There is hardly a facet of medical practice that has remained
untouched by the juggernaut of healthcare reform. Old practices
have fallen by the wayside. New systems have been implemented to
take advantage of strengths and to mitigate weaknesses. No tenet of
the old ways is allowed to remain unchallenged. Medicine now makes
sound business as well as sound medical decisions. And radiology is
no exception...or is it?
To put the question right out front: How many practices are
designed to take advantage of all that interventional radiology has
to offer?
Interventional radiology is the prototype of a minimally
invasive discipline. Let's look at how some other medical
specialities are handling minimally invasive techniques. These
days, cardiology groups rarely recruit anyone who is not an
"interventional" cardiologist. The cath lab is the centerpiece (and
the most lucrative piece) of their practice. These groups are
aggressive in looking for other interventional vascular
applications outside of traditional cardiology boundaries.
Gastroenterologists and pulmonologists treat the "scope" portion of
their practice the same way. Even some infectious disease
specialists are getting special training in placing PICC lines
because they want a piece of the minimally invasive pie.
Now, how are most radiology groups handling this opportunity to
gain market share? Outside of academia and a few notable private
practices, most groups have done little to change the basic work
structure that has been in place for the last 20 years. A typical
setup has everybody doing everything-interventional cases mixed in
with plain film, CT, US, or MR reading-and most members of the
group are doing interventional cases on call.
Why is this a problem? Because the recent changes in healthcare
reform have resulted in a window of opportunity for interventional
radiology to experience unprecedented growth (and reimbursement).
But it won't happen unless the garden is tended. Profiling and
outcome analyses data are directing insurance companies to a
reimbursement system that will only pay "qualified" individuals for
interventional procedures. A Certificate of Added Qualifications
will probably come into play. In addition, physicians will not
refer patients unless a consistent level of interventional
radiology service can be provided 24 hours a day, seven days a
week. What about capitated systems? Conventional wisdom says you
are only as well off as the contract you negotiate. Capitated,
sub-capitated, and carved-out contracts are some of the options
that allow designing a setting for interventional radiology which
will optimize return and benefit the entire group. But you won't be
sitting at the table negotiating if you don't have a competitive
interventional practice.
Try to imagine how modern businesses run, say a software
computer company. They may (or may not) provide the full range of
applications, but they are anything but static. They pour
resources, development, and marketing into those areas that are
"hot" or predicted to grow. As things change, some areas may be
given more resources, while others are minimally supported and some
even discontinued. Ah, but radiology is not really that much like a
business, you say. Have we not discontinued (I hope)
pneumoencephalograms, and would not IVP's be considered minimally
supported at most practices? Have we not expanded to more efficient
and financially rewarding outpatient imaging centers?
So, what's hot? Interventional radiology. Why? Because it's
doing the right thing for the right reason. Even if it wasn't
attractive from a business point of view, who wouldn't prefer a
needle stick and six-hour recovery time over a twelve-inch incision
and a one-week stay in the hospital? This is the future of
medicine. Subspecialize the interventional portion of your
practice. Deliver dedicated, high-quality, and consistent service.
Allow the interventionalists the opportunity to build the practice;
dare I say even reward them for results. The whole group will
benefit. But the window won't be open for long. Part-time
interventionalists cannot compete with other specialities such as
cardiology, nephrology, and vascular surgery, who see the
opportunities, allot the necessary resources, and make the
necessary changes to develop and provide a service. If the
interventional part of your practice is not producing the highest
profit margin of any section, it is because you choose not to
support it. In doing so, you have chosen to limit the development
and growth of your practice and radiology as a whole.
Dr. Selby is Professor of Radiology and Co-Director of the
Division of Interventional Radiology in the Department of Radiology
at the Medical University of South Carolina in Charleston.