Roundtable: Hospital-Based Practices
There have been several roundtables on hospital-based practices here at the RBMA Fall Educational Conference, and I finally got a chance to duck into one this morning. The room was packed with attendees eagerly awaiting the discussion to come. An introduction from RBMA past president Pat Epting set the tone for the session: “Some of you sent in some questions ahead of time, but I don’t like them,” he said, drawing laughs. “So let’s open it up to the room.” Nancy Holland of High Point Radiological in North Carolina asked, “Our hospital just came to us with a clinical integration program with the cardiologists. They were letting us know in advance that they would carve out cardiac/nuc med from our next contract. What’s to stop this from happening with other specialty groups, and since some of these exams are going to take place in our department, what can we do to protect ourselves from legal action?” An audience member responded that High Point will be responsible for every study done in the radiology department. “They’re going to end up taking your scheduling time at the hours they want, but you can’t get away from it—because of the direct supervision rules, your docs will be responsible.” Epting added, “With our hospital, in the case of CTAs, we said we’d share reading of the studies, but we were sub-contracting to the cardiologists. They wanted it the other way around, but we said no. It’s difficult to protect ourselves because we don’t provide the inpatient. The relationship we have with the hospital administration boils down to how nasty that particular administrator wishes to be toward us. It’s something we all experience, but we have to be careful because they will erode a number of things.” “Have people thought about what’s the point of the contract?” another audience member asked. “We still have it, it’s beneficial at times, but really all it does is bind you.” Some audience members indicated that they’d never had a contract—one group hadn’t had one for 23 years. Epting interjected that the contract prevents other radiologists from being on the staff at the hospital. “That’s the only advantage to having one that I know of,” he said. Then Epting turned the subject to bundled payments, asking if anyone’s encountered the issue. “They’re telling us ours is coming pretty soon,” an audience member said. “They’re trying to negotiate with large employers in our area. Right now it’s just in the talking stages, but I’m wondering how much we’ll be able to bring to the negotiating table if the hospital does contract directly with these employers. What’s it going to do to us?” By contracting directly with employers, the hospital is hoping to keep its financial situation as level as possible, she went on. “Are folks seeing the hospital being more involved in forcing the group to take certain payor contracts, even if they’re unacceptable economically?” an audience member asked. “What we’ve been able to do in the past is put some accountability and restrictions in that—if it’s not reasonable, the hospital has to help us negotiate a reasonable fee,” someone responded. “Some of the out of network regulations being passed are already forcing our hands,” added another audience member. (Read more about that in our coverage of yesterday’s sessions.) “Eventually, we’ll see more and more of it, but it’ll be from state regulators who are forcing the issue.” “On self-pay, have we had any luck out there with the hospital helping to collect?” Epting asked. Judging by the incredulous laughter in the room, it didn’t seem like too many attendees had made this tactic work for them, although a few compromises were mentioned: “We set a cash price for the high-end modalities and worked cooperatively with the hospital,” responded one audience member. “They collect 100% of the money and give us our portion after the fact. It’s a fairly new program, but I think it’s a step in the right direction.” Turning the topic to physician productivity, Epting mentioned the July meeting during which the ins and outs of dealing with radiologist partners was discussed. Radiologists want to know who among them is working and who isn’t, but how do managers handle the ensuing conflicts? “I think I’ve been doing some version of this for 10 or 12 years,” an attendee responded, “and have had it referred to as ‘my evaluation,’ like it’s my personal evaluation. Then you hear, ‘Oh, it’s because the others are cherry-picking.’” A rumble of laughter from the rest of the room indicated that this isn’t an uncommon experience. “We never gave out RVU information before,” said one audience member, “but recently some of the radiologists decided they wanted it. So we run them compared to others with like responsibilities in the group. What we tell them is you can ask for the information any time they want, but we’ve been doing it for two years and no one’s asked for it.” A few groups did say that they are linking RVUs to bonuses as a means of encouraging productivity, although Epting added that he’s not sure this approach is entirely fair: “If we’re truly going to provide best service, how can you do that and work on RVUs for bonuses at the same time? Somebody’s still gotta read plain films.” After that, the discussion drew to a close. I sensed a lot of frustration in the room, and the list of covered topics on the whiteboard certainly painted a portrait of an industry in transition. It’ll be interesting to see which of these issues have resolved themselves by next fall—and which have intensified. I’m betting we haven’t seen the last of bundled payments or RVU-based productivity measurements; how about you?