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President's Address |
1 From the Department of Therapeutic Radiology, University of Minnesota, 494 Delaware St, Minneapolis, MN 55455. From the 1999 RSNA scientific assembly. Received February 28, 2000; revision requested March 14; revision received and accepted May 23. Address correspondence to the author (e-mail: levit002@tc.umn.edu).
ABSTRACT
Six departments of radiology and six departments of radiation oncology from areas with low, medium, or high managed care penetration were asked to complete a questionnaire designed to address the impact of managed care on research and scholarly activity. Information, when available, was taken from fiscal years 1993 and 1998. Questionnaires were followed by site visits to the 12 departments. The study showed that departments with medium to high managed care penetration reported more dissatisfaction in their ability to remain active in their education and research goals. Results indicated that for the period surveyed, the departments needed to increase clinical time to make up for decreasing patient care revenues. In turn, this has reduced the time and money devoted to scholarly activities. Information from this study will be used to develop a trends database for all U.S. radiology and radiation oncology departments. This, together with a more comprehensive study by the RSNA, will assist in measuring the current and potential long-term impact of managed care and other system changes on the practice of radiology and radiation oncology.
Index terms: Education • Radiology and radiologists, research • Radiology and radiologists, socioeconomic issues • Therapeutic radiology
Teaching, research, and community service ... are essential to a sound, compassionate health care system. Not only are these social responsibilities, they are investments in the health of each of us over the long term.
Robert H. Fletcher, MD, MSc (1)
With the current focus on the marketing and economics of health care, the discussion of health care is rapidly becoming one solely of dollars, policy, budgets, and marketing strategies. At risk is a diminished sense of the central purpose and mission of medicine as a service to care for people who are ill. As health care professionals, we are being challenged to clearly and strongly define who we are and what we do to prevent this erosion of the central purpose of our profession, as well as to help shape the future of our profession under the current rapid changes.
Our primary responsibility is to our patients. As radiologists and radiation oncologists, we strive to bring the best technology and clinical expertise to the patients who come to us. To achieve this, we need to support and participate in scholarly activities that inform us of the best ways to care for our patients. Active participation in organizations such as the Radiological Society of North America (RSNA) is critical for the dissemination of knowledge through sponsored research, educational opportunities and programs, online services, journals, and meetings (Fig 1).
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Our ability to participate in organizations such as the RSNA, as well as our ability to engage in education and research, are being curtailed by diminishing patient revenues nationwide. As centers of education and research, academic health centers are particularly under threat from the combined dominance of managed care and legislation from the 1997 Balanced Budget Act. For almost the past 50 years, revenue received from patient care delivered at academic health centers and from research has been used to support all areas of academic health center activities, including teaching basic and clinical science. In most academic health centers, this revenue contributes up to 90% of the budget. With the current focus on cost and budgets, serious problems are occurring within these institutions that are relegating research and education to secondary status, at best. By doing so, high-quality health care is under threat. Without a strong focus on research to develop and test the benefits and risks of new technology and pharmaceuticals, the quality of future care is in jeopardy. Without a strong commitment to education, the skill and problem-solving abilities of current and future physicians are undermined.
Although many studies cite an adverse effect of managed care on scholarly pursuits, most of these studies are anecdotal. Also, few, if any, studies address specifically the influence of managed care on radiology and radiation oncology. In the hope of filling this void, the RSNA developed a two-phase project to systematically and scientifically examine the impact of managed care on the scholarly activities of departments of radiology and radiation oncology in the United States. In phase I, a limited number of radiology and radiation oncology departments with different levels of managed care penetration were selected to assess the impact of managed care on their scholarly activity. A broader goal of the first phase was to determine the feasibility of conducting a similar national study of all radiology and radiation oncology departments in the United States, and with the data collected, to develop a trends database for departments to use to help measure the ongoing effects of managed care on their departments. This will be phase II of the project. Phase I of the project is now complete and is summarized in this report.
SELECTION OF DEPARTMENTS
The RSNA initiated phase I in January 1999, designing it as a prospective case study to examine the effect of managed care on six radiology and six radiation oncology academic departments in the United States during a 5-year period (1993–1998). Departments were selected based on the following criteria: (a) Departments were in metropolitan areas that were identified as having low, medium, or high managed care penetration; (b) the site had to have both a department of radiology and department of radiation oncology; (c) the departmental chair had to have served at least 5 years; and (d) the department was willing to participate in the project.
Prior to the selection of the participating departments, the RSNA staff identified areas throughout the United States where managed care penetration ranged from low to high. Level of managed care penetration was defined by using data from "HMO Penetration and Industry Data: Metropolitan Statistical Areas" by InterStudy Publications (3). High penetration was defined as 50% or higher, medium penetration as 30%–49%, and low penetration as 0%–29%. Generally, penetration represented the proportion of the metropolitan statistical area population that is enrolled in a health maintenance organization.
The departments of radiology and radiation oncology within each level of penetration were then compared to determine how the departments corresponded to the range of managed care penetration nationwide. From this, the RSNA staff were able to select radiology and radiation oncology departments located in varying areas of managed care penetration that were representative of the current distribution of radiology and radiation oncology departments by managed care penetration nationwide. To obtain a fair representation, two institutions with each level of penetration (ie, low, medium, and high) were chosen. Of the six radiology and six radiation oncology departments, therefore, four departments represented low penetration, four represented medium penetration, and four represented high penetration.
QUESTIONNAIRE
Following the selection of participating departments, a questionnaire developed by RSNA staff was mailed to each department (for a copy of the questionnaire used in phase I, please contact the RSNA Office of Research Development at [630] 368-7889). Questions included information about revenues, expenditures, number of full-time faculty, relative value unit production, departmental publication record, sources of funding research, clinical trials participation, number of academic days given to faculty, and number of fellowships for the fiscal years 1993 and 1998. The chairman of each department was asked to complete the questionnaire prior to an on-site visit from RSNA staff. Most departments were able to fully answer all the questions on the questionnaire; however, some departments did not have records of all information, particularly for the 1993 data, and therefore were unable to fully complete the questionnaire. The on-site visit allowed RSNA staff to discuss the questions with the department chair, clarify forms, and obtain recommendations for modifications to the forms and other data.
On the basis of the information gathered from both the questionnaires and the site visits, the RSNA staff developed a national survey questionnaire that will be mailed to all radiology and radiation oncology departments nationwide in phase II of the project. Topics addressed in the survey are listed in Figure 2. The goal of this survey is to establish a trends database for all radiology and radiation oncology academic departments nationwide. The database will help departments measure the ongoing impact of managed care and other health care system changes on research and scholarly activity. The RSNA Office of Research Development, directed by Dana A. Davis, MEd, in consultation with Kent Nash, PhD, the primary investigators of the overall project, will conduct the survey. The results of the national survey will be published when complete.
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Phase I of the study found that nearly all departments, regardless of managed care penetration, recognized the extent of managed care penetration in their market areas. In most cases, managed care was defined as reduced-fee health care. With the exception of one department in a high managed care penetration area, capitation was not an issue because few patients treated at these departments were in capitation plans.
All departments indicated that the growth of managed care firms had influenced their departments, and that Medicare rules and regulations were exacerbating that influence. Departments with higher levels of managed care penetration (ie, medium to high) were more descriptive in detailing the areas in which they felt the effects of managed care: (a) increased total patient examinations, (b) higher billing for services and lower collection rates, ranging from 25% to 50% of billings, (c) lower reimbursement rates because of increased concentration of managed care firms, and (d) increased levels of clinical time required to maintain department revenue.
Departments with medium to high managed care penetration experienced faculty downsizing from 1993 to 1998. Only one department with low managed care penetration reported downsizing but did not attribute it to managed care. Specific effects of managed care on faculty activities, including teaching, research, and publishing, were identified. Underlying these specific effects, and cited by faculty as the primary cause of their inability to fulfill their scholarly responsibilities, was the demand for increased clinical time because of falling patient revenues.
SPECIFIC EFFECTS
Education
Overall, departments with medium to high managed care penetration tended to report more dissatisfaction in their abilities to devote sufficient time and remain active in their educational goals. Specific concerns included the decreasing number of fellows and residents in departments with higher managed care penetration and the recognition that the inability of faculty to give appropriate academic attention to residents and fellows may contribute to this and may also contribute to the inability to retain potential candidates for future staff positions. Another concern was the difficulty in attracting new faculty because of higher salaries and off-time in private practice (Fig 3).
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All departments, regardless of managed care penetration, reported concern over their ability to compete for NIH funding because of increased clinical demands. Some faculty expressed concern that with pressures already existing from the impact on reimbursement rates by managed care firms, accepting NIH funding may be considered a net "cost" and therefore an additional pressure on departmental budgets. Some departments were concerned that external funding was being granted to research in the basic sciences but not the clinical sciences. Other concerns focused on problems with faculty morale and competition among faculty (Fig 4).
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COMMENTARY AND FUTURE DIRECTIONS
There is substantial anecdotal and retrospective evidence that managed care, combined with the Balanced Budget Act of 1997, is threatening to undermine the financing of education and research, which, along with patient care, have been the basic mission and tenets of academic health centers. Many studies document and describe the problems affecting academic health centers as they navigate the market-driven strategies partially enforced on them by managed care organizations (4–12). The problems most frequently and consistently highlighted in these studies are centered on the overall problem of constraints in the growth of patient care revenues, which subsequently constrain the growth of education and research at these institutions. Constraints on academic health centers are further exacerbated by the Balanced Budget Act of 1997 (13–15). Reductions in revenue from cuts in Medicare funding brought on by the Balanced Budget Act of 1997 are estimated to incur cumulative losses of nearly $15 billion for the nation’s teaching hospitals by 2002; this breaks down to about $45 million on average for each teaching hospital (16).
Traditionally, medical education has been subsidized through clinical service revenues, medical school tuition and fees, and allocated money from federally funded Medicare programs. Changes are occurring in all of these areas: (a) Constraints on patient care revenues are restricting funds flowing to education and research; (b) funds from medical school tuition and fees are lower due to decreased medical school enrollment (an average decrease of 8.4% was noted from 1996 to 1997 [4]); and (c) cuts in Medicare resulting from the Balanced Budget Act of 1997 are reducing money available to help fund graduate medical education (4). For example, in 1998, Medicare’s direct payments for residency training totaled $2.2 billion. During the next 5 years (1998–2002), these payments are estimated to be reduced by $700 million. Indirect payments (eg, to cover additional costs of patient care for such things as maintaining trauma and burn units or conducting unsponsored clinical research) totaled $4.1 billion in 1998; during the next 5 years, these payments are estimated to be reduced by a total $5.6 billion (13).
Similarly, subsidizing biomedical research through clinical revenues is eroding over tightening budgets. This affects the money academic health centers are able to set aside for seed money to fund preliminary investigations. In addition, funding from external grants that investigators are able to receive often does not cover the full cost of research. A 1995 study conducted by the Allegheny Health, Education, and Research Foundation found that of the $22 million their foundation allocated to subsidize research, 81% of the cost was recoverable for basic research through external funding, whereas only 50% of the cost was recoverable for clinical research (4). Studies also show a reduced chance of receiving external funding in medical schools with high managed care penetration (4).
Along with these very tangible financial constraints on research and education in the managed care environment, time constraints also are limiting the ability of educators and researchers to do scholarly work. This also affects the amount of time and money allotted for involvement in organizations such as the RSNA. These constraints create morale and retention problems, with many top researchers and educators leaving academic health centers to pursue their scholarly work in other types of institutions.
All of these problems now influencing scholarly activity at academic health centers are evident in the radiology and radiation oncology academic departments that participated in phase I of the RSNA study reported here. The study found that departments with medium to high managed care penetration tended to report more dissatisfaction in their abilities to remain active in their educational and research goals. The demand for clinical faculty to spend increasing amounts of time engaged in clinical duties because of decreasing patient revenues was reported to negatively affect faculty morale, competition among faculty, faculty retention, hiring of new faculty, adequate training for fellows and residents, and ability to devote sufficient time to research.
Ongoing assessment of the effects of managed care on these departments and other radiology and radiation oncology departments nationwide will be part of phase II of this study. With the information collected during phase II, a trends database will be developed. Pending final approval by RSNA Board members, the database will be available to radiologists and radiation oncologists and will help departments measure the ongoing impact of managed care and other potential health care system changes on scholarly activity. Gathering this information will help define the needs of these departments and help us shape the future of these specialties so they will continue to provide high-quality patient care.
To further assist radiology departments, the RSNA also initiated a pilot study in September 1999 to help academic departments in North America improve radiology research activity. Called "Revitalizing the Radiology Research Enterprise," and conducted by a subcommittee with the same name under the auspices of the RSNA Research Development Committee, the program is designed to address the increasing importance of imaging in biomedical science and the need for improved quality and quantity of radiology research by helping departments to "more effectively achieve the progress in biomedical imaging necessary to meet societal expectations of improved health and public welfare" (from the study proposal’s mission statement). The need for increased research activity in radiology is evident in data that show that 10 of the 150 radiology departments in the United States receive 80% of NIH research funds. Moreover, most radiology departments receive less average funding support than other departments at their respective institutions.
To achieve improvements in radiology research, the project proposes to help reengineer the radiology research enterprise by organizing a three-phase program for academic radiology departments that will include a workshop, a site visit, and a follow-up evaluation to assess the departments’ research needs and goals. In addition, the Committee recommends organizational support for an ongoing educational program directed at academic radiology leadership that will include chairpersons and research directors.
Currently, 27 departments of radiology from the United States and Canada have applied to participate in the program. All applicants will be invited to a workshop sponsored by the RSNA to discuss various components that make up successful research programs. From all the applicants, six departments representing varying degrees of success in research will be chosen as case studies. These departments will complete a more comprehensive self-evaluation of their research activities and submit it to the RSNA for critique prior to an on-site visit by RSNA inspection teams to evaluate the research environment of each department and institution. These visits will be geared to help department leaders develop solutions to research barriers. Specific goals are to help departments develop a solid supportive research infrastructure, develop models of success (primarily for residents), develop an attitude that supports and encourages research, and identify sources of funding. Progress reports will be made over the next 2 years to the RSNA Board of Directors, with a final report to be published in 2002.
This pilot project, along with the project reported on here on the effects of managed care on radiology and radiation oncology, reflects the overall need for health care professionals and organizations to participate in shaping the future of medical practice and delivery. Above all, we need to keep the focus on the patient as others try to move the focus to budgets and profit margins. We also need to define the importance of education and research to ourselves, managed care corporations, government, and the public so that we can effectively argue for the importance of these long-term investments that in the short term do not turn a profit. They are not about profit. They are about ensuring that people who are sick will be taken care of with the best medicine we can offer.
There is a great need for health care professionals to be involved in the discussion of costs, equity, and accessibility and to be willing to adapt and create new ways of practicing our craft without sacrificing our essential mission, which is to provide the best possible care to our patients. The quality of care surely will diminish if we are not willing to engage our skills, our problem-solving abilities, and our knowledge of what we do best in the debate over the basic mission of medicine. And most important, we need to better inform the public and our patients of how essential research and education are to high-quality care.
SUMMARY
During the past 5 years, the primary influence of managed care on academic radiology and radiation oncology departments has been the need for faculty to increase clinical time to make up for decreasing patient care revenues; this has reduced the time and money devoted to scholarly activities. Departments with higher managed care penetration tended to report a more negative impact on scholarly activities. Legislation from the Balanced Budget Act of 1997 is exacerbating these effects of managed care throughout the health care system, particularly among academic health centers.
On the basis of information gathered in this case study, a trends database is being developed to help measure the ongoing impact of managed care on patient care and scholarly activity. This database will be the result of a more comprehensive study conducted by the RSNA in phase II. In phase II, all radiology and radiation oncology departments nationwide will be surveyed to assess the current and potential long-term impact of managed care and other health care system changes on the practice of these specialties.
ACKNOWLEDGMENTS
I thank all of the staff at the RSNA who developed and implemented this project, particularly the principal investigators, Dana A. Davis, MEd, Assistant Executive Director: Research and Education, and Kent D. Nash, PhD, Consultant, as well as N. Reed Dunnick, MD, and Wilbur Smith, MD, who helped develop the original questionnaire. I also wish to thank Mary Beth Nierengarten, MA, for her help in writing this article.
FOOTNOTES
Abbreviation: NIH = National Institutes of Health
REFERENCES
This article has been cited by other articles:
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  A. Rahal, H. W. Head, A. J. Jung, X. Garcia-Rojas, D. Vargas, N. C. Dalrymple, G. D. Clarke, G. D. Dodd III, and G. D. Fullerton Combined Radiology Residency/PhD Program for Education of Academic Radiologists: A Response to Revitalizing the Radiology Research Enterprise Radiology, October 1, 2007; 245(1): 14 - 20. [Full Text] [PDF]
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 C.P. Gross and H.M. Krumholz Impact of Managed Care on Cancer Trial Enrollment J. Clin. Oncol., June 1, 2005; 23(16): 3811 - 3818. [Abstract] [Full Text] [PDF]
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G. J. Becker 2000 RSNA Annual Oration in Diagnostic Radiology: The Future of Interventional Radiology Radiology, August 1, 2001; 220(2): 281 - 292. [Abstract] [Full Text] [PDF]
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C. D. Maynard Radiology: Future Challenges Radiology, May 1, 2001; 219(2): 309 - 312. [Full Text]
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