The Coming Crisis in Radiologist - Hospital Relationships

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This is the time of year when visions of sugarplums are fresh in our heads from the RSNA, and we like to reminisce about days gone by when radiologists and hospitals were friends and worked together in harmony for the good of the patient and the well being of the radiologist. Now, that is not to say that somewhere in our fair land things are not copasetic and goals are not aligned. But I haven’t seen it lately. Somewhere in the recent past and in many places in the country, the situation has changed: that relationship has turned antagonistic and the hospital/radiologist relationship is in jeopardy. As a resource, we are more often called upon to assist in changing this dynamic, to act as a reconciler of differences that run deep, so much so that hospitals are often on the verge of terminating contracts and radiologists are fed up with the way they have been treated and would just as soon walk away. When I was a hospital administrator, a long time ago in a galaxy far, far away, we valued the contributions and relationships we had with our radiologists. They were the visionaries of where diagnostic medicine was heading, and we needed to pay attention. Radiology departments were the front door to our hospitals, and referrals often resulted in patient admissions, outpatient surgeries, and the like. We knew radiologists worked hard and created a valuable resource that the attending physicians and their patients needed. But that was before DRA, digital mammography, PET/CT, PACS, voice recognition, IDTF, Stark I, II, and III, locum tenens, nighthawk, multi-slice CT, and, of course, cardiologists. From the radiologists’ perspective, they are overworked and underappreciated and in fact this is very true. Utilization has increased dramatically by as much as 200% over the past decade due to numerous factors and it’s getting worse. ED physicians have also increased their referrals to imaging departments to the point that unnecessary tests account for as much as a third of all ED referrals and is used as a triage tool rather than a necessary diagnostic tool. This increases the workload, often to a point of unsustainability. If some of this unnecessary utilization isn’t controlled, the payers will figure out how to control it for you. Needless to say, that with the radiologist shortage over the past decade, keeping up with the volume has been more than a full time job. Root of the Problem But why are they underappreciated? With pressure to meet turnaround times and volume doubling, there is no longer any time to meet with referring physicians to consult on difficult cases or add their diagnostic expertise. They rarely make calls to physicians who request stat reports, since so many reports seem to be stat these days. Radiologists are reluctant to perform interventional or minor procedures as these take them away from the lengthening work lists they must get through before they can leave for the day. They often close their doors to avoid interruptions, which is often perceived as anti-social or worse, malingering. Hospitals bring out the best and worst in radiologists’ practices, as they should: the most challenging cases, the highest level of physician-patient interaction, the late nights, and the long days. With that come the administrative meetings, the lack of staff resources (or indifference), and capital shortages for this year’s equipment needs. Many patients are uninsured (and this number keeps growing), requiring an altruistic understanding of the patient care mission. Nighttime coverage now costs more than those reimbursements provide, and diminishing professional reimbursements that Medicare and third party payers are unconcerned about exacerbates the shortage. Medical imaging is a series of complex collaborations to one purpose and that has not changed: Provide an accurate and timely diagnosis to improve a patient’s care. Hospital administrators hear the complaints of staff and physicians, with cardiologists and vascular surgeons leading the way, pleading to perform interventional and now, non-interventional CT and MR cases. They too are concerned that radiologists are overworked with not enough “warm bodies” in the department to meet the demands for daily, nightly, or weekend coverage. They hear that radiologists make more money and get more paid vacation than any other physician on staff and yet the Press-Ganey customer service scores for Radiology, their bread and butter lines, are sliding into oblivion. Hospitals need medical imaging services in terms of both revenue and diagnostic capability, and as we know, unsatisfied customers take their business elsewhere. Why can’t customer service be better? Why can’t turnaround time be better? We have better tools with PACS, RIS even voice-recognition dictation, their jobs should be easier, right? And now with digital mammography, what could be quicker than reading 100 mammograms a day? I am reminded of the I Love Lucy Show when Lucy and Ethel are working on the candy assembly line trying to keep up with the speed of the technology, still very relevant today. Why, with salaries soaring, is it hard to recruit full-time radiologists? Because fewer radiologists are filling residency program seats and the ones that do make it to the workforce are snatched up by practices that can offer benefits and amenities that most hospital-based practices can’t. When new radiologists hear of the exceptionally long days, weekend coverage, on-call requirements, and, as a result, diminishing vacation time, they often opt for the path of less resistance. They look for practices with ownership in outpatient centers, more income, less call, and fewer hassles. Through all of this, the quality and value of interpretation is often lost or overlooked as a dimension that both the radiologists and hospitals value, and that is very troubling as both a prospective patient and as a health care counselor. A perceived diminishment of quality results in the undervaluation of the service as a whole and its contribution to medicine. At the GE Beyond conference this past summer, Newt Gingrich, former Speaker of the House and a keynote speaker, explained the imaging cuts caused by DRA as simply as this: “There is no one speaking out for medical imaging, no coherent and resounding message that explains the value of imaging to medicine and the benefits to patients.” It’s time to speak out in support of the radiologist/hospital relationship. Who Needs Who? From 1970 to the late ‘80s, imaging was performed primarily in hospitals. It was uncommon to find, other than x-ray, any imaging in physician practices or freestanding centers. Now less than 40% of outpatient volume is performed in hospitals, causing a significant shift in outpatient revenues away from hospitals. Medicare and other payers are cognizant of this and are working to correct the situation. DRA has shifted the balance of power and revenue back to hospitals and more financial challenges are on the way. If RSNA prognosticators are correct, more than a third of radiologists are expecting to retire in the next five years. The shortage of radiologists will be more profound and impacting than ever before. The bulk of imaging is still performed in hospitals and hospitals need high quality radiologists more than ever. Radiologists may not want to admit it, but they need hospitals too. Hospitals are going to need to adjust their thinking and attitudes about collaborating with radiologists. This may include joint ventures for technical services, assistance in recruitment, subsidies for night and weekend coverage, more creativity in managing departments, improved utilization controls, and respect for the value the radiologists bring to the table. Issues regarding managed care contracting, exclusivity, and non-compete language will need to be explored to an effective compromise that works for both parties. Radiologists will also need an attitude adjustment. They have to recognize the challenges that hospitals face and help to meet those in a cooperative fashion. Quality of service needs to be in the forefront of their minds to ensure high standards of care and customer service to meet all of their customer’s needs. Performance standards are ubiquitous in business, and radiology is a business. Cooperation between staff and radiologists in meeting these expectations is not only necessary it will determine their ability to remain competitive. Great rewards require great efforts and the rewards of a successful imaging service are many to all involved. They say life is a series of compromises, and the problems facing radiology exhibit strong evidence of that. Times have changed since the contractual arrangements of the ‘70s and ‘80s, and relationships and new contracts need to reflect those changes. There is a need for a more collaborative and better working relationship between hospital administrators and radiologists. If hospitals are to maintain a high quality service in diagnostic imaging, they need to have a strong radiology practice. If radiologists want to dominate their markets they need to provide high quality to all their customers, including hospitals. Together, they need support, they need recognition, and they need to be valued for the services they provide. Radiologists and hospitals need to come together for the good of both parties. Bob Maier is president and CEO of Regents Health Resources, Brentwood, Tenn. Regents is a national consulting and imaging services planning and development company that specializes in providing solutions to hospitals and radiologists. Bob can be reached at 800-423-4935, or by email at Bmaier@Regentshealth.com.