IMAGING · RADIOLOGY
about impossible; so even independent practices in that kind of situation are looking to bring people on remotely.” As for size, he says that “The issues you’ll find in large corporate medical practices are the same issues you’ll find within any large, nationally distributed com- pany. When we made the transition
Keith Chew
to a distributed workforce in COVID, all sorts of issues developed. Productivity went up in some areas and down in oth- ers; teamwork worked better in some cases and less well in others.”
Is there some upper limit to practicable practice size? “In any business,” Chew continues, “you get to the point where you start to see diminishing returns based on growth in size, unless you can find better ways to cre- ate efficiencies. And part of the promise of the corporate practices was that they were going to start to bring technology to bear, but they’re not really doing that or doing it well; nobody is. That’s part of the prom- ise of AI [artificial intelligence], to start to understand how we can improve the qual- ity of service, in a manner that actually decreases the cost of delivery. And we’re probably in the worst recruitment market for radiology than ever. Six or seven years ago,” he notes, something happened whose impact is echoing now: the emergence of AI convinced some medical students and residents that AI implementation might actually replace some radiologists with technology. That prediction turned out to be totally false; but it led to a shortage of new radiology residents several years ago, that is leading to a shortage of practicing radiologists now. And, Chew notes, federal healthcare
officials’ focus on bending the cost curve involving specialist physicians is lead- ing to perverse incentives, in his view. “Radiology has had an effective 41-percent cut in Medicare reimbursement over the past ten years”—and yet the complex incentives involved might actually show pay cuts to be penny-wise and pound- foolish over the long run, he contends. “Take low-dose lung cancer screening,” Chew says, to cite one example. “That’s a preventive service that can be offered by radiology that saves money. If you find
“Hospitals can’t survive without radiologists, and radiologists can’t survive without hospitals… But both sides have to stop looking at each other as adversaries and instead work together as partners.” —Keith Chew
a stage 1 lung cancer, cost of treatment is $80,000-$100,000, for treatment, and survivability is 67-68 percent at five years.” But, Chew says, “If you get to Stage 3
or 4 of lung cancer, the cost of treatment is $300,000-$400,000, and survivability at five years is 6-7 percent. And low-dose lung cancer screening costs $300-400 at even the higher-end places. If you can bend your cost curve by providing that service today, that’s massive. But the Medicare Administrative Contractors contracting with CMS [the Centers for Medicare & Medicaid Services]—all of them have refused to pay for it within independent diagnostic testing services, because they say that giving a person a pamphlet on quitting smoking is a therapeutic activ- ity. CMS has finally put its foot down and required payment for the service, but that was short-term thinking, and it took five years.” In other words, he says, “There are a vast number of services done within radiology that, if performed, can lead to early treatment and save costs. So if you truly want to do population health, you need to be rewarding radiologists for providing low-cost services. And we’re looking at the fact that for the most part, the government is most concerned about the short-term cost, over the long-term benefit.” And that’s where the effective 11-13-percent decrease in radiologist reimbursement under Medicare” that’s been reported, is counter-productive to the idea of bringing radiology costs under control, he believes. Amid this swirl of complexity, the fact
that federal healthcare authorities are moving forward to constrain costs in the radiology area through a variety of strate- gies is leading some radiologists to try to rethink things a bit. In an article entitled “Thinking Beyond FFS” and posted to the website of the American College of Radiology (ACR), Ryan K. Lee, M.D., co- chair of the ACR’s Commission on Patient- and Family-Centered Care’s Population
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Health Committee, and who is chair of the Department of Radiology at the Einstein Health Network in Philadelphia, writes that, “With this clear movement away from a traditional FFS [fee-for-service] environment, many specialties have progressively increased their involve- ment with these quality-based models. Radiologists, however, are for the most part still working in a predominantly FFS environment. It is true these newer value- based models are inherently designed more for patient-facing physicians, and this is one reason radiologists have been slower to adopt value-based models. However, as value-based models continue to grow in prominence, it is essential that radiologists engage more in these mod- els—particularly as disincentives for operating in a purely FFS environment continue to grow.”
What can hospital and health system leaders can do In the face of all this complexity, there are things that hospital and health system lead- ers can do, Keith Chew says. “Hospitals can’t survive without radiologists, and many radiologists can’t survive without hospitals, though some radiologists have opened up outpatient centers,” he says. “But both sides have to stop looking at each other as adversaries and instead work together as partners to accomplish the goals that both groups need to accomplish in this tight recruiting market.” Chew says that hospital and health sys-
tem leaders will have to take a hard look at contracts in place in many hospital- based organizations requiring radiolo- gists to participate in every contract that a hospital has with all payers; that aspect of contracting leads to health insurers intentionally negotiating under-market contracts; if hospital leaders can rework just that feature of contracting alone, they can make radiologists happier and open up new partnership possibilities, he says. And, he says, it will be important for health IT leaders, especially CIOs, to really listen to radiologists in terms of their needs and wants around the PACS (picture archiving and communication systems) systems that they implement in their organizations. Hospitals need “a visionary, someone who’s not stuck in doing things the way they do them today,” in order to satisfy radiologists and win goodwill, as they strategize forward to create partnerships that will work in the future. HI
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