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Opinion |
1 From the Department of Radiology, University of Colorado at Denver and Health Sciences Center, 12401 E 17th Ave, Aurora, CO 80045. From the 2007 RSNA Annual Meeting. Received December 19, 2007; accepted January 7, 2008; final version accepted January 10. Address correspondence to the author (e-mail: borgrad{at}msn.com).
Discuss this article online at www.rsna.org/radiology/discuss.
W ith worldwide distribution of imaging services, the specialty in which we trained and that is so beneficial for patients may evolve into a commodity. This evolution toward commoditization is undesirable for both patients and radiologists.
Four premises are central to this issue: First, commodities are objects, products, goods, and articles of trade. Second, restructuring the specialty of radiology as a product will result in its commoditization. Third, the specialty of radiology requires integration of four interlinked components of practice: preexamination evaluation for necessity and appropriateness, monitoring of examination quality, interpretation of examination results, and postexamination consultation with the referring physician. It is the dissociation of these four integrated components that produces a commodity. Fourth, the integration of these four components requires cognition, and integration and cognition cannot be purchased.
Dissociation of the described components of the practice of radiology typically involves the extraction of the interpretation component from the other integrated portions of the specialty. It is important that radiologists recognize that image interpretation alone is an incomplete service. A physician who only interprets imaging studies is not a radiologist, because the other integrated components of a radiologist's profession are absent. A comparison could be made with surgeons who only perform surgery and do not assess the indications for surgery or care for and consult with their patients postoperatively. Surgeons who do not perform this integrated care process are considered itinerant surgeons; this practice is considered unethical by the American College of Surgeons and is considered a violation of the Medical Practice Act in some states. A similar statement could be made regarding individuals whose practice of radiology involves image interpretation only. It is important to differentiate between the images and the integrated specialty described above. Images, like grain or any other product, have always been a commodity. The question currently before the radiology community is whether the specialty will become a commodity.
The problem of commoditization is substantial and is growing. A recent eBay search revealed many listings under the heading "Discounted Medical Services," including "MR Scan + Report at facility near you, discount price $650" and "CT Scan + Report at a facility near you, discount price $450" (1). This approach to imaging fits the definition of commoditization, because the practice of the specialty has been reduced to the commodity of an examination plus interpretation, which can be purchased and sold. The integrated components of the specialty have been dissociated with no regard for necessity or appropriateness of the examination, quality performance of the examination, or availability for consultation at completion of the examination.
The magnitude of this problem was further illustrated in the February 10, 2004, issue of the Washington Post. N. Gregory Mankiw, PhD, then chairman of the White House Council of Economic Advisers, when speaking about the clothing and textile industry, was quoted as saying "We don't have a comparative advantage in producing clothing [and] textiles, and that's one of the reasons we've tended to lose textile jobs. Maybe we've learned that we don't have a comparative advantage in radiologists" (2). These comments reflect a respected and powerful economist's opinion of our specialty as a commodity.
Radiologists should also be mindful of the magnitude of the problem of commoditization, because it threatens their higher-paying positions. Hospitals searching for new sources of revenue might view the salaries paid for the higher-paying radiologist positions as a revenue resource. They could tap into this resource by contracting with after-hours imaging or teleradiology services rather than local radiologists. The after-hours imaging or teleradiology service would pay average salaries for what had been higher-than-average paying positions. The local radiologists would be eliminated. The after-hours imaging or teleradiology service and the hospital would split the profits of this differential in payment between average salaries and higher-than-average salaries, which could be very substantial.
Radiologists' views of their involvement in patient image evaluation sometimes differ from the opinions of clinicians and the public. Radiologists envision an imaging protocol in which the data from a patient examination, which the radiologist has determined to be necessary and appropriate, are transferred to the radiologist for interpretation and subsequent reporting to the referring physician. The physician then uses the examination results reported by the radiologist in patient care. Clinicians and patients sometimes have a different perspective: In their ideal scenario, the imaging results requested by the clinician, regardless of necessity or appropriateness, would robotically arrive at the clinician's office directly and bypass the local radiologist owing to the use of a computer-assisted diagnosis system, should such become available, or the use of an after-hours imaging or teleradiology service, which might provide quick interpretive-only results. In the latter scenario, patients and clinicians view the local radiologist as a middle man who obstructs rather than facilitates health care delivery. While radiologists may not agree with patients and their clinical colleagues regarding the optimal sequence of imaging events, they should be mindful of the opinions that differ from their own.
Commoditization may occur at various levels. With the least aggressive form, local radiologists perform only interpretations for nonradiologists who provide imaging services in their office for financial gain, regardless of necessity or quality. A more aggressive form of commoditization results when regional, national, or international teleradiology companies interpret images or broker image interpretation for nonradiologists, again providing interpretation services only. The most pernicious form of commoditization occurs when organizations not only interpret and broker interpretation but also assist nonradiologists in developing their own facilities, with no regard for necessity, quality, or consultation. In this scenario, the organization benefits from the fees earned as a site developer and subsequently as an image interpreter and/or interpretation broker.
There are many drivers toward commoditization, including technology, after-hours imaging and teleradiology services, financial incentives, reimbursement policies, radiologists themselves, imaging growth and requirements for expertise, and patients. These drivers share the commonality of interpretation only, with a dissociation of the other integrated components of an imaging examination, including necessity and appropriateness, performance quality, and consultation. Radiologists should be mindful that a portion of their reimbursement is based on the payer's requirement that they provide consultation as well as interpretation.
Technology is driving the radiology specialty toward commoditization through digitization, increased bandwidth, picture archiving and communications systems, computer-assisted detection, and improved transfer software. With use of improved transfer software through broad bandwidth, digitized images are easily transferable to picture archiving and communications systems stations for interpretation only or clinical review by anyone anywhere. Clinicians are no longer motivated to visit the radiology department for consultation with the radiologist, because the images and the report are available in their office.
After-hours imaging and teleradiology services are commoditization drivers because they offer nonintegrated interpretation-only services. The availability and use of these services has more than tripled since 2004 (3) (Jonathan Sunshine, PhD, personal communication, October 2, 2007).
Financial incentives drive the specialty toward commoditization as payers, imaging utilization management firms, and hospitals seek to maximize profit margins by brokering radiologists' fees at less than full value for interpretation only. Brokering is facilitated through the electronic movement of images for financial gain, without regard for the consultative skill, necessary evaluation, or quality control provided by radiologists.
The reimbursement system also drives our specialty toward commoditization. The technical component of imaging remains lucrative. For the 61.5 million imaging procedures performed in offices in 2006, the technical component was billed more than 75% of the time by nonradiologists (Mythreyi Bhargavan, PhD, personal communication, October 2, 2007). The lucrative technical component encourages nonradiologists to install imaging equipment in their offices so that they can collect this component of reimbursement and transmit images for interpretation only, with no regard for necessity or quality.
Radiologists themselves are sometimes drivers toward commoditization. Radiologist shortages, increased imaging volumes, and requirements for increased expertise with new examinations such as computed tomographic (CT) colonography and coronary CT angiography lead local radiologists to seek alternatives for imaging coverage and expertise in after-hours imaging or teleradiology services for interpretation only. Unfortunately, the results of a recent American College of Radiology survey of radiologists confirmed that the most common reason for using an after-hours imaging or teleradiology service was not its expertise but rather the afforded lifestyle convenience (Jonathan Sunshine, PhD, personal communication, November 4, 2007). When radiologists contract with other physicians to provide the professional component of a service for less than the full professional component fee, they give nonradiologists an incentive to perform imaging for the lucrative technical component of reimbursement, with no regard for examination necessity, quality, or consultation. Poor service from radiologists also justifiably leads clinicians and hospitals to use after-hours imaging and teleradiology services.
Patients' requests for more imaging procedures and immediate results also drive the specialty toward commoditization. They often equate imaging examinations to a laboratory test and often have no idea of the source of the imaging results or the necessity, quality, or requirements for consultation of the examination.
There are substantial consequences of dissociating the integrated components of the practice of radiology and the subsequent commoditization of radiology as a specialty. These consequences include radiologists' loss of control of their specialty and destiny and their loss of personal interaction with physician colleagues, the devolution of imaging studies to the equivalent of laboratory tests, and the public ownership of radiology practices. Although some individuals may tout improved subspecialty expertise, speed of interpretation, and convenience, the consequences of commoditization ultimately are adverse to patient care because examination appropriateness, quality, and consultation are not ensured and are dissociated from interpretation.
Commoditization could potentially lead the practice of radiology toward an assembly-line approach. An interesting comparison can be made between Henry Ford's initial assembly line a century ago, current automobile assembly lines, and the potential devolution of imaging. Photographs of the original Ford plant automobile assembly line (figure 6, http://teamster.usc.edu/
fixture/Robotics/Automation.htm) show 10 men assembling three cars. Photographs of current assembly lines show no human involvement. Will this evolution of the automobile assembly line hold true for the devolution of radiology as a specialty? Will radiologists accept having to work for large publicly traded firms and losing their participation as members of a health care team? More important, will the provision of patients' health care become equated to the assembly of an automobile? Solutions exist to avoid these undesirable transformations.
Radiologists must first recognize the existence of the problem of commoditization and its adverse potential. Our solutions to this problem must foremost demonstrate patient primacy and patient benefit. The current Medicare requirement that image interpretations be performed in the United States may represent a viable solution if radiologists can show legislators that this requirement exists to benefit patients. State corporate practice of medicine acts that restrict the ownership of medical practices to licensed physicians may be another successful solution to commoditization—again, if radiologists can demonstrate patient benefit. Passing legislation solely for the protection of radiologist practices—also known as barrier legislation—would be an unsuccessful solution. Radiologists must document patient benefits, which can be measured by using metrics such as differences in diagnostic error rates, patient clinical outcomes, and clinician satisfaction.
Radiologists can succumb to economic and business pressures or, alternatively, use new technologies that will benefit their patients and themselves. Radiologists can form practice alliances with local academic practices for expertise and with other local groups for expertise and/or coverage. In such circumstances, we must recognize that the threat of practice loss is not from geographically adjacent practices but rather from regional, national, and international corporations that are beholden to stockholders and not patients. Radiologists should internalize imaging utilization management services and eliminate brokers. Each of these solutions could be facilitated by national radiology organizations, including the Radiological Society of North America, the American College of Radiology, and the American Roentgen Ray Society.
Deriving solutions to the problem of commoditization also requires that radiologists provide excellent service as specialty and subspecialty consultants and develop a specialty identity with patients and clinicians to demonstrate the added value of the integrated practice of radiology beyond the confines of image interpretation. Radiologists must gain recognition as a specialty of quality by embracing quality metrics, pay-for-performance standards, safety standards, facility accreditation, and professional certifications such as the American Board of Radiology Maintenance of Certification. We must put a face on our specialty by maintaining and advancing community involvement in local hospital committees and hospital programs. Putting a face on the field of radiology will enhance our reputation as consultative physicians among colleagues, patients, and administrators. Radiologists must accept neither a dissociation of the technical component from the professional component nor an arbitrage of the professional component. We must work as decision-making partners rather than as salaried employees in joint ventures with nonradiologists because dissociation, arbitrage, and employment create further incentives to delink the integrated components of a radiology practice. Radiologists must become more politically active to achieve all of these solutions.
To reach solutions, we must be the innovative specialists developing new technologies, new procedures, and creative business techniques and implementing these advancements in practice to improve health care. Innovation requires personal thought rather than automation.
In the discussion of commoditization, two fallacies must be exposed. Some individuals, who are currently profiting economically from commoditization, espouse the philosophy that the spread of commoditization is inevitable and radiologists who oppose it are antiquated and lack vision and technical skills. They further assert that these antiquated radiologists should acquiesce to the more progressive and enlightened individuals in their group and cease objections. These same individuals also attempt to equate the performance of interpretation alone by a skilled subspecialty-trained individual to a radiologist's performance of an integrated examination. They tout subspecialty interpretation as their only responsibility in a patient's imaging examination. This approach obfuscates the fact that some of the examinations for which they interpret results might be unnecessary, inappropriate, lacking in quality, and performed without consultation.
Face-to-face consultation with a local radiologist adds value compared with communication with an individual at the other end of a telephone line, who is unknown and has never been or will never again be involved in or responsible for a patient's care. These important issues should be discussed forthright, with the motives of everyone clearly exposed. It is hoped that such discussions would be focused on patient primacy. The progression of commoditization could be slowed, stopped, or reversed if radiologists ceased to participate in the process. Commoditization is in its infancy, and radiologists should not accept the fatalistic attitude of individuals who are claiming victory before the battle has been waged.
Changes in the practice of radiology are inevitable. During the course of this inevitable change, however, radiologists' perspectives regarding the problem of commoditization must be long-term rather than short-term. The radiologist with a short-term perspective seeks someone else to take imaging requests and calls at night so that he or she can sleep. The radiologist with a long-term perspective seeks a secure practice so that he or she can sleep at night for the next 20 years.
The integration of the four components of an imaging examination defines the specialty of radiology and the professional care of patients. The dissociation of any of these components may result in commoditization and an assembly-line approach to patient care. Radiologists themselves often encourage this process. Without radiologists, venture capitalists, entrepreneurs, Wall Street traders, and hospitals would have no "product" to offer.
Practicing radiology is the specialty of radiologists. Radiologists are not business pawns; rather, they are physician peers who must always strive to attain the vision of the excellence of care that they desire for their patients.
Discuss this article online at www.rsna.org/radiology/discuss.
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  F. Levy Computers, Conversation, Utilization, and Commoditization: The 2008 Herbert Abrams Lecture Am. J. Roentgenol., May 1, 2009; 192(5): 1375 - 1381. [Full Text] [PDF]
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