The Rising Acceptance of Teleradiology

Teleradiology hasn’t always had a good reputation. Historically, pay was low, interpretations frequently came from overseas physicians, quality might be questioned by local radiologists, and onsite physicians were frustrated that the imaging interpreter wasn’t easily accessible to answer questions.

Criticisms of the field continue, with accusations of it devaluing radiology and making radiologists’ work a commodity. However, it’s growing so quickly that some teleradiology companies are turning to recruiters for the first time to fill the need. The field has changed so much so that some say teleradiology is emerging as its own specialty, separate from diagnostic radiology. Add the narrowing salary gap between teleradiology and diagnostic imaging, and it’s a field that’s coming out of its cocoon and spreading its wings.

Demand increased overall for radiologists, in the last year or so. Within the last 15 to 20 months, physician search firm Merritt Hawkins started seeing the first strains on radiologist demand in recent memory, because the radiologist supply wasn’t adequate. “We also saw that with the teleradiology companies, which surprised us,” said Travis Singleton, vice president of Merritt Hawkins, as many of their recent search requests are for teleradiology positions.

Why the Change?
There are a number of reasons why teleradiology is gaining acceptance and increasing in demand: technology, workload, and lifestyle. “The technology wasn’t there in its current form five years ago,” said Singleton. His company started recruiting for teleradiology companies last year and was impressed with the technical set-ups. “I don’t know that some of the more senior radiologists have seen what can be done remotely,” he said.

Another reason for the increased demand and acceptance is that market conditions have changed. For example, emergency department volume has increased over the past few years. While there’s plenty of published research noting this, said Shannon Werb, CIO of Virtual Radiologic Professionals (vRad), his company has also noticed an increased volume in locations they’ve worked with for more than a year. While an individual hospital emergency department might see a few additional studies each night, “at the national scale at vRad, you see a significant uptick on a monthly basis when we aggregate. We see thousands, if not tens of thousands more [studies], year-over-year, in our customer base,” he said. They expect to read 6.5 million studies this year nationally.

That volume means more work for radiologists. In May 2015, vRad’s staff included more than 350 radiologists. Werb said that in 2016, they’ve already hired about 140 additional radiologists.[[{"type":"media","view_mode":"media_crop","fid":"51578","attributes":{"alt":"Teleradiology","class":"media-image media-image-right","id":"media_crop_3247480580527","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6354","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: 133px; width: 199px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"©Kamira/Shutterstock.com","typeof":"foaf:Image"}}]]

Redefining teleradiology’s role is another reason for the growth in teleradiology, Werb said. Ten to 15 years ago, teleradiology serviced night shift emergency room cases. The cases were over-read by staff radiologists the next morning, and both preliminary and final reads were paid. While that model still exists, with 60% of cases still done that way, Werb said that with rapidly shifting reimbursement changes, some carriers are now only paying for final reads. Those would be done by the teleradiology group covering the night shift.

Some local radiology groups are no longer full staffing the hospital, but rather sending any overflow studies to vRad. “We’re part of the group. We’re on the medical staff of the hospital,” he said. As the teleradiologists get “sticky,” clients start sending them more specialized reads during the day. Sometimes, instead of the group hiring another doctor, they shift that work to vRad. Werb said that one practice they work with used to have 20 on-site radiologists. Now they have 12. “We are the other eight,” Werb said. The group provides the on-site work and maintains the hospital relationship, while vRad covers the remaining work from the cloud. “Teleradiology is a fundamental part of any hospital in the United States today. It doesn’t have to be prelims any longer. That definitional change means we’re starting to consume more of the overall volume, because we’re part of the hospital.”

The third reason for teleradiology’s rise is lifestyle. “For years, younger radiologists gravitated toward shift work,” said Singleton. With teleradiology, the physician doesn’t have to move, worktime is flexible and the money is good. “They’re looking for control, especially the younger generation.”

Who is Being Hired?
Newly hired teleradiology physicians are not all Millennials who just finished residency. Some are in their first five years of practice, said Werb, but others are experienced in private practice and are close to retirement age. Of the 140 radiologists vRad hired since January, Werb said they’re all board certified, with an average eight years’ tenure. About 68% are fellowship trained in at least one subspecialty. They recruit out of fellowship as well as private practice. He said that about 75% of work requested of vRad physicians is subspecialty reads, so the company does look for this expertise when hiring, but that’s not all they look for. But even with that emphasis in teleradiology “subspecialists don’t get 100% of their work in that area,” he said.

That said, those seeking a highly specialized caseload might do better in teleradiology than a traditional private practice. “Younger radiologists are coming out of fellowship or dual fellowship and they can’t find that mix of caseload in anything but teleradiology,” said Singleton.

In some ways, teleradiology candidates are easier to recruit than those seeking private practice positions. “For the most part you have to find them and educate them,” Singleton said. Once they interview, qualify, and get hired, they can take the job and not have to move. But it’s harder in that it’s getting more stringent for them to qualify. “You have to be a sharp doctor and test well or you won’t pass their exam,” Singleton said.

Teleradiology companies are having a hard time filling demand. Singleton said that some are now using recruiters when they need to hire full-time teleradiologists, like someone in a certain time zone or subspecialty. “The talent is getting harder to find. It’s not unheard of for us to be [recruiting] 30-50 teleradiologists at once. That didn’t exist years ago,” he said.

What’s Involved with Getting Hired?
Getting a job in teleradiology isn’t necessarily easy, said Singleton. “It’s a lot more difficult to sign on with a reputable teleradiology company than it was five to 10 years ago.” A company may require a candidate or new hire to go through stringent testing and be shadowed by another radiologist. “We have probably a 70% pass rate at best, for candidates,” Singleton said.

At vRad, once the physician signs the contract, they start the credentialing process and begin getting licensed in 10-15 states, where they’re probably currently licensed only in one or two. It can take six to seven months for a physician to be fully licensed and credentialed. “We build a plan for onboarding any given doctor,” he said. That includes the number of state licenses and a certain number of hospital privileges, often 100-200. Currently vRad physicians have privileges at 2,200 facilities. They’re scheduled based on shift, subspecialty, licensure/credentialing, and other factors. At any given time, vRad is coordinating 8,000-10,000 new or renewed applications for hospital privileges.

Teleradiologists get a corporate-provided workstation and training. Physicians are part of a radiology advisor program for at least six months; they’re paired with a tenured teleradiologist. The company built training cases into their platform, and they review the new hire’s work style, report quality, and anything missed in the study. “Reading teleradiology is very different than on-site,” Werb said. The majority of the cases are over-read the next day by the facilities, which provides active feedback. Quality assurance issues come through the portal, integrated in the platform, and scored and reviewed by leadership. It’s then sent back to the physician. They use this to ensure high quality and adequate training.

Show Me the Money
Proof of teleradiology’s rise and acceptance can be seen in the narrowing gap between average salaries of teleradiologists and those in traditional practice. Merritt Hawkins’ 2016 salary and incentives survey showed that the pay gap between teleradiologists and those working for traditional employers, were only $75,000 apart, where they used to be hundreds of thousands of dollars apart, said Singleton. The survey showed an average radiology salary of $475,000, versus $400,000 for teleradiologists. While a $75,000 pay gap may seem like a lot, Singleton said, teleradiologists work from home, and don’t have to participate in committee meetings or other administrative work that can eat up work time.

Teleradiology continues to be productivity-based payment, not salary-based, and caps out at lower levels than traditional jobs. “It used to be that if you could land a teleradiology job, your salary was next to nothing. You made it all on ‘you eat what you kill.’ It wasn’t anything like the guaranteed living the hospitals would give radiologists,” Singleton said.

Now, teleradiology income is average to above average, if comparing full-time work. The pay difference is more pronounced at higher levels. “You can probably make more as a traditional onsite radiologist, especially if you are in the upper echelons,” he said. “You aren’t going to see that in teleradiology.” The Merritt Hawkins survey showed a high of $750,000 for traditional radiologists’ salaries, versus $550,000 for teleradiology.

While Werb declined to share average salaries of vRad teleradiologists, he said he thought the Merritt Hawkins survey was good. Teleradiology compensation is still ‘eat what you kill,’ also known as productivity-based income. “Our physicians are compensated appropriately relative to the work, effort and time they put in and what full-time positions onsite might look like,” Werb said. There’s a balance between lifestyle and compensation that physicians are looking for, he said. The vRad teleradiology schedule is predominantly seven days on, seven days off. In the off time, “some want to do on-site work. Perhaps they want to use that time to focus on their personal lives.”

One condition that traditionally causes physicians to think twice about moving into radiology is the lack of guaranteed income. “A lot of radiologists were scared of that aspect,” said Singleton. As the market tightens, some teleradiology companies have guaranteed some income just to get radiologists in the door for a few years, said Singleton. After that, the physician will know there’s enough work to keep up their income, since these aren’t salaried positions.

Changing Attitudes
While Werb knows there are radiologists with negative attitudes toward teleradiology, he said the attitude is often politically charged or not well informed. “We do business with about 40% of provider locations that produce imaging,” he said. “That’s close to 1,000 radiology practices. It’s not a relationship built out of animosity – we’re a partner.”

His recruiting firm is not currently working in the teleradiology market, but Brian Nichols, regional vice president of recruiting for The Medicus Firm said he’s heard health care facilities complain that now that teleradiology has been fully embraced, they don’t have the patient interactions and physician-to-physician interactions of the past. One of his client hospitals, which contracted with a small, independent radiology group, raved about having radiologists available to meet with physicians, do monthly follow-up about cases, and have more team interaction.

Is teleradiology as good as having someone on site? You can debate that, said Singleton, but there’s no doubt of its growing popularity. “It’s growing like gangbusters. Hospitals are contracting more and more with these third parties,” he said. “It’s no longer just night call, but a service for all imaging. I can’t imagine it’s happening at this scale if it’s not a good product.”

By virtue of being in the cloud, teleradiology can’t compete with the interpersonal aspect of having a radiologist available in person. But having a mixed practice, like the one Werb mentioned with 12 on-site radiologists and eight teleradiologists in the cloud, might be where the future is headed.