Dr. Pope is a Professor of Radiology and Orthopedics at the Medical University of South Carolina (MUSC) in Charleston, SC. He is also Director of Breast Imaging at MUSC and is a guest examiner in Breast Imaging for the American Board of Radiology. Dr. Pope is a member of the editorial board of this journal and is a Clinical Specialty Director for Radisphere. Dr. Beltran is Chairman of the Department of Radiology at Maimonides Medical Center in Brooklyn, NY, and a Clinical Specialty Director for Radisphere.
Editor’s Note: In an editorial in our September issue (Vol. 39, No. 9, Pages 4-6), I cautioned that if we let them have the nights we risk them taking the days. It was less a jab at teleradiology providers and more a commentary that if we do not provide a high level of service, someone else will. Radiologists must continually find ways to provide a definitive diagnosis that makes the referring physician confident in their ensuing treatment decisions. Drs. Pope and Beltran continue the discussion by delving into the need for an increased focus on subspecialization—bringing value to the forefront of what we do.
Stuart E. Mirvis, MD, FACR
With the political season brewing—some may even say foaming at the mouth—it seems appropriate to throw into the radiological mix a subject that seems to engender a similar frothy response from all imaging quarters: the impending nationalization of radiology. No, we aren’t talking about a governmental takeover of all imaging services with the elimination of competition. In fact it is just the opposite; it will be a free-market capitalistic competition between local radiology groups and larger imaging companies with a regional or national scope to their services.
According to the literature, and the blogosphere, the appearance of these national imaging groups is due to the enabling technology of teleradiology. However, this assertion completely misses the real reason for this new development in radiology practice organizational structure. Technology in and of itself does not create a market demand. There has to be a deficiency or a problem waiting to be solved that finally prompts a unique change in purchasing behavior, thus creating a market. To be clear, in our corner of the healthcare world, we aren’t really talking about free-market economics, because hospitals don’t buy our services; they contract with the radiology provider that offers benefits that best serve the needs of the hospital, referring physicians and their patients. It is the responsibility of the individual practice to make the economics work based on the number of radiologists, the study volume and the fixed payer mix in that community.
But we all would have to be ostriches with our heads in the sand not to recognize that our profession is under pressure to provide more specialization, better service levels and documented quality levels, while facing reduced reimbursements and scrutiny over imaging’s responsibility for the ever increasing cost of health care. This is not, though, as some may bemoan, the meeting of an immovable object with an irresistible force. The very makeup of a local radiology practice has to change to be able to accommodate the needs of their constituents.
Value to constituents
So instead of debating whether or not nationalization of radiology is good or bad, let’s look at our constituents and the benefits they are trying to garner to see if we can at least agree on some common goals. Medical staff satisfaction will always be the first and foremost priority to the community hospital CEO, so quality and service levels will be a non-negotiable element in any practice’s value proposition. Quality of service will need to be continually demonstrated. But CEOs are equally challenged with meeting a bottom line that radiology contributes to handsomely, in terms of technical-fee revenue. If the local radiology group also competes with the hospital for high-margin outpatient imaging revenue, then a national group that does not pose a local competitive risk will be seen as a better ally in delivering radiology professional services.
Most other clinical services have reached a significant level of specialization that is common even in modestly-sized community hospitals across the United States. If radiology is to be seen as an asset to a referring physician, there has to be a similar level of specialization in diagnostic imaging reports. Orthopedists have seen a huge number of images throughout their career, but if you can get them to be candid, they probably can count on one hand the number of radiologists who they feel have given them good clinical insight over the years. So reports have to be of high quality with appropriate subspecialized detail, they have to be directive and they have to be consistent between multiple radiologists who read for a site. We radiologists have too often prided ourselves on our own idiosyncratic means of dictating that we learned from our residencies (no “loss of individuality”). It is imperative in the future for practices to standardize reports with a consistent high quality product. And, by the way, get them those reports fast so that it meets their patient time urgencies.
As a byproduct of subspecialization comes the ability to call a diagnosis definitively so that the referring physician is confident in their communication with the patient and that unnecessary follow-up studies are not routinely recommended. The last thing a patient wants to do is get in a big tube that whirs or, even worse, hammers at them noisily with them worrying about any co-pays coming out of their own pocket.
A practice has to be organized such that it can attract the best radiology talent in terms of clinical interests and compensation. A recent study showed that radiologists read studies in their area of subspecialization only 30% to 50% of the time. Group practice dynamics are definitely different today when the youngest physician coming out of residency with highly subspecialized credentials can produce the most RVUs right out of the box. The traditional partnership track may not necessarily afford the competitive compensation necessary to retain such talent. A national group that compensates based on productivity and quality measures and that also allows a radiologist to read within their specialty 100% of the time is an approach that merits serious evaluation. This is also the antidote to the lament of the commoditization of Radiology.
Contrary to popular opinion, commoditization does not come from teleradiology making all of us look equal. The perception of radiology interpretation as a commodity is the fault of our own profession in that we have put across the façade for many years that we can all read all studies equally well. A large group that subspecializes on every case would actually be supporting the profession in terms of the value of the unique training we have all gone through and the years of experience we bring. It is, in fact, the antithesis of commoditization.
So our profession needs to look at this new national category not with enmity but with amity as it may well be an effective model to deliver these benefits to all radiology constituents. It may also very well be the means by which we retain and restore the clinical value we know we can offer to the healthcare world. Some of these new groups may do a great job at delivering radiology professional services and some may not. But if you talk to a spectrum of community hospital CEOs these days, my guess is that they would have a similar split in what they say about all of us in our current model of local radiology practice delivery. It is time to put down stones and put on your thinking cap on how we can best add value, no matter whether your group practices in one zip code or from coast to coast.