Is private equity investment a panacea for healthcare organizations in rural and remote areas grappling with radiologist shortages? Imaging experts discussed this possibility, along with other alternatives, during a session Sunday, Nov. 26, at RSNA 2023.
Some of the statistics are stark: 136 rural hospitals shuttered between 2010 and 2021, according to one estimate. And another 600 such institutions (or 30%) are at risk of closing due to their financial instability. Vital to their communities, these hospitals continue to grapple with low financial reserves, inadequate revenues to cover costs, poor payer mix, and shortages of radiologists and other professionals.
Catherine J. Everett, MD, MBA, with industry giant Radiology Partners, highlighted private equity’s potential role in supporting rural health. Such investor-backed platform companies may be able to mitigate the loss of imaging services in these communities, providing added support to help smaller practices navigate today’s challenges.
“Rural healthcare delivery is in trouble and private equity may have a role in supporting it,” Everett, who is president and managing partner of Coastal Radiology Associates in New Bern, North Carolina, told attendees. “Large scale radiology organizations can mitigate the loss of rural radiology services and practices. It doesn’t necessarily have to be private equity, it could be a large medical center … or even a large radiology practice,” she added.
To explore how a small practice might benefit, Everett discussed the “theoretical example” of a radiology practice she called “Scotch Bonnet Imaging Associates.” The group serves three hospitals including a 300-bed flagship, a 150-bed hospital and a 50-bed extremely rural hospital. Leaders there realized the following plusses (with added caveats):
1. Infrastructure: Advanced IT platform
- Pros: Teleradiology coverage after hours with final reports, subspecialty interpretations as needed and image sharing for referrals and specialists.
- Cons: Inconsistency of interpretations of after-hours reads, no personal relationships and conversion to the new platform can be “painful and more complicated than expected.”
2. Support personnel and operations
- Pros: IT support to maintain system, credentialing expertise, patient education via service portals, support materials for rads and hospital personnel, billing and coding to boost revenue, and disaster support.
- Cons: National IT support can be inconsistent, local credentialling may become overwhelmed by the numbers, and loss of control “often disturbs radiologists.”
3. Best practices + quality and safety
- Pros: National specialty boards for standardized protocols, internally developed AI tool that automatically alerts interpreting rad of the appropriate follow-up guidelines, and universally installed national AI tools for triage and detection of intracranial hemorrhage, rib and spine fractures, and pulmonary embolism.
- Cons: Everett did not list any for this category, calling it a “real plus.”
4. Radiology support
- Pros: Help with recruiting specialists, providing remote readers, along with on-site support from rads who can fill in for absentees.
- Cons: Different recruiting targets when compared to a small practice, credentialing can always be an issue, and on-site radiologists are expensive.
Alternatives
Radiologist Richard Duszak, MD, closed out the presentation, discussing potential alternative ways in which rural institutions can address patient-access concerns and improve coverage. He serves as chair of the University of Mississippi Medical Center, which has faced issues with staffing and providing enough options for its community.
Duszak highlighted “dramatic” improvements in wait times at the Jackson-based institution, which is the only academic medical center in America’s poorest state. Last fall, its patients were forced to wait as long as long as 30 days for a screening mammogram or 50 for an ultrasound. However, one year later, those numbers have dropped to zero and two days, respectively. One part of the problem: The number of imaging appointment no-shows at UMMC were “incredible,” Duszak noted.
Throughput in interventional radiology also has improved, with UMMC providers handling 380 cases in July 2022, a number that has since climbed to 675 as of August. Despite that, docs are still going home at the same time at the end of the day.
Duszak cited several simple changes the hospital undertook to begin making progress.
“This is not a secret sauce here. I’m not giving any proprietary information,” he told attendees. “I would submit to you that one of the ways that we can improve rural access is to stop talking about it and actually [start] doing things.”
He cited five steps that rural radiology providers can take to improve access:
1. Make your dollars go further: “You’ve got to cut down on the red,” Duszak said. “You may not turn it into black ink, but you’ve got to make your dollars go a lot further. A simple thing: A lot of those in underserved, safety net hospitals have this culture of learned helplessness. ‘Oh my gosh, we’re never going to get all of this business stuff right.’ And that becomes a culture in a lot of places, and I’ve seen this in a lot of institutions, as well.”
Duszak said this step includes cutting costs and beginning to measure productivity.
2. Recognize the reasons you’re having problems with access: Transportation is one of the most common reasons patients fail to show up for IR appointments at UMMC. Providers should look to work with Medicaid transport to address this barrier and phone people the day before to confirm they have a way to get there.
“If they’re not going to be able to do it, I can’t send an Uber out to Philadelphia, Mississippi (which is 80 miles from Jackson), to pick somebody up with our budget,” Duszak said. “But I do have a wait list of other patients that we can work on in to get that wait time down and improve access for others who are in the queue.”
3. Acknowledge illiteracy: “One of the things you have to recognize in poor and rural communities is that illiteracy is rampant,” he said. “Oftentimes, patients are unwilling to admit this. But when they receive instructions, which are all gibberish, it doesn’t mean anything to them.”
UMMC still has long ways to go, Duszak said, but it has started calling patients to confirm appointments and ensure they understand next steps.
4. Acknowledging structural racism: “We definitely have some racial issues that we are still working through in the poor south, in particular. And I think those of us who are trying to improve patient access need to realize: We need to rebuild trust.”
Imaging leaders can’t fix this overnight, Duszak acknowledged. But they should be thinking about ways to drive cultural competence. Matching the workforce to the population it serves is important but can be challenging when dealing with poverty and poorly run schools. “It’s not going to happen very quickly,” he said.
“We do need to make sure that our staffs, whether its schedulers or front desk folks or physicians or nurses, are cognizant of some of the cultural competence needs so that people feel comfortable with us,” he said.
5. Building, inspiring and motivating teams: This can be as simple as asking nurses, techs and radiologists about their ideas to improve access. Duszak also acknowledged pay gaps between rural and urban areas that can impact hiring and service availability.
6. Advocate and lead: Mississippi is one state in which Medicaid has not been expanded, and he believes the radiology community should get involved in advocating to address these needs.
“We can’t do that institutionally as faculty, but I think there are a lot of individuals who are working with our state medical association to do things in this area,” Duszak said, adding that rural radiologists also should advocate for their communities and urge others to consider careers there.
“Some of this is the Nike imperative: We need to just start doing it,” he told attendees.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.