If You Had to Reinvent the Wheel

A friend of mine from med school who went into primary care was recently asking me about the organizational aspects of work in the radiology biz. Specifically telerad, since he knows that’s what I’ve been doing for the past few years.

One of the items of interest to him was the difference in philosophy when it came to compensation for rads doing the work. Neither he nor I had encountered any sizable teleradiology groups that deviated much from the “eat what you kill” method. That is, a rad’s pay is the direct result of how many studies (or derivative “work units,” RVUs, etc.) s/he reads. A rad doing twice the work of another thus gets double the reward.

Most folks in our field know the usual arguments for and against this way of doing things, and if anybody doesn’t, there’s been more than a bit written on the subject (including some older entries of this blog). I, myself, am not in 100% agreement with a pure productivity scheme, just as I did not, when living under a salaried “honor system” that rads would each put forth their best effort as a team, find that it created Utopia.

Perhaps sensing this, my med school pal asked how, given a free hand to create my ideal system, I would structure things. Assuming that I didn’t happen to have handy a roster of ready-to-hire brilliant rads who would each put in 100% all day, every day, as opposed to being motivated by compensation like the rest of humanity. (I don’t, lest ye wonder.)

I didn’t have any quick answers for him, as is often the case with worthwhile questions. I knew I liked the “eat what you kill” approach’s effect on radiologist work ethics…and its tendency to keep would-be slackers away. None need fear (or scheme) that some might become “more equal than others” when drinking from the compensation trough.[[{"type":"media","view_mode":"media_crop","fid":"40854","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6182966873731","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4236","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 136px; width: 199px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Ken Cook/Shutterstock.com","typeof":"foaf:Image"}}]]

On the other hand, understandable concerns about conflict of interest do exist, when rads have every incentive to plow through cases faster and faster with nothing to slow them down other than (one hopes) a desire to do quality work, or at least a reluctance to get sued over something they might not have missed if they were reading 15 cases per hour instead of 20.

Further, not all cases are created equal, and not all referrers might want them to be treated as such. Suppose a client comes along who intends to send mostly cancer-restaging scans, or exclusively second opinion cases (legal, QA, or simply instances where the local radiologists are looking for subspecialist input)…might that client want its cases to receive more of a rad’s time?

Finally, when you’re breaking things down in a per case system, you start having to bean-count. Which client sent how many cases, what’s this rad’s MRI proportion versus that one’s ultrasound, etc. You start needing software and personnel to count and analyze all those beans. And, while this might generate some good statistical data for you to use in various ways, it will also generate errors. Even when it doesn’t, it will generate perceived or alleged errors, and then you’re dealing with blemished goodwill, while having to allocate more resources to investigate each instance.

So I found myself imagining a hybrid approach. The “eat what you kill” approach would predominate, since clearly it’s done well in most of the telerad world and most of the workload (and self-selecting workforce) seems suited to it. And, for the rads happy with that, it would be all they ever need experience.

But there would be another subsection of the practice…one that treated the radiologists involved like professionals (shocker, I know). Yes, just like lawyers and accountants who have hourly rates and somehow manage to conduct their affairs without outsiders trying to condemn them for being “fee for service” harlots.

Clients wanting rads reading their cases outside of the per case paradigm would negotiate with the telerad group to arrive at an hourly rate they were willing to pay for the service. While reading a case for one of these clients, a rad’s time would be clocked by software to ultimately determine how much time got billed for that rad’s reading. To be worth the group’s and reading rads’ while, the hourly rate would have to work out to be higher than whatever average hourly revenue the rads were generating with the “eat what you kill” cases…but low enough that it remained competitive to retain the client.

Not just any rad would be eligible to read for one of these clients. The telerad group would want to have a decent stretch of time working with a prospective hourly-rate rad to ensure he boasted better-than-average accuracy, “played well with others” (picked up the phone for clinicians, etc.), and had previously demonstrated productivity in the “eat what you kill” world. After all, if Dr. X was a radiological wizard but only read a case or two per hour, clients might not be wowed with the service. Similarly, if Dr. Y had previously read 15 cases per hour under “eat what you kill” and, now as part of the new service, slowed to 4-5 cases, his participation might have to be reconsidered.

Are there massive things I’ve overlooked with this? Doubtlessly. Fatal flaws? Maybe, but I’m optimistic that, as with any new venture (which telerad itself was, not all that long ago), a willingness to adapt one’s approach in the face of unforeseen obstacles would grant great resiliency to the enterprise. So, if any venture capitalists are out there…c’mon! Throw me a couple billion and let’s see if this thing could fly.