Radiology’s Impossible Trinity

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 - Richard Heller III, MD, MBA
Richard Heller III, MD, MBA

Since the advent of teleradiology and the new phase of increased competition it ushered in, the nature of the radiology practice has been evolving. Adding to competitive pressures are macroeconomic factors, including governmental budget deficits and reduced reimbursements. With the aging of the population and with health reform’s addition of millions to the rolls of the insured, the potential demands placed on a practice have never been greater. 

As a result of these two evolving pressures—increasing volume and decreasing per-case payment—practices have tried to become more efficient. This has meant trying to maximize the interpretive productivity of radiologists. For many practices, this has led to criticism from patients, referring clinicians, and hospital administrators regarding the length of patients’ waiting times.

Impossible trinity (trilemma) is a term taken from international monetary theory, which states that it is impossible for a country simultaneously to have an independent monetary policy, a fixed exchange rate, and free capital movement. It is possible to have any two of those three things, but it is never possible to have all three at once. 

The impossible trinity of radiology services states that because only two of three conditions can be present, it is not possible to have limited resources (in terms of radiologists), high-quality care, and short waiting times simultaneously (see figure). The impossible trinity of radiology services is directly analogous to the so-called iron triangle of health care, which places cost, access, and quality on the three sides of the triangle. 1,2

Under this concept, an emphasis on one factor (such as quality) necessitates balancing the other two (in this case, cost and access). Translating the iron triangle into the terms of the impossible trinity of radiology service, cost can be understood as limited resources, access relates to patients’ waiting times, and quality relates to both interpretive and noninterpretive services provided by the radiology department. 

The Quality Component

High quality is inherently nebulous, as a term. In this context, however, it includes both the thoroughness of the radiology report and the overall service level (interpretive and noninterpretive). 3

For example, a pulmonary-embolism CT report that only answers the question of embolism and covers the basics of the pulmonary findings might be technically adequate. It is of less value, though, than a more detailed dictation (including pertinent negatives about which clinicians typically want to know) would be. 

For example,  is the aorta seen well enough to look for dissection? Furthermore, a radiologist who calls the clinician upon making a new (and potentially unsuspected) diagnosis of malignancy is providing a greater degree of value than a radiologist who simply reports the finding in the dictation—and moves on to the next case—is providing. 

Waiting time refers, broadly, to the length of time that patients must wait to have an imaging exam scheduled, the time that they spend in the department for the imaging study, and the time that elapses before the final report’s approval. Since long waiting times have a negative impact on both patients and referring clinicians, it behooves all practices to be mindful of them. 

Obviously, many factors outside of radiologists’ control affect waiting times (especially time spent in the department). Other factors, such as report-turnaround time, are directly under radiologists’ control. 

Two Conditions

There are two conditions that must be met for the impossible trinity to be true. First, efficiencies must be maximized; second, there must be sufficient volume to stress the system. If departmental efficiencies are not maximized, there is room to improve without additional resources. 

In addition, because numerous factors other than radiologist availability affect patients’ waiting times in the department, a focus on efficient patient transit through the imaging center is a necessity for all institutions. As for the second condition (volume-related stresses), if the caseload is sufficiently limited, the system will have the capacity to absorb additional patients before resource constraints begin to take effect. 

For many practices, today, there is sufficient volume to stress the system, and groups are functioning with limited radiologist resources to reduce expenses in this time of decreasing reimbursement. Inefficiency has been addressed at many practices,