The Power of Inefficiency

RIchard HellerEfficiency can be thought of as the volume of work done over a period of time. In diagnostic radiology, that has been interpreted to mean RVUs per radiologist per unit of time. With decreasing per-case reimbursement, we have seen particularly strong pressures to increase efficiency. Unfortunately, some practices have done so at the expense of other important functions.

Those activities, referred to as value-added or noninterpretive tasks, provide valuable services—but do not generate RVUs, and thus, are not included in efficiency calculations. I (and others)1-3 have written about the critical value of these noninterpretive activities (which, among other things, provide a level of differentiation that protects companies—and our specialty—from commoditization).

For the local radiology practice, the importance of a service culture cannot be overemphasized. When hospital leaders evaluate the value supplied by a radiology practice, they have a lack of quantifiable data. Measures include turnaround time, but a fast report is not always a good report. Price is another objective criterion, but care that is more expensive doesn’t always equate with care that is of higher quality. Unfortunately for hospital and medical-staff leaders, there is no accepted, objective measure of quality. This means that hospital decision makers are forced to use more limited objective measures and more extensive subjective criteria in evaluating a radiology practice.

When hospitals are approached by an outside radiology-service provider that can promise an improvement in quantifiable criteria, namely turnaround time and price, leaders take notice. We have all heard of radiology practices displaced from their institutions as hospitals seek ways to rein in costs.4-6 Obviously, providing solid interpretive services is a requirement for any radiology practice that expects to have long-term survival, but it’s the noninterpretive services that are key to differentiation. It’s tough to provide those services if the radiology practice is focused solely on maximal efficiency.

An analogy that I like to use is that of a grocery store. In his book How the Mighty Fall, best-selling author Jim Collins writes about formerly iconic grocer Great Atlantic & Pacific Tea Co (A&P)—until 1975, the largest US food retailer—not adapting to the times and not reinvesting in its stores (instead, returning profits as dividends).7 Eventually, A&P withered away to irrelevance—a victim of shortsighted strategy.

A radiology practice that is overly focused on RVU production and efficiency, in an attempt to maintain incomes, while it neglects clinician and hospital client services is following the well-worn path of companies such as A&P. Instead of building walls to fortify its position, it is inviting competition: a scenario that is far more detrimental to a practice’s long-term health than some inefficiency in the system would be.

Few specialties in medicine are as technologically advanced as radiology, and keeping up to date requires an investment of time and energy. For example, CT and MRI protocols are constantly evolving. A radiologist friend recently lamented the fact that sonographic technologists in the practice were not particularly skillful, and many of their exams were thus read as limited.

I asked how often the practice does tutorials with the sonographers and how it provides instructional feedback. My friend responded that the practice’s radiologists are far too busy to spend time teaching technologists how to do their jobs; why would they waste valuable RVU-producing time on such activities? Practices like this one, in focusing too much on RVU productivity, will find (as A&P did) that they have been left behind by a changing world.

The feared risk of inefficiency is wasted, nonproductive time. Writing about the importance of personnel, Collins says that getting the right people on the bus (and the wrong people off the bus) is a top priority of management.8 The right people don’t have to be reminded to work hard because they are naturally motivated.

The right people know that they might have caught up with the worklist temporarily, but it’s no time to play on the computer. It’s time to do those other value-added activities. Furthermore, if the practice doesn’t ever build time into the system to allow for such noninterpretive activities, it might find that the right people have migrated to other practices that do provide more comprehensive services.

As you evaluate how your own practice is adapting to the changing tides of health care, remember the cautionary tale of A&P. Inefficiency might not really be the enemy that some think it is. In fact, with the right people on the bus, it might be the only way forward.

Richard Heller III, MD, MBA, is chief of pediatric radiology in the department of diagnostic imaging at Advocate Children’s Hospital and at Advocate Christ Medical Center (Oak Lawn, Illinois) and is a partner with Radiology Imaging Consultants (Harvey, Illinois).


1. Heller RE 3rd. The total value equation: a suggested framework for understanding value creation in diagnostic radiology. J Am Coll Radiol. Published August 6, 2013. Accessed November 13, 2013.
2. Heller RE 3rd. Twenty-first century radiology. J Am Coll Radiol. 2013;10(1):57-58.
3. Allen B Jr, Levin DC, Brant-Zawadzki M, Lexa FJ, Duszak R Jr. ACR white paper: strategies for radiologists in the era of health care reform and accountable care organizations: a report from the ACR Future Trends Committee. J Am Coll Radiol. 2011;8(5):309-317.
4. Keen CE. When a hospital replaces a private practice—with a teleradiology company. Radiology Business Journal. Published August 30, 2013. Accessed November 13, 2013.
5. Freeman L. Longtime Naples radiologists go to Physicians Regional; NCI hires national firm. Naples Daily News. Published November 20. 2011. Accessed November 13, 2013.
6. Silva E 3rd, Breslau J, Liebscher LA, et al. ACR white paper on teleradiology practice: a report from the Task Force on Teleradiology Practice.
J Am Coll Radiol. 2013;10(8):575-585.
7. Collins J. How the Mighty Fall: And Why Some Companies Never Give In. New York, NY: JimCollins; 2009:154.
8. Collins J. Good to Great: Why Some Companies Make the Leap . . . and Others Don’t. New York, NY: HarperBusiness; 2001:63-64.