By Douglas Smith
President & CEO, Barrington Lakes Group, Inc.
02/19/08

I have been trying to decide, once again, how to respond to a recent communication from a radiology practice executive on a web forum lamenting the recent termination of his group's professional services contract from their hospital. I pondered how to respond to this discussion without irritating at least someone. In the end, I decided there was no way I was not going to irritate at least one or more radiology practices with my commentary, but sincerely hope all readers will take what we have to offer in the spirit in which these thoughts and comments are offered-provocation of thought processes.

Taking into consideration other diagnostic imaging market trends we have all witnessed, directly or indirectly, over the past several years, I am prompted to reiterate advice we have been passionately providing to our radiology clients for some time now.

For those who know me, I need not preface the statements to follow. For those who do not know me, please know I am a vocal (sometimes too vocal), rabid, and evangelical advocate of organized radiology. We encounter thousands of dedicated radiologists who serve their partners, hospitals, respective medical staffs, and patient populations in the communities they serve, with passion, leadership, outstanding service, and clinical excellence.

There is little question we have all seen, in recent years, a sea change in diagnostic imaging. As never before, radiologists have experienced substantial increases in workload. Radiologists are experiencing increased sub-specialty training requirements to meet the steadily advancing applications of advanced technology in diagnostic medicine; steadily increasing administrative and overhead costs; increasing competition for clinically-qualified, leadership-experienced, radiologists; increasingly expensive implementation of regulatory policy requirements; ever-increasing turf encroachment by non-radiologist medical specialties-not to mention continuous demands from hospital administration leadership on a number of fronts-and skyrocketing needs and demands from now-quite-diverse radiology group members-all in an environment of ever-decreasing payment for services provided.

The list of external and internal pressures to the radiology group practice goes on and on.

I cannot begin to count the number of outstanding radiologists who have packed it in in recent years as early as 10 to 15 years ahead of normal retirement.

We, and many of our esteemed colleagues in the consulting profession, have had the pleasure of working with, or have observed, hundreds of outstanding, savvy and astute radiology groups that "re-engineer" their practices to thrive in the same environment that is driving others out of the market.

Unfortunately, we have also all seen a number of radiology groups implode from internal divisiveness, or be summarily dismissed from their markets for a whole host of, what we believe, are unnecessary reasons.

In our experience, the underlying difference between the groups who are flourishing in their communities, and others who are meeting their demise, is a fundamental difference in perspective, culture, and behavior. Some are victims, and some are leaders.

It is way too convenient for any of us to point a finger outward, at forces we believe are to blame for our circumstances and label these issues as "outside of our control," and at further evidence of continuing "commoditization" of our profession as the root cause of all of our troubles.

Organizations, whether medical professionals, accounting professionals, legal professionals, or any one of a host of other businesses, can actively decide to not behave like, or cause others to perceive us as, a commodity-an easily interchangeable part.

The groups who are flourishing, or at least somewhat in control of their destiny, all have one thing in common. They believe they can and must set the imaging agenda in their communities. They decide what, if anything, they might do that could cause them to be perceived as a commodity, and what, if anything they might do not to be perceived as a commodity by their "customers." These groups add value.

These groups believe they have been "asked" by their hospitals and medical staffs to be "in charge" of diagnostic imaging for the communities they serve. They believe in the age-old axiom-"when in charge, take charge." They do not wait to be invited to the leadership table, they assume command and they set the agenda. They craft the imaging strategy for the hospital, the medical staff, the payer community, and the populations of patients they serve. They differentiate themselves from the "commodity providers" in their universe by becoming a value-added component in the delivery of their specialty services to meet the needs of their customers. They behave like, look like, and perform like true medical specialists in diagnostic imaging.

Universally, you will find these thriving organizations occupying a seat of influence in their hospitals. They have one or more partners either on the hospital board or on the medical executive committee, or one has been elected president of the medical staff.

Universally, you will find the thriving groups measuring and publishing metrics on their performance for the community-with pride.

You will find these groups measuring and publishing physician satisfaction surveys (excellently crafted and designed). You will find these groups marketing with a vengeance (meaning, at the very least, meeting face to face with referring physicians, hospital leadership, and community leaders-extolling the virtues of the radiology group on a regular basis-we call it spin control).

Universally you will find these groups "teaching" the business of diagnostic imaging to hospital administration, at all levels, proudly describing the continuous investments they make in order to attract and retain sub-specialty trained professionals to meet the evolving needs of the institution and the evolution of medical imaging applications for effective diagnostic medicine (the tax the group pays for its exclusive contract). They do not complain. They just lay out the facts and decision matrix they need to engage to work collaboratively with the hospital and medical staff to ensure that service levels required can be maintained. Most hospitals have no real understanding of this unique specialty or how it has changed over the past decade or more. These thriving groups bring solutions to issues-not hand-wringing, self-absorbed whining.

Universally, you will find these groups author the diagnostic imaging strategic plan for the hospital, including all imaging user constituent needs-inpatient, outpatient, surgical suites, ER departments, outreach, and new market penetration sites of service. They describe and provide, to these important customers, the market differentiators they need to capture and retain market dominance throughout the continuum of care-in their "customer's language."

Universally, they decide what, if any, imaging services should be outsourced, or performed by non-radiologists-by them, to whom-and toward what beneficial end to the customer, medical staff, and patients.

In contrast, we have also seen groups wave big red flags announcing that they are a commodity, or at the very least, not an integral part of the leadership of diagnostic imaging in their communities. We can readily see an unmistakable pattern of behavior demonstrating a progressive dislocation from their customers.

One can easily send the wrong message to the customer. Unfortunately, many have, by:

• Not recognizing they are in charge-and thus leaving a vacuum of leadership in diagnostic imaging soon filled by anyone who steps up and takes it. They effectively announce their readiness to be led or even dismissed.
• Recommending or insisting that the hospital contract with, and pay for, night coverage via a teleradiology service. It is a short jump for a hospital from "night-hawk" to "day-hawk"-especially if turn-around-time metrics and sub-specialty expertise are well below requirements.
• Remaining on the sidelines while imaging strategies are discussed by the medical staff and hospital leadership, or worse, are absent from the hospital vocabulary entirely. For sure, if you are not in charge, someone else will be and your interests will not be considered.
• Complaining and whining to administration and key medical staff about what you are not earning-especially if your service levels are non-compliant and your group is noticed heading out the door at 5 p.m., while the medical staff is looking around to find a radiologist to talk to-or worse, no one can find a radiologist to talk to in core hours. The kiss of death.
• Staying holed up in the reading room and not regularly meeting (with a positive purpose in mind, not a whining session) with the medical staff and hospital leadership.
• Appearing not-if in fact not-to meet the customer service needs. (Referring physician decisions to in-source imaging begins with poor service from the department of radiology; the desire to solve this issue then quickly translates to a financial decision masked in patient convenience declarations.) Game over.
• Trying to hide behind professional interpretation credentialing standards for other specialties in an effort to keep nonradiologists from eating into your exclusive contract instead of, at least, appearing to want to allow something to happen on your turf, under your direction, control, leadership, and stewardship as the anointed keeper of the keys for patient safety and quality-in return for equitable consideration for dilution of your exclusivity provisions.
• Entering into lawsuit after lawsuit with your customer-evidence there is not, and will never be, a relationship.

We are constantly shocked at "how shocked" some groups are to receive the old "thanks for being here in the past, but we have replaced you" letter from their hospital customer.

Organized radiology needs to be ever vigilant of, and in front of, the changing landscape of diagnostic imaging. First and foremost, do not commoditize yourself-too many groups are doing so, daily. Take charge of your future-your customers want, and need, you to be in charge. For an increasing number of hospitals, diagnostic leadership is a major discriminator in their markets, leading the way for all hospital healthcare delivery services. They want, and need, you to provide collaborative, thoughtful leadership. You are the experts. You are the clinical specialists.

Diagnostic imaging crosses every single line of business at the hospital except pharmacy. Imaging is one of the most, if not the most, profitable business lines in almost all hospitals. Be in charge; become the value-added component the hospital needs you to be, make a recognizable impact. This does not mean you will always see eye to eye on all issues. There will be good honest debate and negotiation, but from an insider position of strength, not an outsider position of mistrust or irrelevance.

We suggest you start an honest and probing discussion among your partners and practice leadership with respect to just how you are stacking up as the entity in charge of imaging in your community. More importantly, ask the question, What will it take to be the recognized and anointed leader in imaging in your community? Truly, what will it take to achieve this level of dominance and differentiation? Is achieving this objective, and the awesome responsibility and position of authority that goes with it, worth the investment of your professional and fiscal treasure? If the answer is no, then look in the mail for what should be a not-so-shocking letter. It is very likely on its way. If the answer is yes, then get on with the business of being the leader you must be. Life will be good-very, very, good.

All of the above is offered to encourage you to actively debate this urgent matter and come to consensus for action within your group-not the one down the street or across the country; but your group, in your community, with your customer. Your future depends upon it. Your security is in your hands. Hard work, but worth it.

Overcoming the Commoditization of Radiology