New Way or Doomsday

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Since the third week of May 2009, a radiology forum at has been on fire. At issue is the takeover of radiology services at a network of Toledo, Ohio, hospitals by Imaging Advantage LLC, Algonquin, Illinois, which calls itself “a nationally recognized radiology management company”1 in a press release. What ignited the forum fire was that the Imaging Advantage takeover occurred with little warning and deposed a radiology group that had been reading at the Mercy Health Partners (MHP) hospitals for more than 30 years. The second factor that upset some radiologists who posted comments was that Imaging Advantage’s business model incorporates a hybrid between on-the-ground radiologists at a hospital and teleradiology services acting as an overflow valve. This is not just teleradiology for night interpretations, but teleradiology deployed as a full-blown adjunct to the on-site staff. Posters fear that other radiology practices could fall prey to companies like Imaging Advantage that would commoditize radiology by using teleradiology as a tool to cut deals with hospitals that are too lucrative for those hospitals to refuse. The threat of such takeovers involving teleradiology is not a small concern in the radiology community. In this case, the point was driven home by the resignation of one of the early pioneers of teleradiology from NightHawk Radiology Holdings, Inc (Coeur d’Alene, Idaho), a major teleradiology provider that does work for Imaging Advantage. On June 8, the very day that Imaging Advantage deposed Consulting Radiologists Corp, Toledo, and took over at MHP, Paul E. Berger, MD, resigned as NightHawk’s chair. In his resignation letter Berger cited “significant differences” with NightHawk management. “These are more than simply philosophic and business-strategy issues and relate to the fabric and core principles that I have tried to inculcate into the mission of the company as a founder, and former president and CEO,” Berger wrote. Berger wouldn’t say whether one of the core principles he adhered to was that NightHawk should not invade other radiologists’ turf. In its early days, NightHawk had been careful to depict itself as a night-reading service only, designed as an aid to existing radiology groups. Berger makes no reference to NightHawk’s involvement in Toledo, although he calls a lot of the AuntMinnie postings “correct.” “I can’t be more explicit than what I said in the letter,” Berger says. “I might be the wrong one on how I think the world is going, but I don’t want to be part of thinking that other way.” Imaging Advantage Imaging Advantage CEO M. Naseer-Uddin Hashim says, however, that there is a lot of excitement attached to thinking another way. “Radiology, the way it’s practiced, is very static,” he says. “I think it should be dynamic; that’s our model. Give the local physicians the tools, the technology, and the resources to serve the patient better. I believe you, [the radiologist], are part of a dynamic system throughout the United States. I’m going to put you into that network.” Hashim describes himself as a former practicing attorney turned entrepreneur. Imaging Advantage began in 2006, he says. He was reluctant to discuss Imaging Advantage’s clients other than MHP, but agrees that the number could be called “several dozen.” Imaging Advantage, Hashim says, might partner with a radiology group, take over the group, or (as in the case with MHP) take over the radiology service contract with the hospital. Whenever it has taken over the contract, he says, it has always offered jobs to the radiologists in the existing group, which it tried to do with Consulting Radiologists Corp in Toledo. He says that it was unusual for radiologists in the existing group to turn Imaging Advantage down cold, as the Consulting Radiologists Corp physicians did. “This is the first time this has ever happened, where the whole group has decided they’re going to hold off,” he says. Hashim denies that what Imaging Advantage was doing amounted to a predatory commoditization or corporatization of the practice of radiology. “We’re exactly the opposite,” he says. “I start by working with the local radiologists and saying, ‘Let me make you indispensable.’” Adding teleradiology into the mix, he says, eases the burden on the local radiologists and improves turnaround times on reports. “When you improve turnaround times, you serve patients better,” he says. “The other thing is that you’re removing stress because radiology is a bottleneck, so you’re improving the entire hospital system.” Hashim says that no payment was made by MHP in the Imaging Advantage takeover. Asked how Imaging Advantage makes money, he mentions efficiencies. “In certain cases, we may also participate on the technical side of the deal,” he adds. “If we increase the volume and efficiency, everybody wins.” He notes that the radiology staff at MHP was assembled by hiring from outside, bringing Imaging Advantage radiologists in from other locations, and hiring locum tenens. He agrees that NightHawk was one of the teleradiology services reading for Imaging Advantage at MHP, but calls its involvement “only a small fraction” of all the teleradiology interpretations. St Vincent Mercy Medical Center Imran Andrabi, MD, is a family practitioner and is also CEO and president of St Vincent Mercy Medical Center, Toledo, the flagship of the MHP network and a level 1 trauma center with over 900 physicians on staff. Andrabi seems to think that NightHawk Radiology has been the primary source for teleradiology interpretations since Imaging Advantage took over; he says, “I think NightHawk is doing it for the moment.” He says that MHP signed with Imaging Advantage believing that radiology report turnaround times needed to be lowered to serve both patients and referring physicians. “We needed to go to a different management model to enable us to do that. For the concept we looked at, we needed teleradiology as an adjunct to on-site physicians to meet turnaround times. From the time something is performed in radiology until the referring physician has it in hand should be no more than 4 hours,” he says. Andrabi says that Imaging Advantage has 12 on-site radiologists and soon will have 14. He says that Consulting Radiologists Corp radiologists were not banned. “We welcome them to be a part of the solution. The door is still open for them to come back, if they want to,” he says. Asked how the transition from Consulting Radiologists Corp to Imaging Advantage is working out, Andrabi says, “It’s going very well. Our CT volumes are up 7% in one week. We have little or no lag on reports. Pretty soon, all our hospitals will be in real time, where there’s no carryover of any reports from one day to the next.” Consulting Radiologists Corp David R. Cervantes, MD, is a radiologist and president of Consulting Radiologists Corp. He says that Consulting Radiologists Corp first heard of the Imaging Advantage contract at MHP on May 19, less than three weeks before the takeover date. Cervantes says that he is troubled by many things about the takeover, but the contract between Imaging Advantage and MHP is not one of them. “If there was a violation of the [hospital’s] bylaws, I have a problem, but otherwise, it was a business decision,” he says. “For me, the shock lasted about 36 hours. I had no ill feelings about Imaging Advantage or Mr. Hashim, just about the whole sneaky, underhanded way it was done.” He says that a turnaround-time proposal made by the hospital several months prior to the Imaging Advantage takeover involved numbers that were “unobtainable.” Consulting Radiologists Corp refused a contract on the basis of those benchmarks, and the hospital did not respond after that, Cervantes says. He reports that Imaging Advantage did offer the Consulting Radiologists Corp physicians jobs, at a pay rate of $1,900 per day for diagnostic and $2,100 for interventional work. He says that a long-term contract was mentioned, but was to be determined only after Consulting Radiologists Corp signed a transition agreement, which it never did. Consulting Radiologists Corp would have been required to shut down an imaging center that it owns and terminate its contract with another Toledo hospital, both by a July 5 deadline, Cervantes says. In a meeting with Hashim, there was talk of some Consulting Radiologists Corp physicians joining Imaging Advantage and of others perhaps keeping the imaging center open. Cervantes says, “We could swap radiologists back and forth, and Consulting Radiologists Corp could take some of the subspecialty work. He was sort of stream-of-consciousness about the whole thing.” In the end, Cervantes says, Consulting Radiologists Corp decided to downsize, and none of its radiologists signed with Imaging Advantage. Some have left for other jobs, two have gone on sabbatical, and two took early retirement, Cervantes reports. Volume at Consulting Radiologists Corp’s imaging center has gone up 50% since Imaging Advantage took over at MHP, and hospitals competing with MHP are seeing volume increases too, he adds. “They are still without radiology directors at all three Mercy hospitals,” Cervantes says. “I know because I have filed a complaint with the Joint Commission.” In its press release,1 Imaging Advantage touts a relationship with Massachusetts General Hospital (MGH), Boston, Massachusetts, to provide 3D rendering services. Andrabi says that the MGH service is not yet up and running at MHP. Cervantes says that the MGH connection was used repeatedly during the transition to reassure clinicians at MHP of the quality of Imaging Advantage. “I think that’s scary for the entire field of radiology,” Cervantes says. “The name MGH evokes top-notch, cutting-edge radiology. It’s one of the shining stars. I think it’s frightening that this shining star is leading the way to the commoditization of radiology services.” Cervantes thinks that Consulting Radiologists Corp, in its downsized version, will survive. He says that the response to its loss of MHP business from the radiology community has been surprisingly strong. He says, “I’ve had phone calls from all over the country.” His callers realize that the corporate takeover/teleradiology business model, he says, “is bad for patient care, and they’re trying to stop it as soon as they can.”