December 2013

What policymakers and payors want from radiology departments is not volume, but value. If radiologists can help hospitals contain costs, improve quality, and increase market share, then these radiology providers will be well positioned to carry their hospitals—and themselves—into the era of quality- and performance-based pay.

If someone asked you to define quality in radiology, what would you say? The precise definition of quality is certainly nebulous, but it has never mattered too much—until now.

There has long been interest in clinical decision support, especially at the time of order entry, but a lack of systems (and credentialed guidelines) has limited clinical use.

On September 9, 2013, Cheryl Proval, editor, Radiology Business Journal, moderated “The Boston Experience: Radiology’s Value Proposition in the New Health-care Paradigm,” a panel discussion held in Boston, Massachusetts, at the RBMA Fall Educational Conference.  The meeting location offered a unique opportunity to explore radiology’s changing value proposition under health-care reform with a panel that represents hospital-based radiology, outpatient radiology, and the payor community.

As citizens and the media debate the cost and growing pains associated with the Patient Protection and Affordable Care Act (PPACA), Cuckler et al¹ (at the CMS Office of the Actuary) predict that aggregate health-care spending will grow at an average annual rate of 5.8% from 2012 to 2022, outpacing the projected growth rate of the US gross domestic product (GDP) by 1%. In 2022, nearly one-fifth of the GDP (19.9%) will be spent on health care, they estimate.

It’s the assumption at the core of GE, IKEA, and Unilever’s strategies; its presence, or lack thereof, guides the investments of billionaire Warren Buffett, among others. Sustainable competitive advantage sounds like something that every business, in every industry, would want to secure. With the advent of digitization and globalization, however, along with continual emergence of disruptors from every corner, is focusing on sustainable advantage still the best way to achieve success?

Saying, “I want it anyway,” the ICU physician insisted that his patient with breast cancer should get an MRI exam to look for lung metastases. My years of experience as a radiologist did not dissuade him; such a test would be a poor way to evaluate his patient’s lungs, even under ideal circumstances (which hers were not). She was on a ventilator, incoherent, and unable to hold her breath, rendering the study a useless waste of time and money. More important, her lungs, just days earlier, had been clear on a chest CT exam—the gold standard for detecting lung nodules. We already knew that she had no lung metastases.

Efficiency can be thought of as the volume of work done over a period of time. In diagnostic radiology, that has been interpreted to mean RVUs per radiologist per unit of time. With decreasing per-case reimbursement, we have seen particularly strong pressures to increase efficiency. Unfortunately, some practices have done so at the expense of other important functions.

Eight years ago, I sent an email to Barry Pressman, MD, FACR, radiology chair at Cedars-Sinai Medical Center (West Hollywood, California). My 75–year-old mother, a lifelong nonsmoker whose primary-care physician had diagnosed lung cancer (based on a chest radiograph), needed a referral to a surgeon. Pressman recommended Robert McKenna, MD, who had helped pioneer video-assisted thoracic (VAT) surgery in this country.