Berger urges imagers to be stewards of radiology

Dr. Paul E. Berger, founder and former board chair of NightHawk Radiology, a $168 million teleradiology firm, is advising fellow radiologists to again emphasize their role as stewards of medical imaging to guard against the teleradiology revolution he helped foment.

Teleradiology works for and against radiology, Berger told an audience of about 300 radiologists and imaging administrators at the 2009 California Radiological Society meeting on Oct. 24. It can improve quality, foster subspecialization, and provide more timely service. But it can also narrow the radiologist's role and destroy his or her valued position in medical practice.

“If we think of ourselves as just film readers, then the specialty risks becoming commoditized,” he said. The resulting generic flavoring of radiology would likely reduce the demand, status, and compensation for board-certified radiologists.

Berger cut all formal ties with NightHawk in November 2008. In his resignation letter, he wrote that he could no longer support the company's direction, policies, and business strategies. In line with teleradiology industry trends, NightHawk expanded from off-hours remote preliminary image interpretation to daytime reading services that could compete against group radiology practices.

But the ability of teleradiology to break down geographic barriers that protect local radiology groups from national competition only partially explains why the value of radiology may fall, he told the CRS audience. Other factors include:

• hospital closures;

• healthcare globalization, with competition coming from India and elsewhere;

• disaggregation of radiology, with subspecialists joining neurovascular or other multispecialty services devoted to specific organ systems or diseases;

• greater efficiency within radiology from PACS and other productivity-enhancing tools;

• declining imaging volumes due to utilization management and appropriateness criteria enforcement; and

• Economic pressure encouraging older radiologists to delay retirement or reenter the workforce.

High-quality medical practice should be at the core of radiology's defense against these trends, Berger said. Metrics that quantify superior performance are needed. Radiologists need good data to prove that they read scans better than medical specialists who are infiltrating the imaging field.

“We've got to have quality metrics to show what sets us apart,” he said.

A return to the specialty's traditional consultative role would also strengthen radiologists' position. PACS has short-circuited the social networks that once bonded radiologists with other medical specialists. Berger proposed that new informatics technology and a commitment to performing face-to-face consultations can rebuild those connections.

The traditional financial compensation model that group practices use to treat all partners as equals should be modified, according to Berger. Beyond a base salary and benefits, a productivity component should be added to the formula. Radiologists who score well on measures of quality deserve a bonus, along with partners and associates who make intangible contributions to the financial health and security of the practice, he said.

“Some partners may be terrific clinical consultants. Others may work especially well with hospital administrators. Dealing with radiation safety and appropriateness of scans should also be rewarded,” he said.

Teaming with hospitals to help them deal with their daunting financial problems will also help radiology's cause, he said. Berger noted that even in good times, the best acute care hospitals have operating margins in the modest 2.6% range. They tend to have huge financial problems during hard economic times because of chronic operating losses. Many have been ravaged since last year's collapse of the nonprofit bond markets. Philanthropic contributions to nonprofit hospitals have fallen steeply.

“We need to be economically aligned with our hospitals. We need to help them in a quality and productivity sense,” he said. “If we get radiologists and hospitals pulling in the same direction, it is going to be a better world for patients, for hospitals, and for us.”

Radiologists can advance the interests of their hospitals. They should “talk the talk” of imaging appropriateness to mitigate wasteful ordering patterns. Productivity improvement should contribute to their profitability.

“Thirty percent of utilization may not be called for. Let's reduce that to 10%,” Berger said.

Radiologists can serve as patient advocates by focusing on radiation safety and quality assurance. Optimal imaging practices can reduce hospital lengths of stays, he said.

Such efforts may mean that radiologists earn less by recommending against unnecessary imaging, but they can strengthen their job security. Radiologists can be mission-critical, according to Berger.

“We are a huge economic aspect of the hospital going forward,” he said. “We can play a major role in the improvement of that system.”