Opportunity Knocks: A Primer on the Primary Care Shortage

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The answer, it turns out, is still emerging. History may provide an apt starting point.

Specifically, before the fee-for-service era push for maximum productivity and imaging utilization, the core assets of radiology included an understanding of imaging technology, test interpretation and provision of actionable knowledge based on the imaging exam. Radiologists were the doctors’ doctor and were often consulted for many clinical questions; the reading room was a hub of clinical activity.

Fee-for-service reimbursement, coupled with the advent of PACS, relegated radiologists to a smaller, but immensely profitable, role. Radiology thrived. Imaging services were a revenue generator for most hospital enterprises. The radiology department adopted a narrow focus on productivity and efficiency. That, in turn, impacted interactions with referring physicians. As radiologists isolated themselves in the reading room, in-depth consultations with clinicians became the exception rather than the rule.

“The fee-for-service reimbursement model has promoted volume over value,” wrote Richard Afable, MD, MPH, of St Joseph Health, Irvine, Calif., and Michael N. Brant-Zawadzki, MD, executive medical director of physician engagement at Hoag Hospital in Newport Beach, Calif., in the July issue of Journal of the American College of Radiology. “Thus, radiologists are pressured to read an ever-increasing volume of studies while disregarding important clinical responsibilities. This has divorced radiologists from their traditional role as consultants to physicians and patients and as integrators of the patient experience between referring physicians and specialists. Radiologists have become piece workers, the ‘read’ becoming their main output.”

Nevertheless, clinical consultation remained an important part of the radiologists’ job. However, not all clinical consults are created equally.

Paul J. Chang, MD, medical director, enterprise imaging, at The University of Chicago Medicine, offers the contrast between a call for a consultation from a referring surgeon and one from a primary care doctor. “My approach to reports and image review is aligned with the surgeon’s. Our discussions tend to be very efficient and short.”

The consultation with a primary care physician is an entirely different story. Most calls tend to take much longer than a call with a surgeon. That’s because the image serves as the entry point for an in-depth conversation about the disease process, with the physician often asking the radiologist a series of questions, including:

  • What is the disease?
  • What do I do?
  • Who do I call?

“This conversation takes a lot of time,” Chang explains. “In the fee-for-service world, physician education is considered a burden because it distracts the radiologist from relative value units (RVUs).”

From Here to There

  • Reimbursement needs to continue to move in the direction of value, particularly for imagers, to de-incentivize maximum productivity and emphasize communication, collaboration and image management. Think advocacy at the national, regional and local levels.
  • Additional research and data are required to determine how to optimally structure teams, patient-centered medical homes and other collaborative partnerships. Get involved.
  • Healthcare enterprises, accountable care organizations, primary care providers and radiologists need to communicate about changing roles, structures and needs. Be part of the discussion.

Part of the problem is the pressure of the primary care environment. Managed care allotted physicians a mere 12 minutes per patient, notes Brant-Zawadzki. “All the primary care physician could do was figure out where to send them, so they could get to the next patient.” Radiology and laboratory testing became the go-to diagnostic services, hence the dramatic rise in utilization through the 1980s and 1990s.

Healthcare reform and accountable care, however, de-emphasize volume and RVUs and instead focus on value. “Before, healthcare providers made more money when the patient got sick enough to go to the hospital. Now, we will make more revenue if the patient never gets to the hospital, which means preventing strokes, heart attacks, mastectomies and so on,” says Chang.

This model requires a different mix of ingredients, including prevention and education, a mainstay of primary care.

Yet, primary care physicians are in short supply, so success will hinge on extending primary care physicians. The dilemma may set the stage for radiologists to