Threats to Radiology and the 20 Ways to Beat Them Back

CHICAGO - It’s a common topic of conversation in radiology today: The profession is under attack from several fronts. This lament is most certainly true, but there are several ways to conquer these problems, industry experts said at this year’s RSNA annual meeting.

But before you know how to fix the situation, said Jonathan Berlin, MD, associate professor of radiology at Northwestern University Feinburg School of Medicine, you have to understand the forces working against you.

The Threats

1. Declining reimbursement: This issue is no surprise. Since 2006, Medicare reimbursement as slowly dwindled. Until recently, the drops only affected the technical component, but this year, CMS retained the multiple procedure payment reduction (MPPR) to the professional component. It will eliminate 25 percent of the payment you receive for CT, MRI, and ultrasound imaging conducted by one or more providers in the same practice, during the same session, on the same day. Add bundled payments, combined codes, and the new accountable care organization model, Berlin said, and CMS is whittling away your reimbursement.

2. Bad job market: Ask any radiology resident, and he or she will tell you there are simply no jobs available in the field. Confusion around reimbursement and the radiologist’s role in health care has prompted many practices and departments to freeze any hiring efforts. Less job opportunity is already equating to fewer medical students pursuing radiology as a specialty, and existing resident morale is at an all-time low, he said.

3. Commoditization: In recent years, rather than focus on all the work associated with diagnostic imaging - the pre-, intra-, and post-service - radiology has placed the greatest emphasis in image interpretation. And hospitals and referring physicians have followed suit, giving the profession the reputation for being a commodity rather than an integral specialty. Many facilities now outsource their image reading to the lowest bidder, and many insurance companies now steer patients to facilities that offer services at the lowest cost.

4. Teleradiology companies: Although shifting night reads initially seemed like a good idea, corporate teleradiology companies are now expanding beyond nighthawk work. Many are now stealing hospital contracts away from local radiology practices, promising to offer high-quality care at reduced cost.

5. Medically-inappropriate imaging: CMS and other health care agencies now estimate that 35 percent of all imaging studies conducted are unnecessary and don’t contribute to diagnosis. A major reason for this is self-referral, non-radiologists who purchase scanning equipment in order to perform studies without sending a patient to an outside radiology practice. In many cases, the physicians are practicing defensive medicine, but they lack the proper skills to correctly interpret studies.

While these challenges are significant, said Vijay Rao, MD, chair of radiology at Jefferson Medical College at Thomas Jefferson University, there are many strategies at your disposal to reverse these trends.

1. “Take back the night”: Don’t outsource to teleradiology companies, and don’t work for them. Instead, find a way to bring night reads back into your practice.

2. Consolidate: If your practice is too small to handle night reads alone, consider merging with a larger group or multiple groups. This move can also increase your ability to offer subspecialty services. Mega-groups, she said, will likely be very common in the future of radiology.

3. Affiliate: Free-standing practices are vulnerable under the new models of care. Contract with a hospital or a larger multi-specialty group. You could even consider becoming a hospital employee. Any of these decisions would help protect your revenue.

4. Build bridges: Work on your relationships with hospital administration and become more active in hospital management structure and culture. Currently, most of these relationships are strained, Rao said, but you can nurture them by serving on committees, getting involved with quality and safety measures, or participating in strategic planning or marketing efforts. Jumping into the hospital culture will show that radiologists add value.

5. Manage your department: Don’t be afraid to take on more responsibility for your department’s management; Hospital administration is generally amenable to letting you do this, and you could get paid for it. Create financial targets and propose getting a portion of the savings if you meet the goal. The more you show administrators you’re a team player and can help control costs, the less likely you are to lose out to a teleradiology company, she said.

6. Control image utilization, even if it hurts: Do everything you can to make hospital leadership understand the importance of order entry and decision support systems. It might take money out of your pocket, but it’s the right thing to do for patients, Rao said. As with department management, work on an arrangement where your department and the hospital split the cost savings from reduced imaging equally.

7. Spread the word about appropriateness: Radiology hasn’t done a good job at educating primary care providers, residents, and medical students about the American College of Radiology’s Appropriateness Criteria. Publish papers in clinical journals other than those dedicated to radiology.

8. Reach out to primaries: Under health care reform, primary care physicians will play a bigger role in patient care. Improved relationships between these physicians and radiologists could enhance diagnostic abilities and decrease the need for engaging sub-specialists, she said.

9. Fix the image: Not the study you’re reading - the image radiology has in the medical profession. According to Rao, radiologists should focus less on money and lifestyle. It’s no secret that radiologists are well-compensated, and much of the hospital often believes you’re not working hard. Demonstrate the added value you bring and shift away from lifestyle concerns.

10. Make it about quality: Focus like a laser beam on improving your quality metrics and develop a way, such as a dashboard or scorecards, to track them. Then, share the result with the hospital. It’s not possible to monitor and improve the more than 300 quality metrics directly associated with radiology, so pick five or 10, Rao said, and work on those. Patient safety, contrast reactions, universal protocols, and outcomes measurements for procedures could be good places to start.

11. Promote research: Radiology needs more research from private practice. Either conduct your own or support someone else’s, she said. Running studies could help change the industry’s reputation for being a commodity.

12. Be a service line: Many hospitals are now creating and publicizing service lines, and most concentrate on five areas: cancer, cardiology, gastroenterology, orthopedics and neurology. Radiology loses out because its providers work horizontally across all disciplines. Suggest hospital administrators consider radiology to be a service line in your facility, Rao said. After all, diagnostic imaging’s contribution margin to outpatient services is 37 percent.

13. Fight radiation hysteria: Yes, undergoing a diagnostic scan exposes a patient to radiation. But, said David Levin, MD, a radiologist at Thomas Jefferson University Hospital, radiologists must work hard to allay the public’s fears by discussing and publicizing efforts to reduce dose, recording dose parameters, and emphasizing patient safety efforts. Educate your patients that a single CT scan will only increase their existing 25 percent lifetime chance of developing cancer by a miniscule amount.

14. Be a consulting physician: To counteract the existing commodity reputation, Levin recommended you act more like consulting physicians. Screen for the appropriateness of imaging tests, work with referring physicians to cancel or change inappropriate scan orders, and be willing to discuss results with the referring doctor. Consider having a consultant of the day where each radiologist sits in an office one day a week and answers questions.

15. Make room for new jobs: It might mean sacrificing some individual income, but you must make room for younger radiologists to come on board. Unless medical students know that they’ll be able to find jobs after they finish training, fewer will select a radiology residency, Levin said. In fact, according to data from the Association of American Medical Colleges, the number of unfilled radiology residency spots jumped by 53 from 2011 to 2012, leaving 86 positions open nationwide. New physicians could help with consultative services, and they could help you rebuild a night or emergency service.

16. Be proactive about dropping reimbursement: Cuts to Medicare payments aren’t going away, but you can prepare. Many of you are already becoming hospital employees, and the trend seems to only be increasing, Levin said. He suggested free-standing practices seriously consider lowering their charges and encourage nearby hospitals to do so, as well. In an era where payers are steering patients to low-cost providers, reducing charges can prevent a loss of business.

17. Bolster the real doctor reputation: Many health care professionals don’t think of radiologists as real doctors, especially now that almost every specialty is involved in some type of minimally-invasive, image-guided procedure. To counteract this, Levin said, build up your interventional radiology services. Negotiate for space for an IR clinic, including recovery areas, care coordinators, and adequate nursing and physician assistant staffing. And then demonstrate how the clinic will help reduce costs and get patients out of the hospital faster.

18. Lobby against self-referral: Although the federal government doesn’t appear interested in policing self-referrals, Levin said, radiologists could find advocates at the state level and with payers. Work with state legislators to craft bills to crack down on non-radiology providers who self-refer. Payers, such as Independence Blue Cross in Philadelphia, can also adopt policies that deny payment for imaging services not provided in a full-modality imaging center.

19. Talk to the press: Get involved with the news media. You have a responsibility to educate reporters about radiology risks, what radiologists do, the problems with self-referral, and all quality and safety initiatives.

20. Demonstrate added value: Show your hospitals and colleagues that you bring more added value to the facility than do teleradiologists. Highlight what facilities will lose if they farm radiology services out to a teleradiology company.

Even with these threats and the many steps radiologists should take to overcome the problems, Levin said there’s no indication that radiology will be going away.

“The population is aging, and older patients use imaging three to four times more than younger patients. There’s also an increase in the number of insured patients under the Affordable Care Act, and new technologies will continue to be developed as years go on,” he said. “If we continue to put the patients’ interest first, behave like consulting physicians, take back the night, and do everything possible to eliminate unnecessary imaging, radiology will continue to be a well-compensated, exciting profession.”