Commoditization of Imaging: What to Do Now
The responsibility for the phenomenon has been placed, at one time or another, on the shoulders of just about every stakeholder in the imaging field. Some say that payors are to blame; others see the growing prevalence of remote reading as the culprit. Has the expansion of IT made it possible, or is radiology merely catching up with other areas of medicine?
"Radiology is a particularly sensitive area of specialization. We don't control our own patients, we rely almost entirely on referrals, and we're completely dependent on technology. There's still an opportunity to reverse the trend toward commoditization, but if we continue with the same modus operandi, we’re headed on a downward spiral."
— Bruce Reiner, MD
Whatever your opinion of its origin, commoditization is clearly at work in imaging, according to Bruce Reiner, MD, director of research at the Maryland VA Health Care System in Baltimore. “There’s an increasing focus on cost and a decreasing focus on quality,” he says. “The government is the largest payor for health services, and they’re constantly wanting to lower costs. There’s an increasing focus on the bottom line.” Reiner explains that imaging is particularly vulnerable to commoditization because it is expensive and heavy on technology. “Radiology is a particularly sensitive area of specialization,” he says. “We don’t control our own patients, we rely almost entirely on referrals, and we’re completely dependent on technology. There’s still an opportunity to reverse the trend toward commoditization, but if we continue with the same modus operandi, we’re headed on a downward spiral.” Anatomy of a Commodity In a 2009 article in the Journal of the American College of Radiology: JACR, Reiner and Siegel¹ outline what they see as the key contributors to imaging’s commoditization: the current focus on the bottom line, deepened by the globalization of imaging services, increased information exchange, and new technological developments. “Consumers of imaging services are focused almost exclusively on cost,” Reiner says, “instead of on the quality differentiators that are crucial to maintaining pricing power and rewarding the technology and service providers who can outperform the competition.” Reiner mentions technology providers because he feels that the technology upon which radiology is so reliant is also subject to commoditization. “The same thing happens to technology. It always becomes commoditized,” he says. “PACS are looked upon now as boxes that are interchangeable from one vendor to the next. Vendors have not been terribly innovative in differentiating their products, based on data-driven objective differences between systems. There’s a dumbing-down effect: Instead of vendors investing in research and development and looking for ways to innovate, they’re looking at cost as well.” The connection between technology commoditization and imaging commoditization, Reiner explains, lies in data mining. The statement that you can’t change what you can’t measure, often repeated in the imaging world, represents a call to action for a community thirsting for hard data upon which standards and benchmarks could be based. “Data mining is the future of all medicine, especially radiology, and the vendors have yet to get it right,” Reiner says. “They have all this technology, but they’re way behind the eight ball in terms of developing tools and resources to support longitudinal data-mining efforts. While the societies have a responsibility as well, I think the vendors need to develop the technology to support them.” Reiner says that for this and many other reasons, the imaging field has not yet truly prioritized quality, and it is therefore subjecting itself to a marketplace where cost remains the primary differentiator. “You need to be able to discriminate based on clinical outcomes—how effective one service provider is at optimizing those, compared with another. Without those data, those standards, and the supporting technology, it gets boiled down to tension on economics and cost.” Industry Commitment Reiner and Siegel note that “a number of economic and political events have added urgency to the data-driven, quality-oriented transformation of medical imaging practice.”¹ This statement is truer than ever before following the advent of health-care reform, with its emphasis on quality initiatives and comparative-effectiveness research. As they note, however, “Although these events provide sufficient external stimulus for quality-oriented change, an internal, discipline-specific infrastructure must support this effort.”¹ In other words, the industry must be committed to change before it can be enacted on any meaningful level. “If I’m in this for the long haul, I cannot continue to operate as is,” Reiner says. “I need to develop a strategy that will counteract this trend, where I can use data not only to make me more productive, but to improve the quality of my performance.” Reiner says that this improvement will require the creation of quality-based metrics, the development of standardized databases to track those metrics, and the integration of those metrics into reimbursement. “The RVU system doesn’t differentiate on quality,” he notes. “When you start introducing quality metrics into the payment model, that suddenly changes. If part of reimbursement is tied directly to quality, then people will pay more attention, because it’s in their economic best interest. In theory, that’s pay for performance, but it hasn’t really made a dent. You have to hit people in their pocketbooks.” Quality can’t be limited to the accuracy of interpretations, either: It also must be evident in radiologists’ reports (in many cases, their only line of communication to the referring providers on whom their business depends). “As radiologists, almost 90% of how we’re perceived by our colleagues is predicated on our reports,” Reiner says. “In this day and age, between teleradiology and PACS, we have so little contact with our colleagues that quality must also be about the quality they perceive in our reports.” Starting the Discussion Reiner looks to professional societies and technology vendors to spur the development and use of quality metrics. “I wish all the lip service, posturing, and politics would come to an end, and people would sit down and ask, ‘What do we need to do to make this right?’ I’d love to see the professional societies and the technology vendors become more proactive,” he says. Teleradiology has a role to play as well, Reiner believes. “I think teleradiology is a great place to begin the discussion,” he says. “The people who are in the smaller community hospitals have been insulated from external competition over the years, and then teleradiology provides that competition for them, and that can be very healthy. In a capitalist world, a company that offers better quality should be able to charge more. When you choose on cost alone, that’s when you lose the big picture.” More Reading - Suggested Steps Toward Decommoditization Cat Vasko is editor of and associate editor of Radiology Business Journal.