Commoditization of Imaging: What Can Radiologists Do Now?

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As telecommunications technology advances, rocking the age-old paradigm of the radiologist tethered to a lightbox, radiologists have freedom as never before: freedom to read from anywhere, hospital or office; freedom to read from home; freedom to outsource night reading to other providers. Do these freedoms come at a cost? spoke with Leonard Berlin, MD, FACR, vice chairman of the Department of Radiology at North Shore University Health System-Skokie Hospital, Skokie, Ill, professor of radiology at Rush University Medical College, Chicago, and chairman of the RSNA Professionalism Committee, on what can radiologists do to prevent the commoditization of their services. What factors have contributed to the growing commoditization of imaging services? Berlin: I think teleradiology is a factor, but it’s certainly not the sole factor. As medical expenses increase, and as more and more radiology is done by nonradiologists, there’s a growing trend of hospital leaders and managed care leaders looking around and thinking that if the radiologists themselves are forfeiting certain activities that they heretofore had claimed they had to do, maybe that means they’re not as essential as they were before. There’s a trend toward training and hiring radiology assistants, and that also has the downside of commoditizing imaging. What role does teleradiology play in commoditization? Berlin: The teleradiology companies have grown, and my own group is guilty itself. We’re on call half the night when we have to work the following day, and all of a sudden this teleradiology company comes along and says, “Our well-trained radiologists can work in places where their daytime is your nighttime, so you guys can sleep, and the following morning you can overread and charge the patient.” We were early customers of teleradiology. Now, there are more than 20 night-coverage companies in the United States, all competing with each other; it really grew geometrically. When you’re recruiting young radiologists, they ask if you have night coverage. They don’t want to stay up all night. Now, hospital administrators are looking around and saying, “If Dr. Berlin and his group are hiring someone else to read the x-ray studies at night, why can’t we hire someone to read the same studies during the day? Maybe we only need half the radiologists.” It becomes a cost issue. Commodities are bought by price, and that’s what’s happening slowly in radiology: that it will be bought by price, not by quality. You mentioned radiology assistants earlier. How does that trend contribute to commoditization? Berlin: This is a movement that’s growing a little bit. There are quite a few radiology assistant programs in the country. Radiology assistants work in radiology departments; they help process patients, they do some fluoroscopy, they do minor procedures under the supervision of radiologists, and the radiologists think it’s great. It alleviates their workload. Anesthesiologists have been doing this for years, but in anesthesiology, the assistant has to work under the supervision of the anesthesiologist. What’s happening in radiology is there are groups around the country hiring these radiology assistants. Now, administrators are saying, “We’ve got orthopedic surgeons doing their own imaging work and cardiologists doing their own CTs in their offices, and we see that radiology assistants are doing this work as well.” What’s to stop administrators from saying, “Let’s start hiring these guys ourselves?” I see that as something potentially detrimental to radiology. There’s short-term gain, but you wonder if there’s long-term pain. What are the risks associated with commoditization of imaging services, from a business standpoint? Berlin: The business risk is losing income. What if I’m in an eight-person group, and all of a sudden, my hospital administrator says, “Times are bad, we’re losing money, and the only way to increase our profit is to decrease our radiologists on salary to just four, and to hire a teleradiology company to cover the rest of the reading at half the cost?” Are there medicolegal risks? Berlin: If teleradiology is done right, no. With the legitimate companies, all of their radiologists are board certified, they are fellowship trained, and they have applications to be members of the medical staff of a particular hospital. That isn’t to say that there might not be people who break those rules, but the legitimate teleradiology companies do not. I don’t think it contributes to medicolegal risk unless someone is cutting corners somewhere. Why don’t radiologists turn the tables and join teleradiology companies? Berlin: Most radiologists view themselves as part of an independent professional group that consults with physicians and so forth. Interestingly enough, these teleradiology companies have no problem finding radiologists to work. You take young radiologists right out of training; if they go to work for a teleradiology company, they can make the same income to work from home and work the hours they want to work—just get up in the morning, work from 9 AM to 3 PM, and make the same money that they could by running around a hospital. It’s an easy job, but if that’s how all of radiology winds up, then we’re nothing more than factory workers. We’re not independent professionals. How can the industry as a whole prevent commoditization? Berlin: That’s the dilemma that the ACR is dealing with right now: How do we preserve our independence as a profession where we pride ourselves on being consultants to physicians? How do we add value to radiology? We know the question, but the answer’s not so easy in coming. How can imaging centers make the best decision when selecting a teleradiology provider? Berlin: We’ve been dealing with a night-coverage company for five years, and we’ve been very happy with it. I’ve never gotten the feeling that it’s trying to compete with us. It’s a matter of good faith. How do you see the relationship between imaging centers and teleradiology providers evolving in the future? Berlin: The ideal would be keeping the status quo. The teleradiology companies are providing a service, and the radiology groups are fine—our group certainly isn’t getting hurt by it. The status quo would be fine, but how can it be maintained? A lot of the teleradiology groups are going public, and when you go public, you have to grow your profit. The only way they can grow their profits is by acquiring more business, and the virgin hospitals that haven’t yet hired a teleradiology company aren’t apt to do it. It may be that it will level off; instead of having 20 companies, there will be eight or nine, and the hope is that there will be stabilization down the road. All we can be certain of right now, however, is the uncertainty. What can imaging centers do to prevent commoditization? Berlin: We have to add value to our services, and to ingrain upon the hospital establishment and the nonradiology doctors that the radiologist is a valuable person to have around—to help select the right exam, to ensure quality, to be a consultant, to see to it that there’s not too much radiation delivered. That’s what we’re striving for right now: increasing value to what we do so that we will not be treated as a commodity, but as a respected contributor to medical care. It’s on the intangible side, but that’s the solution.