The Roadmap to Reform

I have a number of very intelligent friends and colleagues, each of whom are better writers than I am. Sadly (mainly for my readers) I am the one who has the foolishness to expose my talents to the public.

Here is another take on insurance reform, provided not by my friend Bart, but by a different colleague, which also makes perfect sense. I am publishing this even though my friend believes in the “private/public consortium” which I do not, the rest of this vision is clear and essentially uncontestable. In the interest of balanced reporting, I present his plan in its entirety.

Without further ado….


Medicine is sick.

I have talked to hundreds of doctors, scores of hospitals, and many outpatient ambulatory medical center and hospital administrators. They all agree. Medicine is sick. They all agree, something must be done about the way medicine is practiced in America. They all agree that the state of our healthcare PAYMENT system is flawed. I have never encountered anyone who is intimately associated with any aspect of healthcare payment and/or delivery in this country who will say “I like things just they way they are. We have a perfect system.” There seems to be universal agreement that healthcare reform is necessary. There seems to be universal agreement that the status quo is unacceptable. WHY THEN ARE WE GRIDLOCKED? Why are Americans so upset with our lawmakers? Why is there a schism between liberals and conservatives? Why is there no agreement between doctors and lawyers? Do doctors serve patients, or themselves? Are doctors capitalists, or socialists? What is the future of healthcare?

I have my own version of reality to present to you. I can think of only one other conflict that seems anywhere close to as epic and complex as this, the Israeli / Palestinian conflict. Just as there is an agreed upon Roadmap to Peace, I have devised a roadmap to health care reform. I would like to present it for your consideration.

The Roadmap is linear. Each step builds upon the one before it. One can not bypass the order with success. I will also suggest that our current failure in reform is because conservatives want to begin with step number 1, and Liberals would like to begin with step number 10. Conservatives do not want to see step 10 come to fruition, liberals see steps 1-4 as benefiting corporations and not patients. Meeting, and beginning, in the middle will not work. Compromise will fail. We must all see the road map, with its relative merits, inevitability, and progress sequentially, together.

I will attempt to elaborate on each point in series. But the roadmap is as follows:

  1. High deductible, low cost, catastrophic coverage insurance available on the open free market (not government provided, but perhaps government supported).
  2. Removal of exclusionary criteria from normal insurance qualifications such as pre-existing conditions and lifetime benefit maximums.
  3. Price transparency in the medical charge structure. The price of services should be based upon the demonstrated resource based relative value scale, and the price is consistent and transparent, regardless of payer.
  4. Open market for insurance across state lines, and across employers. Open markets are effective markets. Limited, restricted, or bottlenecked markets lead to price inflation.
  5. Insurance portability. Your purchased free market insurance stays with you, not your employer. Employers may offer attractive insurance incentives and health care savings account allotments in order to attract and retain employees, but your insurance belongs to you, not your employer. Employers should not be obligated to provide insurance any more than they should be obligated to provide you with transportation or groceries.
  6. Tort reform will limit the practice of defensive medicine and curb the lotto mentality held by many patients, and many lawyers.
  7. Utilization oversight. Doctors would, and should be compared with national benchmarks as to appropriate utilization and outcomes, and outliers should be examined. This may or may not be done using the payment structure.
  8. Wellness reforms. With responsible insurance companies, payors, and responsible doctors, the patient will be asked to take increasing responsibility for themselves. Healthy lifestyles can be subsidized via discounts and unhealthy lifestyles will be taxed via higher premiums.
  9. End of life care. Responsible consultation and oversight is necessary in this area, but only after the patient has become engaged in his/her plight.
  10. Universal coverage options which include both a two tiered public/private consortium, and establishment of a minimum humane level of care agreed upon by committee, paid for by all, and availabe to anyone.

I look forward to its elaboration. I am just barely idealistic, and nieve enough to think this is actually possible. I believe that heathcare DELIVERY in America is some of the best in the world. However, its PAYMENT system is among the most shameful. Our current growth rate is unsustainable. The bubble will burst….eventually.

Toledo: A Test Case for the Radiology Community

Dalai’s note: The following missive was published in the newsletter of the Ohio State Radiological Society, and copied on AuntMinnie. It was subsequently removed due to “copyright infringement,” but I managed to snag it before it disappeared. If the OSRS wants me to take it down, I will, but I think the message is very, very important for all of us.

Recently, a radiology group in Toledo, Ohio, was displaced by non-radiologist-led company. What occurred has significant implications, not just for the Toledo, Ohio, community, but also radiology in general. Its outcome will likely shape how, where, and for whom radiologists work in the future.

The Consulting Radiologists Corporation (CRC), a group of 19 radiologists, had provided radiology services to three hospitals of Mercy Health Partners (MHP) in the Toledo area for over 60 years. MHP, a part of Cincinnati-based Catholic Health Partners, covers seven hospitals in Northwest Ohio. MHP decided to terminate radiology services from CRC with 19 days notice on May 19, 2009. MHP entered into an exclusive contract with non-radiologist-led, California-based Imaging Advantage (IA) to provide radiology management and interpretation services to all three hospitals. This decision to change providers completely bypassed medical staff and the medical executive committees at all three hospitals. IA pushed their product to MHP using the names of Massachusetts General Hospital (MGH) radiologists and MGH resources like their 3D lab, implying that MGH would be acutely involved in the activities at the MHP facilities. High-ranking MGH faculty members were initially listed on the IA website as “company leadership,” but their listing was suddenly removed following publicity of the connection.

About nine months prior to the radiologists’ removal, MHP administrators told CRC that an outside, “independent” consultant would evaluate the radiology departments to improve services at the their facilities, and report back to CRC and the administration with their findings. CRC believed that hospital administration was acting in good faith to address some issues within the departments, and was candid with their assessment. CRC never received any report from the consultants’ findings.

The consulting firm in question, RCG HealthCare Consulting, is neither “independent” nor unbiased. Many of the board members of RCG were also listed as “company leadership” on the IA website. Several have co-appointments at MGH. There is a clear RCG-IA-MGH axis, whereby presumably RCG would evaluate the radiology department seemingly acting as an “independent” agent, while covertly pushing IA’s services, and using the MGH name to exert influence on hospital administrators. Also, there are people within the ACR leadership who serve on RCG and IA boards. ACR leaders are in their bounds to work with IA and RCG. Ethically and morally speaking, however, ACR leadership should not be in the business of displacing local radiology groups or decreasing the independence of radiology practices.

CRC has been providing radiology services in the three hospitals for many decades with a gentleman’s agreement. In spite of that, CRC had been providing services through many challenges, such as hospital administration turnover, ups and downs of the hospital business, local hospital competition, and changes due to the overall economic climate in the region. The group had always provided services to MHP through good and bad times.

During the short transition, CRC members were offered 3 to 4 weeks of locum work with the verbal understanding to work “longer term” (though not necessarily permanently) as an employee of IA. All CRC members independently decided against this offer due to its ambiguity (no written, official contract was ever offered by IA) and to maintain independence to practice medicine through a radiologist-led group. The group decided to go forward and maintained the existence of the CRC by providing services to another non-MHP hospital, group-owned imaging center, and the Northwest Ohio community at large.

Immediately after the announcement of the termination of services on May 19, 2009, the hospital administration and IA began a smear campaign against CRC and its reputation of high-quality services by various means to justify their action. This included an open letter to Dr. Carol Rumack, President of the ACR, by the CEO of IA, Mr. M. Naseer-Uddin Hashim, as well as verbal communication, meetings, and emails with hospital clinicians, staff, and employees. CRC submitted to the ACR a response to Mr. Hashim’s open letter, refuting the allegations contained therein. In writing, CRC asked the MHP administration and Mr. Hashim to provide evidence for the allegations made in the open letter and an MHP bulletin. To this date, there has been no response to the letter from either IA or the MHP administration.

The post-CRC situation at the MHP facilities are dismal. I have heard from many sources indicating markedly decreased quality of patient care, a very unfortunate event. IA is still relying on temporary, locum radiologists and utilizing help from Idaho-based NightHawk Radiology Services for both day and night work. To my knowledge, IA does not have a permanent radiologist on the ground in Toledo at this time. Many procedures, including IR, are delayed or cancelled, due to the lack of available, qualified radiologists. I am deeply concerned about the decreased quality of and delayed patient care in the community.

Another entity affected by the change in radiology providers has been a radiology residency program. MHP hospitals served as clinical training sites for a residency program under the auspices of the University of Toledo College of Medicine. CRC physicians were accredited clinical faculty at the MHP hospitals. With the abrupt departure of CRC from these hospitals, the future of the residency program was called into question. Mr. Hashim maintained that the residents could still train at the facilities after IA began their radiology services. The Program Director, who is not a CRC member, stated that the replacement of local clinical faculty members with rotating locum radiologists as clinical instructors would violate radiology residency committee (RRC) and Accreditation Council on Graduate Medical Education (ACGME) guidelines. It should be noted that the Program Director was never contacted regarding the eminent removal of CRC from the MHP hospitals prior to their removal. IA maintained in their open letter that CRC was responsible for the removal of the residents, which is clearly not the case. Despite this recent turmoil, the residency program is stronger, with the support and cooperation of non-MHP hospitals in the Toledo area. CRC is still aligned with the University of Toledo radiology residency program, serving as clinical faculty members and committed to the education of future radiologists. The future of medicine in Northwest Ohio is at stake, given that many program graduates stay to practice in the region. Cessation of the program would have made it more difficult to recruit physicians to the Toledo area.

On June 8, 2009, when IA took over radiology services at the MHP hospitals, Dr. Paul Berger, the founder and, until November 2008, CEO of NightHawk Radiology Services, abruptly resigned from the board of directors at the company. Whether NightHawk’s involvement with IA is related to his resignation is a matter of debate, however, in his resignation letter, Dr. Berger stated that “the Company has embarked on business and strategic initiatives which in good conscience I cannot support and do not wish to be a part of going forward.” Since November 2008, the CEO of publicly traded NightHawk has been a non-radiologist. NightHawk’s involvement with IA has caused a backlash against the company from the radiology community. Radiology groups have either cancelled contracts or are strongly debating doing so.

In addition, a recent analyst stated NightHawk’s future strategy should include disintermediation, that is, negotiate with the hospitals directly, thereby bypassing the intermediary, the radiology group. This statement, and the recent events with IA, forced the non-radiologist CEO of NightHawk to issue a letter to its customers, stating unequivocally that the company will not pursue that strategy. I can only presume that the backlash was strong enough to force a CEO to make such a statement.

Even though the current CEO denies pursuing such a strategy, it is only a matter of time before NightHawk deals directly with hospitals, bypassing radiologists altogether. As with any other publicly traded company, the growth of the bottom line is fundamental to growth of the stock, and therefore the profits of large Wall Street investment firms and individuals. Once the company believes they have saturated the market through working with radiologists, the only way to increase profits is to displace groups that did not sign with them. Clearly, one way of pursuing such ends is by offering hospitals an alternative to their current situation. This should be worrisome to private radiology groups.

With the abrupt termination of CRC’s services at the hospitals, many radiologists might be wondering how to prevent such a takeover by outside entities. The ACR code of ethics requires radiologists to notify the local radiology group prior to entering into talks with the hospital administration. IA did not do that, but then again, IA is not a radiology group; it is an MBA- and JD-led enterprise that employs radiologists.

The long-term health of radiologists and their autonomy regarding their practices are at stake here. This is only a trial run, and could be a harbinger of realignment in radiology. Given this and the recent debate over healthcare expenditure nationally, it is important for radiologists to realize that without proactive steps, it is almost inevitable that the field will be commoditized.

First and foremost, the ACR and its affiliated state societies need to be stronger in the protection of radiologists right to self-autonomy. As we know, the ACR is actively involved fighting self-referral, imaging overutilization, in-office imaging services, and protecting reimbursement and patient safety and quality. In addition, the ACR should be active in informing members regarding the perils of non-radiologist-led companies such as IA and NightHawk. The more members are aware of such companies, the more likely members would refrain from using or providing their services to these enterprises. It is in the best interest for radiology as a specialty, and therefore, each individual radiologist.

Second, and I cannot state this enough, radiologists need to provide 24/7 service to their hospitals through different means, such as internal call coverage or developing shared night coverage between local groups. Over the past several years, there has been an increasing reliance on services such as NightHawk to provide weekend and overnight coverage for radiologists. I hope radiology groups realize that by providing their own services, hospital administrators and patients will realize the importance of radiologists as valuable consulting physicians in their hospital.

Third, radiologists need to be more involved in the medical community in their own setting. Radiologists should be more active in the medical staff activities, involve themselves in hospital committees, and have more communication with other clinicians for patient care. All radiologists must also be active in the political process to protect the specialty from outside forces.

Time will tell regarding the long-term result of the IA situation in Toledo, and its business model at large. The situation was chronicled in a recent Radiology Business Journal issue as well as in local media outlets. In addition, the situation has been hotly debated online, in the general radiology forums at Aunt Minnie and Dr. Dalai’s PACS blog.

Why Don’t I Trash Amicas?

Anonymous (who cleverly surfed to my site under InPrivate or some other blocking system) has this to say about my latest Agfa bash:

Oh my.. while I appreciate, and actually anticipate, your posts, is anyone else getting sick and tired about hearing of the pitfalls of every vendor EXCEPT Amicas? Come on!! First of all, I agree with you as I am not a fan at all of GE, Agfa, Siemens, and many others. In addition, I am also an Amicas user!! However, my system crashes and my system has issues, just as does every system out there. I think, and this is just my honest opinion, that readers would better appreciate unbiased views as continuing to knock the others and failing to mention your own products shortcomings is a little silly. However, this is your Blog!!! (And I still love it…..)

I really do appreciate any readership I get, and I thank Anonymous for his (her?) comments.

I have, over the years, dealt with the issue of me and Amicas. No, they don’t pay me, and yes, I am a loyal user. I go out of my way to point out on most occasions that I do not believe the Amicas product is perfect. And it isn’t. There isn’t a “perfect” system out there. I favor LightBeam (and soon Halo) because it lets me work in the manner I prefer, with minimal obstruction.

We have had problems, and service has on rare occasions been imperfect. However, the problems do get fixed, and therein lies the difference. By and large, Amicas listens.

I rant about the other vendors because there are times when this is the only way to get their attention. The recent situation with Agfa is quite telling in this regard. The glitch causing the client to crash is a known problem, and we have been trying to get it fixed for months. The client crash is bad enough, but the examination that was on-screen at the time of the crash DISAPPEARS for several minutes. It cannot be found on the worklist or by searching. Several exams have gone unread because of this, and that impedes patient care. Early on in this process, Agfa’s lower tier response was simply, “We’re talking about it. Change your workflow in the meantime.” That is NOT acceptable, and when I’m backed up to the wall on something like this, I use the one tool I have at my disposal, and that is what you see here. I have since heard from higher levels, and I hope there will be more progress.

To date, I have not had to go through this with Amicas. Yes, we have had problems (the damn thing runs on Windows, after all!) but they have been solved. Occasionally it takes several tries. But Amicas has the good sense not to ignore problems and not to make it seem as if it’s asking too much to fix them. IF they do, I will post about it, but frankly, I’m not expecting that to happen.

The biG Entities out there have systems designed by engineers for some vague prototypical customer, and clearly, some of their solutions suck. I said this directly to one of the senior GE folks to whom I was introduced at the DI booth at RSNA a few years back. The old Centricity Web, for example, is absolutely unusable. The poor GE exec looked like I had just killed his dog. Extrapolating a bit, I take this response, and a lot of what I see and hear, to mean that the folks designing this stuff have absolutely no clue whatsoever how we, the radiologists, use their very expensive products. This filters down to service as well. The suggestion of a workflow change in the current troubles is not a bad idea, in that there are ways to keep the rads from getting their grubby cursors on unfinished exams. BUT, using that approach as a fix for a client-crashing error doesn’t cut it, and it shows some level of disconnect between vendor and customer.

You might think I sit in the corner with my laptop, cackling with glee every time I write something nasty. Nothing could be further from the truth. Frankly, I hate bashing. I’m scared of the trouble I could cause the company involved, as well as my group, my hospital, and myself. But sometimes, ya gotta do what ya gotta do, know what I mean?

Nordstrom’s among only a few remaining retailers follows the old dictum of “The customer is always right.” I don’t think I’m always right, but I know how my end of the business works, and I know when something isn’t working. An issue that sinks to the level of appearing here simply hasn’t been adequately addressed. Really, all I need is for the vendors to listen and respond to their customers, me in particular. I hope that isn’t asking too much.

Please do keep on reading, Anonymous! Perhaps you could send me a list of your problems, and we’ll compare notes.

In the meantime, maybe I’ll find something else to trash!