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Perspectives |
1 From the Department of Radiological Sciences, UCI Medical Center, University of California, Irvine, 101 The City Dr, Orange, CA 92868-3298. Received June 15, 1999; revision requested June 21; revision received June 29; accepted June 30. Address reprint requests to the author (e-mail: rmfriede @uci.edu).
Index terms: Perspectives • Radiology and radiologists, socioeconomic issues
In the previous Perspective (Part I) I reviewed the history of managed care, particularly in California, and discussed some of the changes that have occurred in the practice of medicine with the advent of managed care (1). Some of the major conclusions included the following.
1. Managed care has changed the concept of health, which used to be measured by the 1:1 relationship between physician and patient, to a population-based method of 1:n between physician and population (2).
2. Health maintenance organizations (HMOs) are deeply rooted in California, but the trend in the rest of the United States seems to be more to preferred provider organizations (PPOs), which might be called managed indemnity or managed fee for service. Although this is more costly, it is preferred by patients and physicians to HMO care. HMOs will continue to thrive in heavily industrialized areas, where corporations prefer the lower costs.
3. The government will have to address the needs of the 43 million people who have no health insurance. Under our present system, this number is increasing each year. Government-subsidized HMO programs should be formed to care for this population.
4. Most patients and physicians are unhappy with HMO care, which is regarded as too restrictive. I believe there will be a trend toward "focused care," in which patients will have a menu that allows them to select the type of care desired at variable costs.
The present socioeconomic environment that surrounds the practice of radiology has been and is continuing to be transformed by the rapid changes in the practice of medicine. We cannot separate the practice of radiology from the changes that affect the general practice of medicine. In this Perspective, I examine some of the changes that may occur in the practice of radiology in the next generation.
Look at what has occurred in radiology practice over the past 10 years. Radiology departments that were revenue centers under unrestricted fee for service are now cost centers. Radiologists who previously tried to maximize patient volume now try to control volume by restricting the use of advanced technology to those cases in which there is a probability of beneficial value. The relationship of diagnostic procedures to outcomes will be the main criterion. Intuitive medicine will be a thing of the past.
The changes in radiology are both external and internal. External changes are those concerned with the development of managed care, the emphasis on preventive medicine, the public cost consciousness, and the corporate control of the practice of medicine. Internal changes relate primarily to technology: computerized radiology, picture archiving and communication systems (PACS), integrated information systems, and diagnostic computer aids. I am not going to discuss possible new advances in technology. Over the next 10 years, much of these changes will be in networking, computer-aided diagnosis, computerized radiology, and PACS.
I would like to discuss two general areas that interrelate.
1. The problem of turf and how advances in networking and methods of reimbursement may affect turf.
2. The related question of whether a lesser number of radiologists will be required in the future.
The problems of turf and whether this will affect the number of radiologists required in the future relate to two main areas. The first is how radiology will be practiced in the future by radiologists, and the second is how radiology will be affected by other services that are interested in imaging.
Let us focus for a moment on informatics. Most institutions have their hospital information systems, and most radiology departments have their radiology information systems. Add to this the hospital quality management system, the digital dictation system and PACS of the radiology department, and the computer-aided diagnosis system, and then consider networking the entire lot (Figure). All patient information will be immediately available on the hospital information systems and the radiology information systems, and all imaging and reports will be on the network within the hour. The network will include the referring physician, hospital, and medical departments. This provides for excellent patient service, correlation of all information, and easy access.
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Another potential problem is the formation of groups of nonradiology specialists in different fields that compete for the same imaging volume. There are a few groups today, such as the National Orthopedic Imaging Associates formed in California, that offer consultation in sports medicine by means of teleradiology (4). As networking becomes more efficient, the Internet will be used for image transmission, and then the possible turf problems are mind-boggling. Orthopedists, emergency physicians, chest physicians, and many others believe they are capable of interpreting images in their field, and pricing may become the major factor.
Therefore, the enormous advantages of linked networking, which will shortly be available, suggest two major potential turf problems: the first, from large radiology groups that attempt to dominate a regional area and the second, from specialist clinicians who believe they are capable of interpreting the image in their specialty.
How do radiologists avoid these pitfalls? They have a built-in advantage in that they are on-site and supervise the technologists; they must maintain this advantage. They must try to become involved with the management of the managed care organizations; this is extremely important. They know the referring physicians and relate to them; they must cultivate this relationship. The radiologists must maintain their expertise at a level above that of other clinicians, both in their knowledge of imaging and in their clinical knowledge of disease. Then, they must compete on price and quality and realize that today price is every bit as important as quality. There are systems that radiologists in large institutions have instituted to protect their departments. A common example is the linking of the report to the image so that images are not available without the report. This type of protective mechanism, justified by radiologists in that it prevents clinicians from misinterpreting images on their own, will work only as long as hospital or managed care administrations support the radiologists.
With the problems mentioned above, will there be a lesser need for radiologists in the future? In 1998, Sunshine and colleagues (5) published the results of their questionnaire from 1995–1996. They noted that the average radiologist's workload, adjusted for relative value units, had increased 13% since 1991. They calculated that, on average, a patient received 18% more radiologic services in 1995 and 1996 than in 1991. From these data, they concluded there is no surplus of radiologists. They did not take into account possible changes in the practice of radiology, such as those just mentioned.
What are the factors that could lead to a surplus of radiologists?
1. If managed care succeeds in decreasing radiologic volume, particularly technologically complicated procedures, such as magnetic resonance imaging and computed tomography, the need for radiologists may be affected. Although those involved with cost control would like to limit such procedures, this will be difficult since they are productive and frequently influence outcome. Any decrease in such procedures will be more than offset by substantial increases in interventional procedures. Limitations will be primarily in the area of duplication and repeats, and much of this has already been corrected. Although examinations may decrease, I believe the decrease will be modest and will be offset by the increase in interventional procedures. If radiologists are left to practice as they are today, the overall requirement will be for more radiologists.
2. If managed care fosters the development of the radiographer as a nonphysician clinician, this could affect the need for additional radiologists (6). It would not surprise me if some states establish 1-year training programs for bright senior technologists to function as physicians' assistants in radiology, similar to what is happening in some areas of England and to what may be starting in Canada (Stevensen G, oral communication, 1999).
3. The most worrisome problems are still the turf problems, which will increase as networking becomes more efficient and widespread. Turf wars are part of the history of radiology. This is amply indicated by the fact that 50% of imaging is not done by radiologists (7). If large radiology groups dominate regional areas, as previously discussed, the overall need for radiologists could decrease by 15%–30%. If it becomes standard practice in managed care for clinical specialty physicians to interpret images, the decrease will be greater.
Much of the turf problem will depend on how radiologists are reimbursed in the future. I am presuming that outside of California, PPO or managed indemnity care will be dominant. Patients and physicians are unhappy with basic HMO care, and I believe that HMOs will mutate and offer more choice of physicians and fewer restrictions, which, of course, will increase costs. Although PPO care is more expensive than capitation in HMO care, physicians and patients prefer it. With PPO care, radiologists are paid a reduced fee for service, which encourages competition from regional groups of radiologists or nonradiologic clinical specialists. When radiologists are involved in capitation in HMO groups, turf problems will not be as substantial.
In the future, I believe that small group practices will disappear, and radiologists will practice in large groups of 20–40 radiologists to provide contractual services to managed care organizations. Clinicians will also be practicing in large multidisciplinary groups. I believe that these large clinical groups will attempt to hire radiologists on the basis of salary or capitation rather than fee for service. Therefore, there may be less fee for service in radiology than in other clinical disciplines. Overall, incomes will decrease below today's levels.
Radiologists are also vulnerable to being reimbursed on the basis of clinical volume, a variant that I believe will be fostered by managed care and will lead to competition between radiologists within a given group. Institutions or managed care groups may institute a base salary for radiologists plus a variable factor based on volume. This could lead to radiologists' attempting to increase their clinical efforts to increase their income, with the secondary effect of reducing the number of radiologists required.
From the above, one can see that although radiology may increase in volume, the need for radiologists may decrease.
With the dominance of family medicine and managed care, will radiology become more of a general specialty? I believe this will be fatal to the specialty, since images will be readily available on the network. If we do not encourage subspecialization in radiology, we will be encouraging all specialists to read their own images. We should consider combining specialty disciplines, where feasible, to allow broader coverage. This is already evident in the suggested combination of genitourinary and gastrointestinal radiology into abdominal radiology.
A major problem will arise with interventional radiology and neuroradiology. Currently, in many departments, interventional radiologists are unhappy with their economic status and relationship with other radiology subspecialties. Interventional radiologists and neuroradiologists will probably attempt to establish themselves in an independent service loosely affiliated with radiology, but clinical disciplines will exert increasing control over procedures. Many disciplines, including cardiology, gastroenterology, oncology, urology, vascular surgery, neurology, and neurosurgery, have already entered the interventional imaging arena.
Managed care may want certification in these specialties, but there is no indication that managed care will limit those procedures to only the radiologist. In a few scattered instances, I know that clinical departments have already incorporated interventional radiologists into their ranks and have assumed control of procedure; this may increase in the next few years. To avoid losing control of the bulk of interventional radiology, we must join with the individual clinical services in a multidisciplinary approach, which would probably be of overall benefit to the patient. I realize the dangers in such an approach in that we are removing the radiologist from the central control of radiology. However, in complex interventional radiology, I believe this will be necessary and will be the only way that radiologists will maintain some degree of control. This is particularly true since more and more of interventional radiology will be performed on an outpatient basis, with less hospital control of governance. The final shape of the future of interventional radiology and neuroradiology will probably be decided in the next 5–10 years.
There are many imponderables about the future of radiology 10–20 years from now. Overall, I believe that radiology volume will probably increase, and there will be a substantial shift in numbers to the more complicated studies, which will increase the relative value numbers. I believe interventional procedures will increase dramatically and move into the outpatient arena. I have discussed some of the major problems that are predictable: the problems created by the immediately available images; the problems that will occur in interventional radiology; the changes in practice that will be fostered by managed care, namely, the development of large multidisciplinary groups that may hire radiologists to serve within the group; and the increasing use of nonphysician clinicians, which may include radiographers in the future. Add to this the number of problems that will arise in the future and that cannot be predicted today, and we can see that the future will be interesting.
It is unfortunate that organized medicine has not been a leader of change but more a reactor to change that it considers unpleasant. Medicine has not declared its heritage—that of being the patient advocate. Physicians, to the layman, have too often appeared to be more interested in their own pocketbooks and comfort. That is not the way leadership is born.
The radiologist provides an important service to the physician and patient. Radiology is the triage of medicine. There is no question in my mind that radiology will continue to grow in the future—the only question is, in which garden will the growth take place?
As a postscript, what will happen to radiology in the future is a matter of opinion and conjecture. I am sure that many readers have their own concepts on future developments. I encourage all such futurologists to send me their opinions; I would like to learn from them.
References
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