AuntMinnie.com is pleased to present the second installment of Leaders in Imaging, a series of interviews with individuals who are shaping the radiology landscape. We spoke with Cynthia Sherry, MD, chair of the department of radiology at Texas Health Presbyterian Hospital in Dallas. Sherry also serves on the American College of Radiology's (ACR) Task Force on Relationships Between Radiology Groups and Hospitals and Other Healthcare Organizations.
AuntMinnie: What prompted the ACR to form its Task Force on Relationships Between Radiology Groups and Hospitals and Other Healthcare Organizations? What does it hope to accomplish?
Sherry: There have been a number of recent relationship breakdowns between radiology groups and hospitals, some of which were high-profile in the media. Because most radiologists and most radiology practices are hospital-based, such relationships are a topic of critical interest and importance to most radiologists, and, therefore, these breakdowns captured the attention of the ACR leadership. The ACR convened the task force for the purpose of identifying the issues surrounding these relationship breakdowns, assessing the underlying causes, and suggesting possible steps for improvement.
Cynthia Sherry, MD, chair of the radiology department at Texas Health Presbyterian Hospital in Dallas.Your recent study on the relations between radiologists and hospitals (Journal of the American College of Radiology, June 2010, Vol. 7:6) found that tensions between hospitals and radiologists have been increasing. How are these tensions played out, and why are they growing?
Hospitals are making more and more demands upon radiology groups, mostly for service- related issues -- like shorter turnaround times, increased availability onsite, and more subspecialty interpretations -- but also for contract concessions like nonexclusive arrangements, noncompete clauses, and clean-sweep provisions, which is automatic termination of medical staff privileges without fair hearing upon loss of contract.
And radiology groups are facing relentless downward pressures on revenue streams, causing them to redouble efforts to maximize per-person productivity and to look for other sources of income, such as imaging centers. As a result, radiologists may resist the hospital's request for expanded service and/or enter into an imaging center business that is competitive with the hospital. The tensions continue to grow as the downward financial pressures on both parties exacerbate the problems.
Are radiology groups losing power in the relationship dynamic with hospitals? Is this causing hospitals to drive harder bargains when renewing contracts with groups?
I don't think that radiology groups are necessarily in a "one-down" position when negotiating contracts, because it is so very disruptive to a hospital's operations to replace the radiology group. Generally speaking, hospitals will try to avoid such a drastic maneuver.
But the commoditization of radiology and technology advancements together have contributed to the fact that groups are, indeed, much easier to replace today than in past years. Hospitals can and will replace a group if the relationship continues to be adversarial and service issues unaddressed. And radiology groups are finding some contracting points very difficult to negotiate favorably and are therefore forced into a compromise position.
Do you believe that most radiologists are aware of the need to change the way they approach their hospital partners, or do they only become aware of it when it's contract renewal time and the hospital is negotiating more aggressively?
Radiology group leaders across the country are becoming more aware of the changing healthcare dynamics, including those in hospital-radiologist relationships. But I suspect that the majority of radiologists who are engrossed with the challenges of simply leading a productive clinical career may not be as aware of the changing business and political dynamics. It's critical for group leaders and department chairs to increase efforts toward educating their member radiologists about current trends so that all radiologists can participate in the needed behavioral changes.
Do you think the best avenue for radiology groups to survive is to work more closely with hospitals, or to become more independent so they're not so reliant on a single hospital contract?
A little of both works best. Orientation to service, willingness to consider compromise, ability to conduct business professionally, and commitment to quality improvements are key elements hospitals are demanding from radiologists today. But diversification of a group's portfolio can help protect it from becoming too dependent upon one hospital's business. So, yes, a group must create a business portfolio that allows them to survive if their hospital relationship fails.
What are some concrete measures radiologists can take to strengthen relationships with hospitals?
The best scenario is for hospitals and radiology groups to have their goals closely aligned. In this scenario, groups are less likely to lose their contract and they are most likely to thrive. Radiologists must work toward developing an ingrained sense of service orientation toward their customers: patients, referring physicians, and hospitals. This means striving to see the others' perspective, providing value-added services, and integrating into the medical, political, and social structures of their hospital and community. Radiology groups must expect and demand appropriate leadership training and skills for their practice leaders who interact with hospitals and empower them to speak on behalf of the group.
To what extent are digital technologies like PACS and teleradiology to blame for this changing dynamic?
These technological advances have been extremely powerful and beneficial for patients and for the entire field of imaging. They are also changing the marketplace, making it possible for radiology service providers to develop and expand from pure nighttime service to turnkey operations that include daytime work. And these companies have found weaknesses in the service provided by radiology groups and are competing aggressively, marketing themselves based on a spectrum of value-added services and by offering technological savvy -- perhaps by using specialized worklists in PACS so that subspecialist radiologists can read the exams in their area of expertise no matter where they are located, or by using a common PACS so that workload can be more evenly spread among a group of radiologists, or by using technology to "close the loop" on critical results reporting, to name a few.
How can radiology groups compete with teleradiology firms?
Radiology groups can successfully compete with radiology service providers by excelling on quality measures such as subspecialty reads and onsite availability, and by providing services that improve safety, quality, and department operations and contribute to a hospital's overall strategy and goals. These services vary from place to place, depending on local needs, but might include developing standardized imaging protocols for MRI, CT, and ultrasound, and then tailoring these to specific patient or referring physician needs; ensuring that imaging protocols are safe and implemented correctly to reduce radiation exposure to patients; helping to implement appropriateness criteria for referring physicians ordering imaging tests; or helping radiology directors and hospital administrators with strategic planning for capital acquisitions, including imaging equipment.
The other way to compete is by integrating deep into the hospital and referring physician world socially and politically. These are the ways a group can make themselves indispensable to the hospital administration and referring medical staff.
Do you think radiology is becoming a commodity? Why?
I think we're already there, but that the pendulum will soon begin to swing back a little the other way. Hospitals, as well as radiology groups, are wising up, becoming much more aware of the value a stable, high-performing radiology group brings to the hospital operations and the satisfaction of the medical staff. And radiologists are getting back to some of the basic tenets of a service organization.
The work culture of the past is one in which a radiologist's value rested solely upon how many accurate reports were generated within a day of work. Committee work, personal consultations, and leadership activities were devalued. Radiologists became more and more isolated by this monolithic focus on productivity, and this isolation was reinforced by PACS, because fewer and fewer referring physicians came by to personally consult with the radiologist or telephoned the radiologist for verbal reports.
Radiologists came to believe that all they had to do to be successful is show up on time and dictate good reports. And when there was a radiologist shortage, maybe this was true. But now, groups really can be replaced by others who will provide the services, leadership, and congeniality that have been recently lacking. So being a successful radiologist or radiology group requires a skilled and committed multilevel approach in which each member of the group is contributing to the overall performance of the healthcare team.
Do you see the trend of radiology groups consolidating to become larger, more subspecialized entities as a positive one? Is this a viable model for radiology to go forward in the future?
The abilities of a group to provide 24/7 coverage and subspecialty reads, and to maximize business efficiencies from economies of scale, are enhanced by larger groups. So I think this trend toward larger groups will continue over the next few years.
Do hospitals have any responsibility in terms of how they use radiology services?
Good relationships are contingent upon efforts from both parties. It's in the best interests of hospitals, radiologists, patients, and medical staffs for hospitals and radiologists to build bridges and mend fences.
Should radiology training be changed to deal with the new radiology landscape? What would you suggest?
I'd suggest a renewed focus on professionalism, plus leadership and management training embedded in residency programs and required for board certification. And ongoing leadership education for radiologist leaders and group members throughout their careers would help, too.
How do you think radiology will be practiced in five years? Ten? Is the model of radiologist as entrepreneur ultimately doomed, or can it be salvaged?
I think the changes we see in the next few years will be largely determined by the new healthcare reform laws, and no one really knows yet how those laws will play out. It's safe to assume that imaging is still in the crosshairs and that our payment rates will continue to decline.
At the same time, quality and safety efforts throughout hospitals and through government agencies and policies will continue to change processes and operations. These two trends together will create demand for greater radiologist efficiency to maintain productivity, leaner business models to reduce overhead expenses, and a greater emphasis on quality metrics, process improvements, and value-added services.
Cynthia Sherry, MD, is chairman and medical director of the department of radiology at Texas Health Presbyterian Hospital in Dallas. She is also a medical director and managing partner for Southwest Diagnostic Imaging Center. She has served as president of the American College of Physician Executives (ACPE) and of the Texas Radiological Society, and she has been awarded fellowship in the ACPE and the ACR. Currently, Sherry serves on the ACR Board of Chancellors as the commission chair for practice and leadership development, as well as on the board of directors for the Dallas County Medical Society.
By Kate Madden Yee
AuntMinnie.com staff writer
July 8, 2010
Related Reading
Rads need to improve hospital relationships, June 1, 2010
Leaders in Imaging: Dr. Leonard Berlin, May 25, 2010
Virtual radiology: How does it affect knowledge transfer? May 25, 2010
Are hospitals playing hardball with radiology groups? April 22, 2010
Radisphere skirts local groups in bid for hospital contracts, April 15, 2010
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