Teleradiology: For or Against?

Radiology professionals seem to be split down the middle about whether teleradiology services are good or bad for the field.

At least, according to the attendees of the Economics of Diagnostic Imaging event in October 2013, where 47% of the 120 attendees said they were outsourcing their night call; which is down from 50% the year before. Of the 53 percent who didn’t currently outsource night call,  only 3% planned to do so at some point.

Event organizers have polled their attendees – mostly radiologists and executives from radiology practices and hospitals – for the past three years. This is the first time that between 25% and 30% said that they were either seriously considering or were in the process of bringing overnight call back into their practice.

Teleradiology is Struggling
What do these numbers mean? To Larry Muroff, MD, CEO and president of Imaging Consultants in Tampa, FL, it points to a shrinking market for teleradiology services. Does that mean that teleradiology is no longer capable of causing change – and perhaps some sleepless nights – within the radiology space? Far from it.

One of the realities faced by large teleradiology firms – which Muroff prefers to call national entrepreneurial radiology companies – is that many of these companies are now privately held by venture capital firms, which typically expect a return on their investment within five years.

“Teleradiology company leaders can tell their venture capital funders that their radiologists are qualified and have great relationships with their customers, but the reality is the pressure is on vRad and all of these privately-held teleradiology companies to be profitable – and many are choosing to pursue contracts directly with hospitals,” Muroff said. He adds that there is added pressure on smaller groups to grow larger or to affiliate with other groups to provide around-the-clock coverage.

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If Ben Strong, chief medical officer at Eden Prairie, MN-based vRad looks back 10 years, many of the larger radiology practices that wanted to work with his company were looking for convenience: they wanted to allow their radiologists to take nights and vacations off. Smaller practices just didn’t have access to the subspecialty expertise his radiologists could provide around the clock.

Fast forward to today when vRad, which describes itself as a global telemedicine company and the nation’s largest radiology practice with over 450 physicians, is still holding on to contracts with these radiology practices, which are facing increased cost pressures.

Strong attributes vRad’s success to its technology platform that routes the right cases to the right radiologists at the right time. This keeps the company’s radiologists busy all night – in a way that no local or regional group can do Strong said.

The impact has been the reduction in cost per study to vRad and, by extension, to the practices and other healthcare organizations it serves. 

An “Assembly Line” for Radiologists
The typical teleradiology workflow is “an assembly line where radiologists are forced to read cases really fast because their per-unit reimbursement is so low. One after the other. The faster you read, the lower the quality,” said David Levin, MD, professor and chairman emeritus of the department of radiology at Jefferson Medical College and Thomas Jefferson University Hospital in Philadelphia, PA.“You make mistakes, and you’re not as interested in reading about the clinical circumstances.”

While he values the technology that allows radiologists to do their work from their office or their home, Levin said that teleradiology companies that are charging $25 to $35 for interpreting an MRI are devaluing the work that radiologists do. He acknowledges that teleradiology has an important role to play as a complementary service, in particular for the small radiology groups that contract with teleradiology companies for subspecialty reads and night and vacation coverage.

“When you have radiologist ‘boots on the ground,’ who are available for interventional procedures, they can do biopsies, drainage or replace a tube or do an angiogram,” Levin said. He also values the expertise on-site radiologists provide in determining the appropriateness of a particular imaging exam and the relationships those radiologists can build with referring physicians as they consult on patient cases.

Concerned that teleradiology companies are rapidly commoditizing the services provided by radiologists, Levin suggests that radiologists – particularly those at medium- to-large practices – work one or two weeks of nights each year, and that their practices take back night call coverage from teleradiology companies. “[Doing two weeks of nights a year is] not going to interfere with anyone’s lifestyle. Trauma surgeons and primary care physicians are always working nights and weekends, and radiologists should become more comfortable doing so as well,” Levin said.

Then there’s the focus on the output of the radiologist’s labors: Namely, the radiology report, said Ezequiel Silva, MD, a practicing radiologist at South Texas Radiology Group in San Antonio, TX. “The focus on the report is the real threat to the practice of radiology, and that can lead to commoditization.”

“I think that we, in radiology, have basically created this phenomenon,” Silva said. “Younger people in a hot job market didn’t want to work at a practice that had night call. Since then, the job market has become much tighter. Younger radiologists are willing to do virtually anything to get a job. We are basically paying the price now for our decisions that were based on quality of life over dedication to providing night call coverage within the practice.”

Continuing Controversy?
Teleradiology is not expected to go away, and might even grow, or at least change, in the next few years. Licensing and credentialing for radiologists at teleradiology companies who provide interpretation services across the country is both expensive and cumbersome. Elizabeth Krupinski, PhD, professor and vice chair of research in the department of medical imaging at the University of Arizona, is encouraged by the Federation of State Medical Boards’ (FSMB) release in September of a drafted interstate medical licensure compact. The drafted compact – which still needs to be approved by seven states and would be voluntary – would provide physicians with an expedited process for licensure in a state other than the one where they live.

Krupinski realizes there’s a lot of hard work ahead in terms of realizing the goals of the FSMB’s compact. Still, she’s optimistic, having observed that the FSMB and the American Medical Association have demonstrated more favorable attitudes regarding cross-state licensure over the last couple of years.

While Strong admits that he was once “grateful for the burden” of licensing and credentialing for each of vRad's radiologists, he’s now in favor of a “future interstate agreement that would be strict” and may make it easier for his company, which maintains more than 8,000 state licenses for its radiologists.

Encouraging radiologists to think more like business people, Muroff said that radiologists need to understand that large, aggressive teleradiology companies constitute the most disruptive force to the conventional practice of radiology. “You can argue that that’s for the good or the bad. If you don’t think it’s a disruptive force, then your head is in the sand.”

Still, Muroff is not entirely sure that large teleradiology companies will continue to exist, at least as they are currently organized. “One of the major national companies is in trouble, and had funding pulled by its investors. This may happen to other companies as the job market turns, as more radiologists and fellows are able to pick and choose the positions that are more to their traditional liking,” he said.