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Changing Relationships between Radiologists and Hospitals

Part I. Background and Major Issues¹

¹ From the Department of Radiology, Massachusetts General Hospital, Harvard Medical School, 14 Fruit St, MZ-FND 216, Box 9657, Boston, MA 02114. Received August 16, 2007; final version accepted August 28. Address correspondence to the author (e-mail: jthrall{at}partners.org).

As a specialty, radiology has prospered from its close relationship with hospitals, which have typically underwritten substantial capital costs for equipment and facilities and have supplied a steady stream of patients requiring diagnostic imaging and interventional procedures. Likewise, hospitals have benefited from having close associations with radiologists who have generally taken comprehensive responsibility for providing imaging services in exchange for some level of exclusivity or "franchise." Under the historic, often informal, franchise concept, radiologists have taken the good and the challenging alike as their responsibility—covering the emergency department, providing venous access services, and dealing with time-consuming complex cases, among other issues—in exchange for benefits to the overall practice.

Radiology groups are now losing substantial components of their favored status as franchise holders owing to a variety of factors, including the loss of turf to other providers and the shift in the protocol for care delivery from a predominantly hospital-based inpatient focus to an increasingly outpatient focus. At the same time, the needs and expectations of hospitals for better quality and more timely delivery of imaging services are steadily increasing, so radiologists are being asked to do more—for example, provide real-time 24-hours-per-day, 7-days-per-week (ie, 24-7) coverage—with less exclusivity and less practice security. The progressive erosion of the franchise model is threatening the historic symbiotic relationship between hospitals and radiologists and is reshaping the way imaging services will be provided in the future.

	MAJOR ISSUES FACING RADIOLOGISTS AND HOSPITALS

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
The five most important issues that are causing the reshaping of relationships between radiologists and hospitals are (a) the granting of privileges to nonradiologists to perform imaging services, (b) the substantial shift from an inpatient to an outpatient location as the dominant site of care delivery, (c) the expectation of hospitals that radiologists will meet increasingly stringent service and quality standards, (d) the requirements of hospitals for more coverage—especially 24-7 emergency coverage, and (e) the perceived need for more specialization among radiologists.

	RADIOLOGY PRACTICE MODELS AND VENUES

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
How important is the hospital as a location for radiology practice? According to the findings of a 1999 survey of radiology practices conducted by Cypel and Sunshine (1), more than 90% of multiradiologist practices, as well as just over 50% of solo practitioners, served hospitals. Multiradiologist practices substantially outnumber solo practices, and the data indicate that a majority of radiologists practice at least part time in hospitals. Moreover, 36% of multiradiologist practices reported serving hospitals only (1). The survey data establish that radiology is a strongly hospital-based discipline, and, therefore, relationships between radiologists and their affiliated hospitals are highly important to the specialty. Of the 532 multiradiologist practices responding to the Cypel and Sunshine survey (1), 83.0% characterized themselves as private radiology groups, 6.5% characterized themselves as academic groups, and 7.0% characterized themselves as part of a private multispecialty practice. The fact that the academic groups responding to the survey tended to be substantially larger than the other multiradiologist groups is related to the generally larger average size of teaching hospitals versus all hospitals.

The majority of private groups report owning their practices in entirety (1), while academic and multispecialty groups are often owned by entities that are not controlled directly by the radiologists, such as professional corporations, university faculty practice programs, or hospitals. Radiologists in private groups are typically partners in the group, while academic radiologists and those who work in federal institutions are typically salaried employees. The differences in practice models are important when considering the issues that are now arising between radiologists and hospitals and the kinds of risks facing radiologists. However, the number of permutations in both the types of hospital governance and business structures and the types of radiology practice models makes it impossible to consider them all in detail.

	PRIVILEGES GRANTED TO NONRADIOLOGISTS FOR IMAGING SERVICES

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
Hospitals of every stripe are under intense pressure from nonradiologist physicians to grant them privileges to perform imaging services. The pressure comes in multiple forms. Specialists in vascular surgery and neurosurgery, among others, have recognized that their practices have changed because of imaging methods. The treatment of intracranial and peripheral aneurysms was once entirely surgical. These aneurysms are now frequently treated with image-guided percutaneous interventions. Vascular surgeons and neurosurgeons have obtained training to perform image-guided intravascular interventions to recapture business and reassert control of these areas of practice. The boundaries between specialties have always been fluid and ill defined, and some might argue that nonradiologists are simply trying to recapture ground lost to radiology during the past 2 decades.

Although many physicians in other specialties who are seeking privileges from hospitals to perform imaging-based examinations and treatments are undertrained according to radiology standards, hospital administrators often feel compelled to grant them privileges for competitive reasons, especially in cases where the physician may have staff appointments at multiple institutions. A cardiologist or surgeon may "shop" between institutions and take his or her patients to the hospital that is most amenable to granting privileges for the desired procedures.

The use of interventional catheter-based diagnostic and therapeutic procedures such as peripheral angioplasty and stent placement has sharply increased as physicians outside of radiology have adopted them. With regard to Medicare patients, Levin et al (2) presented data showing that the rate of growth in the performance of peripheral vascular interventions by cardiologists (181%) and vascular surgeons (398%) from 1997 to 2002 greatly exceeded the rate of increase in the performance of these procedures by radiologists (29%).

The triple-digit percentage growth in the volume of stent placements and angioplasties performed by nonradiologists is eye catching and raises the troubling question of whether the control of both patient treatment and referral for procedures by the same physician promotes unwarranted use. The net effect of increased use, whether appropriate or not, has been greater scrutiny of imaging by payers. The passage of the Deficit Reduction Act of 2005, which savagely reduced reimbursements for outpatient high-technology imaging, may well have been influenced by the perception of runaway growth in imaging costs. Thus, changes in turf may expose all providers to adverse downstream effects if they result in overuse.

Radiologists simply have not been able to meet the demand for some imaging procedures, and other physicians have used this shortage as a convenient rationale for obtaining privileges. The ubiquitous use of bedside ultrasonography (US) in the delivery suite, examination room, emergency department, and operating room has made it virtually impossible for radiology groups to reasonably provide coverage under all of these circumstances. Thus, this imaging modality is now widely practiced by nonradiologists in hospital as well as outpatient settings. Other examples of lost turf abound for diagnostic studies and therapeutic interventions and are influencing every part of the radiology practice.

In academic settings, the need for trainee education in imaging methods is a commonly used lever to obtain privileges. A department or service declares to the institutional leadership that it will no longer be competitive in recruiting residents or fellows unless the faculty can receive privileges and train the house staff in imaging-based methods. While this may be true, these forays for new privileges—couched as educational needs—often precede changes in the formal training requirements defined by the Accreditation Council on Graduate Medical Education (3), making the consideration for changes in privileges less objective and more political than desirable.

For academic radiology departments that lose turf, the flip side of the training gambit is greater difficulty in providing enough case material for their residents and fellows to meet the usually long-standing and clear-cut Accreditation Council on Graduate Medical Education program requirements. Even if the newly privileged specialty agrees to provide training to the radiology house staff, the increased total number of trainees can exceed the amount of case material available in a given institution.

When Massachusetts General Hospital established a vascular center 3 years ago and granted privileges to cardiologists and vascular surgeons to perform peripheral vascular interventions, internal referrals to the radiology department for these procedures decreased dramatically while the total number of fellows from the different departments requiring training each year more than doubled. Fortunately, we were able to establish an affiliation with a very busy nearby hospital, where our fellows have been able to access a more than sufficient amount of case material to meet their needs as we rebuilt our practice through new referral sources and new marketing strategies.

Whatever the reason or justification for the surge in interest in performing imaging procedures among nonradiologists and the granting of privileges to them by hospitals, the net effect has been a substantial loss of turf and a loss of exclusivity on the part of radiologists. The turf losses are asymmetric in that they invariably involve attractive well-paying work without other similarly characterized new work to offset it. Lost turf never seems to result in fewer responsibilities to oversee technical operations, technologist training and management, protocol preparation, or participation in technical compliance issues or in a cease of having to provide emergency or off-hours coverage—even for the involved procedures.

Radiology groups looking to their affiliated hospitals for support in turf battles or for relief in making up for financial losses generally have not found it, and the long-term consequences of losing turf are not yet completely understood. These consequences involve practice economics, scope of practice, teaching, quality of care, and quality of work life—all-important determinants of the health of radiology practices.

	SHIFT TO OUTPATIENT CARE

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
The increase in outpatient services, including high-technology imaging, has accelerated during the past 2 decades and has required hospitals and radiologists to reorient their thinking. When I joined the Massachusetts General Hospital radiology department in 1988, approximately 60% of the 360 000 examinations performed each year were for inpatients, and 40% were for outpatients. Today, the percentages have largely reversed, with 64% of the 600 000 annual examinations performed in outpatients and 36% performed in inpatients.

Hospitals have been slow to respond to the outpatient trend, and a number of factors need to be better addressed. The use of shared facilities for inpatient and outpatient services remains common but has become progressively less satisfactory and less competitive. Relatively well outpatients do not want to experience the inconvenience of having to travel long distances to crowded hospital campuses with limited parking and then probably wait beyond their appointment times while emergencies are accommodated. Moreover, while many hospitals have built or expanded dedicated outpatient facilities, these centers are often right next to the hospital and thus are only a partial aspect of what patients want—good service and quality close to home in a convenient setting.

A related problem that weighs heavily on radiologists is the impossibility of simultaneously optimizing service and economic return for inpatients and outpatients in a single shared facility. The key service issue for inpatients is the turnaround time from study request to study completion. Fast turnaround shortens lengths of stay and improves stakeholder (patients, nurses, and referring physicians) satisfaction. Given the unpredictable demand for inpatient services, some slack in the schedule is needed to guarantee a timely response. Rapid turnaround supports a good return on the investment for inpatient imaging facilities: Individual procedures are not reimbursed for most inpatients within the prospective payment system, and the financial return comes from facilitating the overall care process rather than maximizing procedure volume.

For outpatient services paid for with fee-for-service reimbursement, the return on investment hinges directly on the total procedure volume. Slack in the schedule hurts productivity and is less necessary than it is for inpatients because studies are scheduled electively and there is less variation in the duration of examinations for outpatients compared with that for variably sick inpatients. Schedules simply cannot be optimized for both types of patients. Radiologists bear the brunt of trying to juggle between competing goals on behalf of their institutions when a hospital imaging unit is shared for inpatients and outpatients. They run the risk of being criticized for leaning too far in one direction or the other.

In many instances, contracts or organizational governance structures restrict radiology practices—both private and academic—from establishing their own outpatient centers and competing for outpatient business. In these situations, the radiology practice is subordinate and in some sense held "hostage" by the interests and prerogatives of the host institution and the visions and insights of institutional leaders and administrators.

The slow response of hospitals to fully adjust to the shift to outpatient care, including restrictions placed on radiologists (discussed earlier), has left a vacuum for outpatient imaging services that is being energetically filled by physician and nonphysician entrepreneurs. Many radiologists are being locked out of sharing ownership of outpatient facilities because of the terms of their hospital relationships. Ironically, many of the physicians providing imaging services in nonhospital outpatient settings have appointments at the same hospitals as radiologists, but they are not hospital based and thus not constrained by contract provisions or the other limitations that radiologists face.

Radiologists risk losing out several fold—first by not being able to independently pursue outpatient work apart from whatever services the hospital may or may not offer and also when their attending physician colleagues bring them difficult or perplexing cases to review. These encounters often start with an "are you busy" as the nonradiologist staff colleague presents the radiologist with a series of studies obtained in his or her office for consultation, with no reimbursement. Radiologists may also lose out by not being able to blend relatively simpler outpatient work with more complex and time-consuming inpatient work.

Radiologists also risk losing out in situations where someone else controls the professional reimbursement and seeks to "arbitrage" the radiology professional fee by offering the radiologist a discounted amount to interpret examination results. Periodically, legislation is introduced in Congress to prevent such arbitrage for Medicare patient care by prohibiting anyone from billing the Centers for Medicare and Medicaid Services for more than what it cost them to deliver the professional service.

For reasons that are difficult to fathom, a large segment of the hospital industry has not awakened to the needs or interests of hospital-based radiologists to expand outpatient services; rather, it has expected these radiologists to wait for the institution to take such an initiative. The old axiom of "lead, follow, or get out of the way" is being honored in the breach.

	QUALITY AND SERVICE

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
As acute care medicine has become more dependent on information from imaging studies to make prompt accurate diagnoses and to guide therapy, the expectations of stakeholders who consume and oversee imaging services—referring physicians, patients, and hospital leaders—have increased with respect to service and quality. Turnaround time, from study completion to availability of the final report, is a key metric that speaks to both quality and service and is an exemplar for these increasing expectations. Hospitals are pushing for better performance to facilitate overall patient throughput and to meet the expectations of referring physicians and patients for prompt service.

The Massachusetts General Physicians Organization recently instituted an internal pay-for-performance program aimed at improving quality and service. Report turnaround time was the metric chosen first for radiology on the basis of discussions between physician leaders within and outside of the department. Modern radiology information systems allow each step in the reporting process to be measured on a radiologist-by-radiologist basis and overall for the department.

A closely related issue is how radiologists communicate their findings. In the past, radiologists had great latitude in the form of report they could generate—structured versus unstructured—and in determining whether special direct communication was required. Today, the Joint Commission and other organizations are stipulating the circumstances for different levels of communication, and radiologists will be audited to establish whether they have complied. The trends in turnaround time reduction and the tightening of reporting structures and communications are clearly beneficial in achieving better outcomes of care, but they place a greater burden on radiologists, with no additional compensation.

Radiologists are not alone in facing a new level of scrutiny or in needing to comply with increasingly specific practice standards. However, the new imperatives from the Joint Commission and other groups bear disproportionately on inpatient care, where compliance is a condition of accreditation, and hospital-based physicians, including radiologists, likewise bear a disproportionate burden as de facto partners of their host institutions. These challenges highlight the desirability of a balanced practice where less intensive outpatient work is balanced with intensive inpatient work that is further encumbered with new layers of oversight.

	COVERAGE

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
Hospital-based radiologists are facing the consequences of their remarkable success in applying advanced imaging methods to the care of patients seen in emergency departments. Computed tomography (CT), magnetic resonance imaging, and US are heavily used in the emergency setting, with transformational effects. Exploratory surgery is a thing of the past, and patients can have definitive therapy initiated promptly for many conditions, without extended periods of observation to allow clinical signs and symptoms to become more apparent.

In the pre-CT and pre-US era, during night hours, radiologists could often count on their colleagues in the emergency department to review conventional radiographic studies aimed largely at detecting pneumonias and fractures. The radiologist would perform a final interpretation the next morning. Life was good. Most emergency physicians are not trained to interpret cross-sectional studies, and radiologists are now faced with the need to provide 24-7 coverage. Hospital administrators expect such coverage, and it is hard to argue otherwise from a quality-of-care point of view. However, providing night coverage is expensive and is especially challenging for smaller groups. Imaging coverage demands for nonemergent care are also increasing, with the need for access to these procedures on evenings and weekends for the convenience of patients and to facilitate same-day surgery.

Commercial and private teleradiology services have been established (4) to meet the needs for 24-7 coverage. With this approach, a hospital or radiology group contracts with an outside provider entity that performs a preliminary or final interpretation of overnight examination results. Financial arrangements are variable, but in most cases, the radiology practice either foots the entire expense or shares it with the host institution.

While radiologists recognize the need for 24-7 coverage, it can be hard to swallow in situations where a hospital has just granted privileges to nonradiologists to perform imaging examinations or image-guided interventions. Somehow the zeal to deliver services attenuates as the short hand of the clock circles around from day to night. Moreover, with the loss of the franchise concept for radiology practice, there may be fewer financial offsets to make up for the added expense associated with night coverage.

	SUBSPECIALTY PRACTICE

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
The trend in medical practice toward more specialization is especially acute in radiology. The number of imaging methods applicable for use in each organ system has increased, and the overall complexity and sophistication of radiology practice have skyrocketed. These factors have prompted an increase in the number of radiologists undergoing fellowship training. Academic and larger private practice groups are now highly subspecialized.

Problems arise in practice settings where specialists from other disciplines expect specialty-level expertise from radiologists and it is not available. Smaller groups are coming under pressure from their colleagues—and, in turn, from their affiliated hospitals—to provide specialty-level expertise through either recruitment or teleradiology. In smaller practice settings, there simply may not be enough work in the various subspecialty areas to justify recruiting a different person for each one. Yet the pressure remains since the need for access to expertise is driven by the needs of individual patients and not the nature or size of the radiology practice.

Some observers believe that the general practice of radiology is no longer tenable in the era of specialized medical practice. General-practice radiology groups may be able to meet the challenge of subspecialization by accessing subspecialty interpretations in selected cases through teleradiology providers. However, they risk creating a threat to their practices if the referring physicians perceive that a greater value is available from the outside sources than from the onsite group.

	CONCLUSION

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 
Radiologists and hospitals are closely linked by their mutual interests and still need each other despite the tensions facing them. To maintain the goodwill and synergy that have characterized the relationships between radiologists and hospitals for many years, both groups need to step back and review the directions they are taking to determine whether there are practice models that can meet their respective needs while acknowledging that the parameters of these models will likely be substantially different from those in the past.

Can hospitals provide radiologists with what they want—reasonable practice security, equitable opportunities to provide service, and flexibility to grow their practices—while achieving their own objectives of delivering better service to patients and other stakeholders, achieving reasonable financial returns, and accommodating nonradiologists who request privileges to perform imaging? Can radiologists meet heightened expectations for quality and service while sustaining setbacks in job security, scope of practice, and reimbursement per unit effort? It is worth the time and effort of both sides—radiologists and hospitals—to explore and resolve these questions.

	FOOTNOTES

 
Author stated no financial relationship to disclose.

	References

TOP INTRODUCTION MAJOR ISSUES FACING RADIOLOGISTS... RADIOLOGY PRACTICE MODELS AND... PRIVILEGES GRANTED TO... SHIFT TO OUTPATIENT CARE QUALITY AND SERVICE COVERAGE SUBSPECIALTY PRACTICE CONCLUSION References

 

1. Cypel YS, Sunshine JH. Basic characteristics of radiology practices: results from the American College of Radiology's 1999 survey. AJR Am J Roentgenol 2003;181:341–349. [Abstract/Free Full Text]
2. Levin DC, Rao VM, Parker L, Bonn J, Maitino AJ, Sunshine JH. The changing roles of radiologists, cardiologists, and vascular surgeons in percutaneous peripheral arterial interventions during a recent five-year period. J Am Coll Radiol 2005;2:39–42. [CrossRef][Medline]
3. Accreditation Council on Graduate Medical Education. Policies and procedures. ACGME Web site. http://www.acgme.org/acWebsite/home/home.asp. Accessed August 15, 2007.
4. Thrall JH. Teleradiology. II. Limitations, risks, and opportunities. Radiology 2007;244:325–328.

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				J. H. Thrall Changing Relationships between Radiologists and Hospitals * Part II. Contracts and Resolution of Issues Radiology, February 1, 2008; 246(2): 343 - 347. [Full Text] [PDF]

This Article Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Thrall, J. H. Search for Related Content PubMed PubMed Citation Articles by Thrall, J. H.