Radiology’s Unique Vulnerabilities—and Enduring Strengths—During the Pandemic

Sept. 8, 2020
The medical discipline of radiology has been undergoing a period of exceptional and unprecedented instability during the COVID-19 pandemic—with an unpredictable path going forward into 2021

It was sobering to listen to a webinar that was presented last month on the business of radiology. “Pandemic Revenue Cycle Management: Perspectives and Practice,” was presented on August 17 by the editors of Diagnostic Imaging, and sponsored by Nashville-based Change Healthcare. The speakers were moderator Melody Mulaik, president of the Cedar Park, Tex.-based Revenue Cycle Coding Strategies; Christie James, senior manager for radiology revenue cycle optimization at Massachusetts General Hospital and immediate past president of the Fairfax, Va.-based Radiology Business Management Association (RBMA); and Greg Nicola, M.D., a practicing radiologist, executive leader at the Hackensack (New Jersey) Radiology Group, ad chair of the Commission on Economics at the Reston, Va.-based American College of Radiology (ACR).

The three presenters shared a wide range of information and insights regarding the current state of radiology practices and of integrated health systems with radiology departments and services. Not surprisingly, initially, when on March 18, the Centers for Medicare & Medicaid Services (CMS) essentially shut down nearly all elective procedures, radiology was hit particularly hard, as the countless routine diagnostic imaging procedures that are routinely carried out prior to elective surgeries, became unnecessary, even as healthcare consumers, justifiably frightened by exploding rates of COVID-19 infection, chose to avoid a great deal of even needed medical care. At the same time, the leaders of all patient care organizations were having to move as much care delivery as possible to remote, in order to optimize the safety of both patients and clinicians and staff.

As Dr. Nicola put it, “[T]he elective procedures were decimated at first,” Hackensack Radiology’s Nicola reported. “At our worst, we were down 85 percent in northern New Jersey, for about ten days, mainly because there weren’t elective procedures. Those slowly ramped back up over time, and we’re starting to see numbers comparable to prior to COVID.”

How did that impact the clinicians and staff at Hackensack Radiology Group? “We had to cut staff and furlough staff,” Nicola said. “We have about 20 partners out of about 45 radiologists, and the partners did not collect any salary for about two-and-a-half months, just to keep our business afloat. We wanted to keep our outpatient centers at a minimum level of throughput, and consolidated procedures in some of them. But the money from Medicare and the government through Payroll Protection and the Provider Relief Fund were just not enough to keep our business afloat, so we forewent partner salaries for two-and-a-half months.”

As of late last month, diagnostic imaging procedure volume had returned to something relatively close to pre-pandemic levels, but some of the disruptions that came about at the outset of the pandemic actually continue to impact how radiologic care is delivered, Nicola said last month. “We now have virtual waiting rooms, and patients like it because they’re safer now,” Nicola said during the webinar. “And so we’ve created the concept of no more waiting. You pre-register, you’ve moved to preparedness for your visit. And we still have a little bit of imaging capability at our imaging centers. And our CT volume has never reached 100 percent of capacity. And moving to electronic has allowed a lot of our people to become more efficient.”

In other words, the COVID-19 pandemic is starting to reshape care delivery in new ways, including around patient convenience and preferences. This is something that has long been a thorn in the side of all of U.S. healthcare delivery, not just that of radiology; but radiology may see the impact of previous consumer discontent playing out in particularly pointed ways. Indeed, Nicola said, “I do see some long-term problems in continuing to function in this way; hopefully, we’ll be able to create hybrid systems.”

That said, he added that “We’ve implemented drastic scheduling changes that looked at ways to help people staying at home.  We are doing more remote readings, and radiologists are appreciative of being able to work at home; we’ve also created greater flexibility of scheduling for physicians, and by separating out different types of urgent care, emergent care, etc., has helped us a lot—adjusting what people are doing on a day-to-day basis.”

But what about the medium- and longer-term impacts? Asked how he and his colleagues adjusted to loss of productivity during the first months of the pandemic, Nicola said that “I can’t speak for a large organization with many specialties. We gave up looking at RVUs for a couple of months; we just looked at absolute volume and made staffing decisions, but we didn’t hold radiologists responsible for productivity for the past three months; we’ll gradually ease back into that. The other element about holding people accountable for RVUs is that your case mix matters a lot in radiology. Certain specific CPT codes have been devalued over the years, and others not; the neuroradiologist and body radiologist are working with very different factors. Until we can look at specialty benchmarks in the way we had before, it’s awfully hard to evaluate productivity.”

Importantly, Nicola noted, “The physician fee schedule really has been flat for decades, with respect to costs. That will have to be looked at. And Medicare decided that budget neutrality would stay within the physician fee schedule, and that has impacted radiology. ACR is working with Congress on ways to mitigate that hit. And the hit is happening at a time when we have exciting developments with AI and machine learning; but how do you actually bring in AI into your practice when you’re facing an 11-percent hit, and can’t afford it? It involves paying doctors fairly, and involves a complex problem.”

So there you go. Really, what’s happened to radiological practices during the COVID-19 pandemic speaks to the complexity of the financial and operational space that radiologists are inhabiting in the current policy and payment landscape in the U.S. healthcare system. The reality is that senior CMS officials have had radiology billings in their gunsights for years now, and have fashioned full sets of regulations to try to bring down what many see as unreasonably high expenditures, for diagnostic imaging procedures, in a healthcare system groaning under the weight of cost increases, and with the prospect of total U.S. annual healthcare expenditures expected to reach $6 trillion a year within the next six years. In short, if there’s a single medical specialty that was already the target of policymakers’ and payers’ focus for spending cuts, even prior to the emergence of the COVID-19 pandemic, it was radiology.

There appear to be a few irreducible implications of all of this. First of all, it’s clear that the purchasers and payers of healthcare are going to continue to try to hammer expenditures for diagnostic imaging procedures, going forward, regardless of how the pandemic plays out across the healthcare system; that is going to be an ongoing theme in the next several years. Second, the ongoing consolidation of radiological practices—whether within ever-larger consolidated, even nationwide, radiology meta-practices, or inside integrated health systems—is inevitable. The days of the two-, three-, and four-radiologist practices are nearly over now; the economics are simply not there.

Third, the consumer experience will loom ever larger, going forward. As Dr. Nicola referenced, consumers do not like to wait. And if there’s a single impact to the entire “consumer empowerment” narrative in U.S. healthcare emerging out of the pandemic, it’s this: consumers were already deeply dissatisfied with the long wait times and relative lack of responsiveness of providers and patient care organizations, in U.S. healthcare, prior to the emergence of the pandemic. Now? Consumers are totally over the idea that they have to be treated like cattle, sheep, or even sheepdogs, in healthcare. If Amazon can service their needs quickly and conveniently, why can’t healthcare? There simply are no longer any excuses. And so all of those who are directing and managing radiology services, as well as practicing radiologists themselves, will need to figure out how to streamline all radiology-related services, in order to make healthcare consumers feel good about feeling well. There’s no longer any option involved.

And of course, all of these phenomena are playing out during a period of exceptional instability and unpredictability in the world that radiologists and their staffs inhabit. No one knows for sure exactly how all this will play out, except that, clearly, there will always be a need for diagnostic imaging services to be delivered and for images to be interpreted and for reports to be produced. An additional element in all this will be artificial intelligence (AI) and machine learning—a phenomenon of maximal importance in the most interpretation-based, and most technological, of the medical disciplines.

So what Dr. Nicola and the other industry leaders testified to in that webinar last month was and is a real thing; what no one can know is exactly how everything will play out. But all of this will be in the spotlight in the next few years, and radiology deserves close observation in the next few years, as the U.S. healthcare system moves through and out of the COVID-19 pandemic. Radiologists are truly living the ancient Chinese aphorism about the curse of living in interesting times—and everyone knows that the times could get even more interesting in the coming months. This is absolutely one of those “stay tuned” situations.

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