A corporate offshoot of radiology benefit management (RBM) company MedSolutions, Nashville, Tenn, has begun marketing a program of subspecialized teleradiology services to payors. Called Premerus, the new company describes the program in a video demonstration on its Web site (www.premerus.com/), characterizing diagnostic error as “a real problem, perhaps even an epidemic.” To support the Premerus contention, the video mentions (but does not cite) a study comparing mammographers with general radiologists, in which generalists had an extremely high error rate, while subspecialists erred at a negligible rate. Gregg Allen, MD, medical director for both MedSolutions and Premerus and a former family practice physician, acknowledges that aside from mammography, which radiologists readily admit is not an optimal modality for soft-tissue analysis, the evidence does not exist in peer-reviewed literature to substantiate the claim that diagnostic error is a problem. “If you look at the amount of documentation of error rate, or, frankly, documentation of quality-improvement efforts in radiology in the outpatient setting, there’s hardly anything out there except for mammography,” he says. “It doesn’t stand to reason that there is no error problem. You can’t say, ‘Just because it hasn’t been studied,  that means there is not a problem.’” According to Allen, MedSolutions is not flying totally blind in its claim that diagnostic error is a problem. “We are basing much of our premise on simulation work: one study (and a second is underway) where we have looked at concordance rates for MRI and CT between the at-large radiologist—and some of these films may not have been read by radiologists—and subspecialty readers who are in the Premerus network,” he reports. “The nonconcordance rate is running in the realm of 38% to 45%. That’s a study we are happy to share with potential clients, but it is probably not yet ready for publication in a peer-reviewed journal, although we are looking at that issue as well.” The ACR Responds The position of the ACR is that there is no such problem. “In fact, there are studies showing that radiologists have lower error rates than physicians without radiology training who interpret their own images,” Bill Shields, ACR counsel, notes. “Perhaps more important, we are not aware of any peer-reviewed studies indicating that Premerus radiologists are more accurate than, or even as accurate as, non-Premerus radiologists.” The identity of the Premerus subspecialty teleradiologists is currently a mystery. Allen inferred that at least one major teleradiology network is involved and will be providing the technology infrastructure to support the movement of images. “We have efforts underway on both fronts,” he explains. “We wouldn’t want to be totally beholden to some existing service that would have the technology available, so we are pursuing both fronts with regard to the technology piece.” Allen promises that the identity of the Premerus teleradiology partners will be divulged when its first pilot program is announced in June or July. “We can provide more information at that time,” he notes, “but I will tell you that the program will be—and I think this is the intriguing part—inclusive of local radiologist expertise in any of the markets where Premerus is implemented.” Allen said Premerus is constructing a network that will include some radiologists who are in teleradiology networks today and will also include private-practice subspecialist radiologists in markets where Premerus is going to operate, all as independent contractors. “On the face of it, it appears to be a threat to local radiology groups, and I don’t think it’s going to turn out to be that at all,” he says. “Our early discussions with some of these types of groups have been very, very positive.” The Business Plan The lack of hard data on diagnostic error notwithstanding, Premerus has devised a business plan and begun marketing the program to the same insurance companies and managed care companies to which RBM services are offered. The Premerus position is that the subspecialty teleradiologists in the Premerus network can deliver better-quality care by reducing error through attention to detail and avoidance of equivocation in reporting. The program will be implemented primarily in the outpatient setting for CT, MRI, and mammography. “We are not seeking to get into the teleradiology business from a unit-cost perspective,” Allen explains. “The play here is not to dip into the radiologist’s professional fee or get some kind of fee from the imaging centers that might participate in the Premerus network. It’s really all about where savings can be demonstrated in the overall cost of care. We’d seek our compensation from those savings.” Allen says that Premerus is currently working on documenting the potential savings associated with accurate diagnosis. “We have developed a cost/outcomes methodology that is fairly manual today,” he acknowledges. “It is actually something we are having reviewed by Thomson [Reuters Healthcare] Medstat, an actuarial company. They have looked at our methodology, and they are reviewing that and giving us comments. We are hoping to issue a statement about that in the near future.” Meanwhile, Premerus has also launched a Web site, YourMisdiagnosis.com, where it has solicited anecdotes from patients who have experienced a misdiagnosis. Two stories have been posted since April. Legal Roadblocks As it moves into an arguably more clinical role in the management of radiology services, MedSolutions is studying the teleradiology market for clues as to where the legal roadblocks, including restrictions on the corporate practice of medicine, may lie. “Our attorneys have looked at that, and we’ve looked at that issue with regard to what teleradiology companies might be facing in the same vein, and there’s been no case work that has been shown to have a negative impact on the teleradiology business,” Allen says. He reports that Premerus will seek opportunities among other diagnostic technologies, including laboratory and surgical technology, and, eventually, genomic testing. Shields says that Premerus may encounter legal challenges. “Certainly, regulators in states that prohibit the corporate practice of medicine could determine that MedSolutions is violating their laws,” he comments. “Unfortun­ately, each such state has its own law and implementing regulations, as well as regulatory rulings and court decisions interpreting those laws and regulation, so it is difficult to predict how an individual state might proceed.”