Alan D. Kaye

Quality Improvement Guidelines for Percutaneous Drainage/Aspiration of Abscess and Fluid Collections

THE membership of the Society of Interventional Radiology (SIR) Standards of Practice Committee represents experts in a broad spectrum of interventional procedures from both the private and academic sectors of medicine. Generally Standards of Practice Committee members dedicate the vast majority of their professional time to performing interventional procedures; as such they represent a valid broad expert constituency of the subject matter under consideration for standards production. Technical documents specifying the exact consensus and literature review

Masters of Radiology Panel Discussion: Women in Radiology— How Can We Encourage More Women to Join the Field and Become Leaders?

145 outside my domain of expertise, and I will keep my comments brief to hear more from our women on the panel. The sex imbalance in radiology concerns me on a number of levels but perhaps most because of its implications that, as a specialty, we may not be equally welcoming to all. In a time when women are at least equally represented in other medical specialties, it is not due to a sex imbalance in medical students. I do not know exactly what the reasons are, but it is worth assessing women medical students’ perceptions of the nature of the work, career opportunities, role models, work-life balance, etc., and then working to improve where we can. Norbash: To have increasing numbers of women join radiology, it would be helpful to create an atmosphere where women fundamentally are appreciated and valued, given parity where leadership and research positions are concerned, and given the autonomy and resources to create appropriate mentoring and support services. Simultaneously, there will need to be attention paid to resources and need to establish the appropriate environment to secure work-life balance. Specific actions should include formulating match lists to ultimately yield 50% of matched women in each department, formulating policies to ease women residents’ desire to start a family, and balancing faculty to promote and celebrate the advancement of women radiologists to positions of responsibility and leadership. Beauchamp: We also should keep in mind that diversity is an opportunity not an obligation. Extensive research shows that as you increase the diversity of your groups, productivity, creativity, innovation, and problem solving also increase. Also relative to this conversation is the case of diversity in terms of getting more women in medicine. We are missing an opportunity, given the Masters of Radiology Panel Discussion: Women in Radiology— How Can We Encourage More Women to Join the Field and Become Leaders?

Preventing Another Group From Displacing Your Practice: Perspectives From the 2010 AMCLC

Most hospital-based radiology practices have enjoyed stable long-term relationships with the institutions they serve. Recently, however, an increasing number of hospitals have replaced established radiologists. In some cases, the incoming group provides only a small number of on-site radiologists and uses long-distance teleradiology for the bulk of image interpretations. Such technology, along with changing market forces, places many practices at risk. A number of strategies to maintain and foster long-term service relationships were discussed by the ACR Council and are reviewed herein.

Turf Wars In Radiology: Recent Actions Against Self-Referral by State Governments, Commercial Payers, and Medicare—Hope Is on the Horizon

Self-referral in imaging creates a problem for our health care system in that it leads to higher utilization and costs. Although it is still widespread, there are indications that some states, some regional payers, and the Centers for Medicare & Medicaid Services have begun to take some actions to limit this potentially abusive practice. At the state level, these actions include consideration of anti-self-referral laws, crackdowns on scan-leasing schemes, the institution of mandatory facility accreditation programs, and bans on the installation of advanced imaging equipment in physician offices. Some commercial payers have instituted strict privileging programs in imaging, closed their panels to any facility that is not a full-service imaging provider, and begun requiring accreditation of advanced imaging modalities. The Centers for Medicare & Medicaid Services plans to institute an antimarkup rule and prohibit independent diagnostic testing facilities from leasing space or equipment to nonradiologist physicians, and it has indicated that tightening up the loopholes in the Stark laws may be in the offing. In this paper, the authors review all these recent developments and their implications.

Referring physicians' attitudes toward international interpretation of teleradiology images.

OBJECTIVE We evaluated referring physician attitudes toward the international interpretation of radiologic images. MATERIALS AND METHODS A five-question, scenario-based survey describing features of a hypothetic local radiology firm compared with those of its hypothetic overseas counterpart, international radiology, was sent by mail to 350 physicians from a broad range of medical and surgical specialties. One hundred nineteen physicians responded, for a response rate of 34%. Referring physicians were asked to indicate their preference for local versus international interpretation in each scenario using a 5-point Likert scale, with a score of -2 indicating a strong preference for international services, 0 indicating no preference, and 2 indicating a strong preference for local services. RESULTS When all variables are held to be equal, referring physicians strongly prefer local services (mean score, 1.77; SD, 0.77). When international teleradiology provides either a 2-day faster turnaround time for reports or a 30 dollars lower out-of-pocket cost to the patient, referring physicians still prefer local services, although less than they did with all variables held equal (mean score, 0.42-0.44; SD, 1.30-1.40). When international teleradiology provides both a 2-day faster turnaround time and a 30 dollars lower out-of-pocket cost to the patient, referring physicians preferred international teleradiology, albeit only slightly (mean, -0.25; SD, 1.50). Finally, when the credentials of the international radiologists are perceived to be less than those of the local radiologists, even in the face of faster turnaround time and 30 dollars lower cost to the patient, referring physicians overall strongly prefer local services (mean, 1.51; SD, 0.86). CONCLUSION Referring physicians prefer local interpretation of radiologic images to international interpretation when all things are equal. However, the timeliness of image interpretation and the cost to the patient are important factors in this decision.

Masters of radiology panel discussion: The future of the radiology job market

127 Part of the question when you look at a microscopic trend is, “Does this extrapolate out to a long-term problem or not?” Personally, I am optimistic about radiology. I’m very bullish. The challenge that we’re facing is our inability to fundamentally and eloquently verbalize the added value we bring to every single interaction and transaction. We have to be more specific in terms of demonstrating how beneficial we are to health care delivery systems; to referring physicians; and, most importantly, to our society’s health. If we can truly demonstrate the throughput value of radiology and speak the language of value, then the sky is the limit for our growth and we will flourish. This is particularly true in an accountable-care organization (ACO)like capitated and bundled world where radiology is all about sunken costs and wholepatient throughput and less about rationing individual departmental transactions. In such a world, we may ultimately be facing a time of high-throughput radiology where radiology is depended on [in the medical field] and production management with novel developments, such as high-throughput computer-aided diagnosis (CAD), will advance to the point where we become reconciliators of unusual and abnormal findings. Similarly with therapeutic radiology, there will have to be high-quality delivery and an understanding of how radiology adds value. As you look at interventional radiology universally, it has to be more of a patient-centered engagement rather than a technologically proficient service. My sense is that as radiology evolves to meet the technical demands of the future, there will be a dramatic need for many more radiologists, but it can’t be business as usual. We’re going to have to change the way we engage payers and patients. We have to be much more descriptive in terms of the value we bring to every single diagnostic and therapeutic transaction. Masters of Radiology Panel Discussion: The Future of the Radiology Job Market

What Is the Role of the Radiologist in Holding Down Health Care Cost Growth

919 (ACOs) creates an alignment that we should welcome. In the ACO model, the radiologist can bring value by playing the central role in ensuring that the appropriate imaging study is performed to address the clinical question as well as by ensuring that a study is not performed when it will not impact the clinical management of the patient. It embraces the radiologist’s participation as a true consultant and clinician. ACOs reward the radiologist for helping our clinical colleagues understand and embrace the rationale for the imaging recommendations we are providing so that they find our input essential in attaining the common goal of providing patient-centered costeffective care. This value is what drew many of us into radiology. ACOs also reward the optimally efficient performance of imaging and imaging-guided intervention and give value to the role of the imaging in decreasing length of stay, lowering returns to the hospital, and improving contribution to margin. Another opportunity for radiologists in ACO models is to establish regional networks for imaging transfer. In so doing, the unnecessary duplication of imaging in the emergency department because of prior studies not being available to the referral center can be minimized. This is significant given that up to 20% of the cost of radiology in the emergency department setting is due to duplication of imaging studies. At Harborview Hospital at the University of Washington, we have a virtual private network to 150 hospitals that has enabled us to decrease this unnecessary duplication as well as avoid unnecessary delays in care that can occur with repeat imaging. We are also using this network to identify irreversibly injured patients who will not benefit by being transferred to our level-one trauma center; avoiding unnecessary financial burden for the patient and the patient’s family. We need to do a better job of using technology to take cost out of health care so that What Is the Role of the Radiologist in Holding Down Health Care Cost Growth?

Masters of radiology panel discussion: the commoditization of radiology.

© American Roentgen Ray Society IntrOduCtIOn. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Drs. Howard P. Forman and Marcia C. Javitt. The panel will review topics of importance in the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Forman: When we discuss a commodity in the context of this conversation, what we are talking about is something that is a relatively undifferentiated good as opposed to a valueadded good. This good is something that can, whether you buy it from John Smith in San Francisco or from Ellen Rogers in New York, basically provide the same benefits and therefore can be priced equivalently. On the one hand, we don’t want to become a commodity. We want to believe that we add special value compared with a peer or a nonradiologist. On the other hand, being a commodity is not necessarily bad. There are some very expensive commodities out there: palladium, platinum, and gold are expensive examples. A commodity in and of itself is not without value; it’s just undifferentiated. There has been a lot of a discussion in the lay press as well as radiology journals about this fear of commoditization. Do you think we’re headed toward commoditization? Why or why not? Additionally, what should we do to either prevent heading in that direction or, if you believe it’s beneficial in the long run, what should we do as a specialty to preserve the professional aspects of practice while still allowing the standardization of delivering care? Larson: I would like to dissect a little further what we mean by commoditization. Underlying this discussion is the fact that imaging has become widely available and information technology has made images portable, enabling competition in diagnostic radiology where it was not possible before. In any competitive marketplace, competition occurs on three general bases: technical quality, service, and price. In this context, I would roughly define radiologic quality as the quality of the images and the accuracy and helpfulness of the radiologic consultation. I would define service as all of the other aspects that affect the desirability of the interaction, such as report turnaround time, 24-hour coverage, pleasant patient experience, etc. The distinction is important—quality refers to technical and clinical excellence, whereas service refers to how responsive, available, and friendly we are. All three bases are important, but radiologic quality is our raison d’etre and also the most difficult to measure. Therefore, I would define commoditization (in the sense that most radiologists use it) as competition that occurs based primarily on cost and service, with little regard for clinical quality. Competition is generally regulated in markets such as medicine where there is a risk for “supplier-induced demand,” such as self-referral, and where quality is difficult to measure and the consequences associated with poor quality can be severe. This helps ensure minimum quality standards, but it comes at a price: stifled competition weakens market incentives to constantly improve quality and service and to decrease costs. We must accept that competition is a core value of Western society and that it does not necessarily lead to decreased quality. Thus, although it is laudable to try to prevent a “race to the bottom,” blanket opposition to competition in all forms comes across as self-serving and detracts from focused efforts to preserve quality. In fact, if it is structured correctly, a competitive marketplace can, and often does, create a “race to the top.” Under such a model, individuals and groups cannot expect their practices to perpetually thrive if they consistently provide mediocre expertise or poor service. Furthermore, in a competitive market, it is the customers, not the radiologist or group, who get to determine wheth

Masters of Radiology Panel Discussion: Responding to Health Care Reform and Other Market Pressures

M. C. Javitt is an unpaid consultant to Code Ryte and her husband owns stock in Code Ryte. H. Hricak owns stock in Hologic. D. B. Larson is a case contributor to Amirsys and is reimbursed on a contract basis. IntRODuCtIOn. Each quarter, the AJR will publish the transcripts of the Masters of Radiology panel discussion hosted by Dr. Howard P. Forman and Dr. Marcia C. Javitt. The panel will review topics of importance to the field of radiology and share their unique insight into how these issues are shaping or will shape the future of the specialty. Forman: Today’s topic is how radiology practices should respond to the possibility of health care reform and other pressures facing radiology. Our panel was chosen based on specialty, career stage, or institution type. Our goal was to provide representation across the specialty. I’d like to start with how practices are responding to health care reform and to what extent you believe we need to embrace efficiency. Is it good, bad, or does it make no difference in our practice? Crowe: There’s a conflict between what drew many of us to medicine and the way we are often forced to practice today. Hyperefficient practice is necessary, but it is often synonymous with spending less time with patients and referring physicians. If your practice is driven solely by economics, it is a wonderful example of why economics is called the “dismal science.” This outlook fundamentally threatens the more enjoyable features of medicine and is one thing that I think is critical to maintaining one’s love of the field—feedback from one’s colleagues and interacting in ways in which teams or groups of people function to make patients better or systems better. So I’ll throw that challenging idea out on the table and let others share their opinions. Messinger: I have a little different philosophy on that. In my experience, those physicians who want to maintain a relationship with you by seeing you in person or on the telephone do it. Those who do not, haven’t and probably won’t. I appreciate what Jack said, but I’m not too concerned, at least in my practice, about that aspect of the pattern of hyperefficiency. Hyperefficiency by its very name should be good and probably is good in many respects. I am concerned, however, about how this trend is going to affect our workforce. Will it decrease the number of radiologists we need? If it does, how does that impact medical schools? Several years ago, we had more people saying “you don’t go into radiology anymore,” and that diminished the quality of our candidate pool. Now we’re seeing outstanding candidates, but I’m concerned that by becoming hyperefficient, relying so much on technology, and by trying to maintain a set income we’re going to try and “make do” with fewer radiologists. Javitt: My response is bound up in how I view our business as well as our responsibilities. Our work product is a report and that report does not reflect how much time it took to generate it or what cognitive skills were required to make it. But that is essentially the product by which our productivity and efficiency are judged. And my view is very grim because I think the hyperefficient practice we’re about to increase and promote will not equate cost and value; they’re actually at odds with one another. I think we’re solving for a cost-efficient system, not necessarily a system that places a value on accuracy or on the intangible things that we do as radiologists to take care of patients and the places where we interact with them. We need to marry cost and value to solve for hyperefficiency. Larson: A major source of this problem is that the reimbursement environment for radiologists provides strong incentives for productivity and weak incentives for quality. Individual radiologists and groups are financially penalized when they take time to focus on difficult cases, defer to subspecialists when appropriate, or work with hospitals to make system improvements. Many politicians and health policy analysts are starting to recognize this as a problem Forman et al. Masters of Radiology Panel Discussion

Practice management issues for radiology residents: focus on self-referral.

As residents, we are most concerned with learning interpretive skills, as well as becoming compassionate, competent physicians. Given the stress of passing all of our discipline’s board examinations, only minimal time is devoted to the practical aspects of the business of radiology. To be more equipped to begin and succeed in our careers, as well as to plan for and participate in the future of our specialty, we believe that there should be more of a focus on economic, business, ethical, and legal issues affecting radiology in our 4 years of training. Many training programs provide didactic series on noninterpretive skills. In addition, the ACR and the Association of Program Directors in Radiology created and distributed to all training programs a set of videotaped lectures to supplement residents’ learning in such areas as practice management, ethics, and communication skills. Although additional good information is scattered throughout the radiology literature, residents may not have the time or inclination to explore it. Yet creating highly informed radiology residents is vital to maintaining the future economic and political fortitude of our specialty, which should be everyone’s priority. In this column, we discuss the phenomenon of self-referral, which is one of the many socioeconomic topics that should concern residents during their training and that require the attention of educated radiologists now and in the future. By highlighting self-referral, we hope that we will spark interest on the part of residents and provide a nidus for future learning.