Another Perspective

I read with interest the recent article by Cynthia Keen, “When a Hospital Replaces a Private Practice.”¹ The featured group is portrayed as an example of the type of practice that currently is being replaced by teleradiology companies. Poor customer service, substandard turnaround times, suboptimal call coverage, and lack of peer review are among the alleged failings. If that’s true, the group’s demise is understandable, but it should be viewed as the exception, rather than the rule. I again stress: If that’s true. Allow me to tell a story that I feel better exemplifies what really is happening in our radiology community. I am an associate professor of radiology at the University of Chicago and a fellowship-trained interventional radiologist. For the most recent 10 of my 22 years at the university, I served as the medical director of radiology at Louis A. Weiss Memorial Hospital, a 236-bed hospital in Chicago’s North Side. Weiss Memorial Hospital was one of the four Chicago hospitals owned by Vanguard Health Systems (purchased by Tenet Healthcare Corp on October 1, 2013). My radiology practice was staffed by 3.5 FTE radiologists: a fellowship-trained neuroradiologist (with 35 years’ experience), a fellowship-trained musculoskeletal radiologist (with 10 years’ experience), a second fellowship-trained interventional radiologist (two years out of training), and me (with 22 years’ interventional-radiology experience). Mammography was covered by two fellowship-trained mammographers who were part of the Breast Center at the University of Chicago. We provided 24/7 interventional coverage, as well as specialty backup by fellowship-trained faculty in all modalities. During our 10-year stay, our service garnered the highest ratings in the hospital—from both physicians and patients—on Press Ganey surveys. Statistics tracked and addressed included turnaround times, reporting of critical values, reader discrepancy, peer review, procedural-complication rates, biopsy results, and more. We also achieved ACR® accreditation in mammography, CT, and MRI. Despite these achievements (and despite maintaining the highest level of care), we lost the contract. The hospital’s CEO never relayed a single complaint, never requested that we change our practice in any way, and never instigated a meeting to discuss renegotiating our contract. Why We Lost the Contract Vanguard—or more directly, the equity company that owned Vanguard, the Blackstone Group—was an investor in its own teleradiology company: Imaging Advantage. In fairness, the radiologists employed by Imaging Advantage for teleradiology coverage seemed to have excellent credentials. What was of no consequence to the hospital administration was our level of excellence, documented using all criteria. In addition, a teleradiology company cannot remotely provide state-of-the-art mammography service or 24/7 interventional coverage, especially with our level of training and experience. Again, none of this mattered. Weiss Memorial Hospital hired two radiologists who had just completed their fellowships (in neuroradiology and musculoskeletal radiology), and created a part-time position for our most senior radiologist. Mammography was to be covered by whichever radiologist was willing to read the exams and perform biopsies, regardless of experience or training. Interventional radiology is now covered by a fellowship-trained interventional physician who is one year out of his training. Each day, he splits his time between Weiss Memorial Hospital and West Suburban Medical Center (Oak Park, Illinois), another former Vanguard hospital in the Chicago market. A radiologist without fellowship training has recently been covering his scheduled vacations. What Matters Most Unfortunately, radiologists have encountered a perfect storm. Jobs are scarce, particularly in major cities, and the reasons for this are multiple. With a constant trend of decreasing reimbursements in imaging (since 2006, CMS has cut radiology payments 12 times) and unprecedented cuts soon to arrive, many established groups, both private and academic, have stopped hiring. Radiologists are feeling the squeeze. In September 2012, Vanguard administrators made the announcement that they would no longer be paying stipends to supplement a group’s income. For most medical practices at Weiss Memorial Hospital, regardless of the specialty, this is almost unworkable, as the payor mix is approximately 60% Medicare and 20% Medicaid. Around the same time, Crain’s Chicago Business reported2 that William Foley, then the Chicago-based senior vice president of operations, received 47,598 shares of Vanguard stock—worth about $461,0000—as a bonus. The Vanguard Chicago market generated 12.7% of the company’s $4.9 billion revenue for 2011 (about $628 million).2 A conscious decision had clearly been made: Pay the administrators instead of the radiologists. A week after my group left Weiss Memorial Hospital, Vanguard sold all of its hospitals to Tenet Healthcare. Vanguard’s stock doubled in value on the day of the sale. Currently, hospital administrators and corporate investors hold most of the cards. With time, this may change, as the job market improves. History shows, however, that radiologists have never been stagnant, and they continuously reinvent themselves and their field. I believe that part of the answer lies in expanding partnerships between private practices and academic institutions. While it did not save the Weiss Memorial Hospital practice, that does not mean that the model was a failure. Universities need to change their way of thinking and expand their vision as to how to provide health care. In the meantime, as my former chair of radiology told me, always take the high road; work hard, provide excellent care, and do the right thing. I would add: Thank God that you have a job. Jeffrey Leef, MD, is an interventional radiologist and associate professor of radiology at the University of Chicago.