic imaging during pregnancy and lactation. Wait, seriously? Like, that's your evidence? Like, there may very well be evidence that imaging centers do a good job of pediatric radiology, but I'm going to argue this ain't it. But this was the type of evidence that they were citing. But I want to be fair to them, though, because they're not wrong about that cost differential. What this graph shows is that gap, that differential between getting extremity MRs in a hospital, an outpatient department, or going to one of the freestanding imaging centers. While there's geographic variability, there's a consistent theme. It's a lot cheaper, sometimes a lot, lot cheaper, to go to the imaging centers and get your imaging done at a hospital outpatient department. So you can see what motivated their policy. There is a cost differential. They're not wrong. But from a pediatric perspective, from a pediatric radiology perspective, we felt this was the time for advocacy, to advocate on behalf of children. So what were the steps that we went through? Well, the first was we wanted to define the issue. What are we going to be advocating about? Let's really think about it. So that was the first step. What is our issue? The second one, we had to find friends. Because even if we got every pediatric radiologist in the country together, I mean, there aren't that many of us, so we'd have a hard time advocating. If it was just us, we need to find friends. Then we had to build a campaign. And once we had taken those steps, we were ready to go ahead and begin doing some advocacy. So what was the issue? How did we want to define it? We wanted to make it very simple, easy to understand. And it was very simply this. The Anthem policy breaks the first rule of pediatric care. Children are not little adults. Their policy makes a 10-year-old child, treats it just like they're an adult, and that breaks the first rule of pediatrics. Children are not little adults. I mean, that's essentially what the issue was about. Now, we wanted to convey to Anthem why this is important and why we think that children should be imaged in a facility that specializes in caring for children. And the first one was explaining to them the value of pediatric radiologists. Not that other radiologists are not competent to be reading pediatrics, but pediatric radiologists are specially trained to look for pediatric pathologies, to differentiate normal variants from pathology. This is what they do. This is what they're specially trained for. And there is a value to having pediatric radiologists. But well beyond simply the value that we as pediatric radiologists add, there's a lot more value in the children's facilities. So for example, the pediatric staff, the technologists. Everybody who's imaged kids is familiar with the idea that it's challenging, right? Kids move. So even getting a diagnostic exam without sedation can be very challenging. Children's facilities are very used to this. They're used to working with families, making it easy and painless for the child or as painless as possible to get through these types of examinations. That's a value add that these pediatric facilities have. They have special protocols. For example, protocols with lower radiation exposure that they work on. We want to limit disruption to the families. I'll give you an example. Let's say that the child had a seizure and they have to go see a pediatric neurologist. If the pediatric neurologist is at the children's hospital, they might have to take a second day off work to go get the imaging done at some outpatient imaging center because they're not just going to the hospital. They have to go here and then go here and they can be in different places. So the parents might have to take off a second day of work and it might break up the medical record. So for example, they got their imaging done at the outpatient imaging center, but somehow they have to get the images and the report over to the children's hospital, to the pediatric neurologist. Do they get a disc? How are they going to figure that out? There's all those logistical barriers. Are they going to have it re-read at the children's hospital? There's all sorts of barriers that are put in place when you start breaking this up. And if we're being honest, the 10-year-old cutoff was arbitrary. The only difference that I can really think of, the only reason they chose it, was because nine is one digit and 10 is two digits. Like, that's my guess. Like, honestly, that's my guess for why they made the distinction. Nine is one digit, 10 is two digits. That seems like a good a place as any to draw the line. Seriously? I mean, I'm guessing. So the next step was finding friends. So obviously the SPR, the Society for Pediatric Radiology, was interested in this, but we weren't enough. So we looked at who else would advocate with us. Well, who else really cares about pediatric care? The American Academy of Pediatrics, our colleagues. So they were on board with this. But who else? Well, this directs care away from the hospitals. The Hospital Association is going to support this too, so they were our friends. But what about the AMA and the ACR? Because those are big tents. Interestingly, they got on board with this too. And I want to give props to the ACR for doing this, because if you think about it, the ACR is a big tent, and it represents the radiologists that work in the hospital. It also represents radiologists that work in the imaging centers. And so the ACR took a principled stand on this issue, even though, you know, if they got members on both sides of the fence, they took a principled stand, what was right for patients, what was right for families, and protecting patient and family choice. So the policy was announced in 2017, and in September of that year, the AMA sent a letter to Anthem talking about how misguided this policy was. That was followed a couple months later from a letter from the SPR leadership saying the same thing. That was then followed, after that, from the ACR and 10 other societies, again, advocating for why this policy was misguided. That was then followed by another letter with the ACR, as well as the emergency physicians and the hospitals, also to Anthem, telling them the same thing. Then the American Academy of Pediatrics followed up. Then the ACR followed up again. This was all in a little over six months' time, right, from like fall of 2017 to spring of 2018. Anthem was just getting hit with these letters from societies talking about how misguided this policy was. And it wasn't just getting letters. We were making sure this was in the press. So we wrote articles in it, in JACR, in the ACR bulletin. We got it in the trades. We were trying to get it in WAVE publications, trying to make sure people were aware of this issue, going beyond our little circle. Now, you may have noticed that ACEP, the American College of Emergency Physicians, was in that group. They were not on our initial list of friends. But a funny thing happened as we were going through the process. Turns out that ACEP was already engaged in advocacy with Anthem. In 2015, Anthem rolled out a policy that said that if you got emergency care, and Anthem later determined after the episode of care, that wasn't really an emergency, they would deny payment, and the patient would be on the hook. And so then ACEP got involved to advocate for their patients because you don't want patients sitting at home going, is it a heart attack or is it heartburn? Is it a heart attack or is it heartburn? And again, there's prudent layperson standards. There's all sorts of laws on the books, but this was a big issue. So ACEP was already engaged, and this involved imaging. So ACEP turned out to be a natural ally in this. So Anthem announced their policy in 2017. We just showed you letters, advocacy groups, phone calls, all this. What was the result? Well, in 2019, UnitedHealthcare, the largest health insurance company in the country, did the same thing. So United looked at what Anthem did and said, yeah, no, we're going to do the same thing. Gets one notch worse. Cigna, which is also one of the five largest health insurance companies in this country, looked at what Anthem and I did and goes, yeah, no, we're going to do that too. Not only had our advocacy not worked, were we getting Anthem to roll back what they had done? It was spreading. It was getting more ubiquitous. It was getting momentum. We had clearly not succeeded in what we were trying to do. It was not fun. But we knew we were doing the right thing. So we knew the right thing to do was to be persistent. So we reached out to Cigna and United, and Cigna, not long after they announced it, and we started talking to them, actually rescinded the policy, and they said, fine, exclude pediatrics. Once we spoke to them and they started understanding, they were like, fine, we'll take back the pediatric aspect. Anthem and United, however, did not. So what do you do? You stick with it. So we kept talking to them both. And then earlier this year, United actually pulled back their policy. What about Anthem? The first one to roll it out, they dug in their heels. Cigna rolled it back. United rolled it back. Anthem, nah, we're good. So what do you do? You be persistent. So the ACR and the SPR sent this letter in the spring of this year. Again, making a point, advocating for children and families what the right thing to do is. And then in August of this year, Anthem posted this on their website. They revised their policy. They excluded pediatrics from their site of care policy up through 18 years of age. And in fact, they cited the evidence that we had been telling them in their general information. They recognized that children need specialized equipment. They recognize that children are more radio sensitive. They recognize that dose exposures may be higher in these imaging centers that don't routinely image children. They were quoting back to everybody the things that we had been telling them. It wasn't falling on deaf ears. What happened next? So Aetna, as it turns out, is one of the other five largest insurance companies in the country. They'd been silent this whole time until fall of this year. And then they announced their policy. They were gonna do a site of care policy. They excluded children. What Aetna had done, they didn't wanna be a first mover. They sat on the sidelines. They watched Anthem do it. They watched United do it. They watched Cigna do it. They watched Cigna roll it back. They watched United roll it back. They watched Anthem roll it back. So when they announced their policy, they left out pediatrics. This was a battle that we won that we never had to fight because we'd won those other battles. So what lessons do I think we can take home from this campaign? The first is that it was a coordinated approach. We really thought about what the issue was. We tried to make sure the issue was very clear and understandable. We looked for allies. I have no doubt in my mind that had we not had allies with us, pediatrics, AAP, ACR, others, this would not have been successful. If it was just SPR, if it was just us and Peds Radiology, it would not have been successful. Finding allies was key to advocacy. This is a great example of persistence pays off. This was years in the making and there were a lot of losses along the way. This is a great example of persistence paying off. And momentum matters. That Anthem started the policy, but they were also the last to roll it back. And I don't know this for a fact, but it's my belief that had Cigna and United not rolled back their policy, Anthem would not have rolled back theirs. But once Cigna rolled back theirs and United rolled back theirs, boy, that was a lot of pressure. That was a lot of momentum for Anthem to be like, look, you guys are way out of line here. Like, I mean, other payers are doing it too. You guys are way out of line. I think that helped push this through, that momentum matters. It mattered when we were losing and it mattered when we were winning. And I think the proof is that Aetna, we won that battle without ever having to fight it. So if I have one take-home message for this, for you all to take home, it's this. If you're passionate on an issue, speak up. Be the squeaky wheel. This issue was taken care of because physicians stood up. So I want to encourage all of you, when you have an issue that you're passionate about, that you think needs to be taken care of, don't be afraid to speak up. Be that squeaky wheel. Thank you very much. Good afternoon. In this session of our radiologists at the table, I'm going to be talking about lessons learned from the National Lung Screening Trial and beyond. Any discussion of the NLST has to start with the Early Lung Cancer Action Program, which under the leadership of Claudia Hinchke and her colleagues, was a single-arm study of 1,000 subjects who received both CT and chest X-ray. It was the results of this trial, published in the Lancet in 1999, that catapulted CT onto the radar of U.S. policymakers and the medical community. Among the observations from the LCAP trial were that CT was much more sensitive than chest X-ray in identifying lung nodules, CT identified more malignant disease than chest X-ray, and more stage one cancers were seen with CT. Around the same time, in 1998, the National Cancer Institute established the Cancer Imaging Program under the leadership of Dan Sullivan. Dan convinced the NCI of a need for an imaging network akin to the NCI Cancer Therapeutic Cooperative Groups. He was sufficiently compelling that an RFA was published and a number of different organizations applied to this grant. The award was ultimately won by Bruce Hillman on behalf of the American College of Radiology, hence the name, American College of Radiology Imaging Network. Akron provided the scientific talent, committee organization, statistical expertise, and infrastructure to support clinical trials. Turns out the NLST was an example protocol within that application to conduct screening for lung cancer as an RCT. At the same time, the Prostate Lung Colorectal Ovarian Investigators who had been in existence as a organization since 1993, simultaneously initiated the lung screening study, which was designed to determine the feasibility of doing imaging-based CT screening for lung cancer. Akron and LSS individually presented their concepts for a randomized trial to the NCI's Board of Scientific Advisors in 2001. The NCI's Board of Scientific Advisors had a number of concern. First, they felt it was unlikely that CT screening would achieve a 50% mortality reduction and therefore recognize that a larger sample size would be required. Second, they were concerned that insurers may not cover the costs of downstream diagnostic testing for positive screens within a randomized trial setting. Third, they had concerns about the potentially deleterious impact of smoking cessation or CT screening on smoking cessation, fearing that screening might give smokers a false sense of security. Ultimately, they advised the LSS and Akron protocols to merge. And thus it was that LSS and Akron merged to become the National Lung Screening Trial. They presented a unified trial to the BSA, proposing 50,000 participants who would be followed for up to eight years. Their protocols and data collection were harmonized and a common data and safety monitoring board used. Well, the culture of the NLST, Akron, and LSS were very different. The LSS was a well-oiled machine. It was an NCI-sponsored contract with an existing infrastructure through the PLCO sites. Akron, in contrast, was led by radiologists with expertise in CT technology, image interpretation, and clinical practice patterns, but had no preexisting infrastructure and very limited clinical trials experience. It was Akron physicists who first initiated the standardization of imaging protocols, which would become very important and serve as a model for future imaging trials. In conjunction with the LSS physicists, this combined team standardized 18 imaging parameters across 14 different scanner platforms, which guaranteed not only consistent image quality across 33 sites, but served to refute future criticisms of technology obsolescence. However, for Akron, the objectives of the NLST went beyond the basic epidemiologic question of mortality reduction. As such, they determined that they should perform pulmonary function tests to be able to correlate COPD with lung cancer risk. They collected biological specimens for the future validation of molecular biomarkers of lung cancer. They collected quality-of-life data and, in fact, were able to use quality-of-life data in order to enable a formal cost-effectiveness analysis. If there's any question about politics in science, we need look only to the National Lung Screening Trial, which was one of the most controversial trials of the NCI. Within the trial itself, there was skepticism between the experienced LSS and the untested Akron clinical trialists. Fortunately, this was quickly alleviated when Christine Berg, a radiation oncologist, assumed the helm of the LSS team. There was also strong external opposition to the NLST, and these individuals met with the NLST investigators and the NCI director, who at the time was Dr. von Eschenbach. The NLST investigators were persuasive in defending the methodologic strength, sample size, and importance of the trial. In particular, Akron, with its broader goals and scientific credibility, led to the release of Akron to accrue as many subjects as possible. As such, the Akron sites went from an initial accrual target of 10,000 to ultimately enroll almost double that number in the course of the trial. The NLST and the NCI recognized that the future adoption of CT by CMS and private insurers would demand a mortality benefit and a cost-effectiveness analysis, and it was these considerations that drove the requirement that the NLST be successful. Unfortunately, the initial divisiveness between scientists ultimately compromised the lung cancer community itself, because it sent mixed messages to the lay and medical community during that period of time. There were a number of challenges in the conduct of the trial. The first was even the choice of the chest X-ray for a control arm versus no screening. You'll remember that at this time, there was no recommended screening test for lung cancer. However, a number of primary care physicians and pulmonologists would relatively regularly order chest X-rays to screen their smoking patients for lung cancer. Secondly, entrepreneurial early adopters offered screening in clinics and shopping malls, which competed with the NLST accrual and had the potential to contaminate the trial. Third, there were challenges in recruiting minority populations. This wasn't unique to the NLST, but was certainly a concern in a trial of this magnitude. Finally, the data collection and database entry requirements were extensive and required a lot of the trial investigators and their staff. What were the end results? What did radiologists bring to the table? Well, first, the ACRIN investigators accrued 19,000 of the 53,454 participants. Second, they, with the LSS investigators, brought this trial to the finish line. We did find a 20% relative lung cancer mortality benefit with CT versus chest X-ray. Third, early on in the course of enrollment, the ACRIN sites appreciated that we were underrepresenting a number of minorities. Seven of the ACRIN sites got together and established targeted strategies for each of the sites. Ultimately, it was these seven ACRIN sites that enrolled 78% of minority participants in ACRIN. ACRIN also collected the data that documented the relationships between COPD and lung cancer. They established the biorepository to evaluate blood, saliva, and urine molecular biomarkers. They collected quality of life data on short and longer term effects of screening on participants and finally, they completed the cost-effectiveness analysis that was ultimately published in the New England Journal of Medicine. Finally, are we still at the table? It is fundamentally important that radiologists drive imaging-based programs if we are to remain relevant. In the setting of screening, that means that we must communicate directly with patients and providers to ensure adherence to the screening regimens. It means that we lead the multidisciplinary nodule conferences and provide follow-up communications with primary care physicians if recommendations change. It means that we be available for individual patient questions and consultations. It also means that we include smoking cessation as a service to patients within the screening program, which means that our staff who manage the screening programs must be certified in smoking cessation counseling. Ultimately, these are our patients and it is important that we follow them from screening to diagnoses to treatments and outcomes. In fact, most of these data are required or requested as part of the ACR lung screening registry. So with that, I will end and thank you for your time. Hello, I'm Edda Pisano and I'm going to speak today about radiology research advocacy, our radiologists at the table. I hope by the end of my talk, you will all be able to answer an emphatic yes to that question. Today, I'm going to talk about the trajectory of funding for imaging research at the NIH, as well as advocacy at the congressional level, at the funding agency level, and at the level of the Center for Medicare and Medicaid Services. When I talk about the congressional funding advocacy effort, I'm going to focus on the Academy of Radiology and Biomedical Imaging Research. For direct advocacy to the NIH, I'm going to focus again on the Council on Early Career Investigators, which is part of the Academy, plus encourage all of you to understand how you can advocate for your own research. And then finally, I'm going to focus on the Center for Medicare and Medicaid Services and how NOPR, the National Oncologic Pet Registry, really was a successful effort by radiologists to prove that pet worked for cancer imaging. Last but not least, I will tell you how you can help advocate for imaging research. The trajectory for diagnostic radiology research funding over the last almost 30 years has been impressive. It has gone from under $100 million to almost $700 million in that period of time. It really has been impressive, and a large part is due to the outstanding science that is really happening in many, many institutions across the world. That's the most important factor leading to the increase in funding. Advocacy is also very important. This is a picture of Carolyn Meltzer, the chair of the Department of Radiology at Emory and a former president of the Academy, speaking with Congresswoman Anna Eshoo of California at the MedTech event in 2018. This is how we advocate for research, by meeting one-on-one with our congressional representatives and telling them how important research is. However, it's not just to Congress. I encourage all of you to understand how we also have to work with the funding agencies and CMS to get research funded and then paid for by the payers. I'm going to focus first on Congress, and then I'll move on to the others. The Academy of Radiology and Biomedical Imaging Research is our primary way we advocate for research funding in Congress. It is a non-profit organization based in Washington, D.C., led, as you can see on the left here, the woman in the center is Renee Kruwe, and this is her staff. It consists of membership of over 200 imaging societies, academic radiology departments, patient advocacy groups, and industry partners. Both ACR and RSNA are founding members of the Academy. The Academy's mission is to advocate on behalf of the entire medical community to secure federal funding for medical imaging research at the NIH and other governmental agencies through education and collaboration, and utilizes the skills of its members. The breakdown of how the Academy is set up is pretty straightforward. It's an overarching umbrella organization, which consists of imaging societies as well as an academic council that is made up of academic radiology department chairs. Through the academic council, there are two other groups, the Council of Distinguished Investigators, which is senior level researchers in academic radiology departments, and the Council of Early Career Investigators in imaging, who are generally early to mid-career researchers in the academic radiology departments. The Academy partners with the Coalition for Imaging and Bioengineering and Research, which consists of patient advocacy groups, bioengineering organizations, and industry partners. These groups get together once a year to sponsor a MedTech event on Capitol Hill, where our most exciting imaging science is displayed. It lasts for several hours, food is served, congressional staffers, congressmen, senators show up to hear about what's going on in the world of medical imaging. And then, the next day, the same people who set up the MedTech event, all those junior people, all the senior people, all the members of the Academy, executive committee, and board show up on Capitol Hill to tell Congress how important our work is. This is an extremely important event for the funding for medical imaging research. Probably the biggest accomplishment of the Academy really started at its inception, however, and I would be remiss if I didn't mention that the Academy was really founded to help us get, help we in radiology research, get an institute that represented the science of imaging inside the NIH. So the Academy was founded in 1995 with funding from the major academic and radiology societies, academic departments and radiology societies, plus donations by everyday radiologists. Eventually we partnered with the engineers who were also seeking a new institute and created the NIBIB. It was, it was eventually created by Congress and signed into law by President Clinton in December 2000. The current director of the NIBIB is Bruce Tromberg, Ph.D. He's an optics and photonics expert, has co-founded a bio-photonics company. He's a former professor of biomedical engineering and surgery at UC Irvine. He holds over 23 patents and is expert in the clinical validation and commercialization of devices. So we are in very capable hands with him at the helm. Last year, Congress, in its efforts to address COVID, appropriated an extra $560 million in supplements to NIBIB on top of its $410.7 million base funding. This was partially used to fund the RADx Tech program, which produced COVID testing. You can see the data shown on the slide yourself. Over a hundred organizations supported, were supported by the RADx Tech contract program and produced the first over-the-counter tests for COVID and 32 authorized FDA tests. In addition, last year, the NIBIB funded MIDRC, the Medical Imaging Data and Resource Center. It was through a supplement to its base funding in August 2020. It's a collaborative project of the ACR, the RSNA, the AAPM, and the University of Chicago Gen III. It collects imaging and medical data on COVID, approximately 60,000 cases to date, and provides access to de-identified data in a public conclave. That resource can be used for AI development and testing, and there is a part of the data set held back for validation by the FDA. In addition, another big accomplishment of the Academy was the convening of the Intergovernmental Working Group on Medical Imaging, which happened through the White House National Science and Technology Council in the Office of Science and Technology Policy based in the White House. It was led by Rod Pettigrew and Richard Cavanaugh. Rod was the first director of NIBIB. Richard Cavanaugh is with the NIST organization. It really had a goal of advancing research and improving the fundamental understanding of medical imaging. The key recommendations of the roadmap were to standardize image acquisition and storage, including standard linkages to clinical data, which is very important in the era of AI. To apply advanced computation and machine learning to medical imaging, again, another nod to AI. To accelerate the development and translation of new high-value medical imaging techniques, including patient access in underserved areas, and to promote best practices in medical imaging, including through accreditation and education. Another big effort by the Academy is to teach the mid-career and junior faculty how to advocate both to Congress and to the NIH for their own research projects. That is through the Council of Early Career Investigators in Imaging, or CC. This is an annual program where mid-career researchers who are nominated by Academy member institutions and societies go to Washington, participate in the MedTech event and the Capitol Hill Day, and have informal conversations, training sessions, and advocacy meetings with members of Congress. This is the way the Academy teaches those who are just learning how to do research, or midway to their successful careers, how to be advocates for the future of their field. This past year, just a few months ago, in September of 2021, the class met in Washington. You can see everybody's masked here. These are the faculty that were present in this picture mostly, some trainees as well. They visited over 30 congressional office staffs and over 60 NIH program officers. That brings me to the next point of advocacy where radiologists are well-represented, and that is at the NIH. The Academy hosts an NIH day that's coincident with Congressional Day, so that the CC members can show up one time and visit both Congress and the NIH. But this kind of event is not limited just to CC members. I encourage all of you, if you're doing research, to reach out to your program officers. Whenever there's an RFA or RFP, there's a person's name on it. Do not hesitate to call. Do not hesitate to Zoom. Do not hesitate to visit. This is the best way to learn how to improve your research and how it can fit the RFA. It will give you a friend inside the institution, the NIH, that might help you get funded. This is really a very important tool to becoming a successful funded investigator. Now I'm turning to talking about funding and how we get research funded to support the ultimate implementation of research in a clinical setting. Perhaps the best example of this is NOPR, the National Oncologic Pet Registry, which was founded during the days of Akron in the early part of the 21st century and overseen by four nuclear medicine experts. Ed Coleman, Barry Siegel, Bruce Hillner, and Anthony Shields. It really was required by CMS before they would pay for FDG-PET or sodium fluoride 18-PET for the management of patients with cancer. It was started under the Program for Coverage for Evidence Development, which is essentially a program that will pay for new technologies while the evidence is being accrued. This particular NOPR project was funded by industry with advocacy for the Academy of Molecular Imaging, now the World Molecular Imaging Society. It led to payment by Medicare and private payers for FDG-PET for specific cancers and indications. Unfortunately, it was a failure for sodium F18-PET, even though 45,000 PET scans and images and information about the clinical course of patients was collected. Sometimes advocacy does not work. Sometimes the evidence development pathway is unsuccessful, but the evidence accrued does help our patients eventually. I believe that there might be an opportunity to appeal some of these matters as things progress and it's very important for us to participate in these programs and Medicare, the CMS, makes it available to us. So how can you help? Well, the obvious way is to use your voices and advocate. The Senators and Representatives, your Congress people, really do pay attention to what you say to them. Write to them. Write to them multiple times. Participate in your department's efforts to advocate. Visit the Hill. Visit the funders. Join the organizations that fund advocacy for research, such as the RSNA, the ACR, the American Rencum Ray Society, the Association of essentially all the basic subspecialty societies including AMWA. Use your voice. Research advocacy really does work and radiologists, yes, are at the table. Thank you.

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