Searching for a Better Fit
By Chuck Green
Radiology Today
Vol. 21 No. 2 P. 26

With hospital consolidations steadily remaking the health care industry, streamlining radiology services is imperative.

Over the past decade, hospital consolidations have seemingly become about as common as Amazon Prime deliveries. According to the National Institute for Health Care Management, there have been more than 90 hospital consolidations each year since 2012, topping out at 115 in 2017. Additionally, a recent survey by Definitive Healthcare found that one-fourth of health care professionals cited health care industry consolidations as the biggest trend of 2019. In 2018, Definitive tracked more than 800 mergers and acquisitions and nearly 860 affiliation partnership announcements.

Not surprisingly, this frenzy of consolidation activity has raised an important question for radiology managers and administrators: When facilities streamline, what are some of the challenges and important considerations for incorporating multiple radiology service lines? Chris Tomlinson, enterprise vice president of radiology/imaging, clinical lab and pathology, and emergency and hospital at Jefferson Health in Philadelphia, and the 2019–2020 AHRA president, has had a front row seat to the process after overseeing consolidation at Jefferson.

“Our approach was to create a governance group to hash out the details of which processes and products we’d standardize,” Tomlinson says. “We wanted to balance local decisions and accountability with enterprise thinking. The leaders realized that sometimes things wouldn’t go their way and other times it would.”

At AHRA 2019, Tomlinson gave a presentation, “Building a Large Radiology Service Line: Big Wins and Pitfalls,” focusing on how hospitals streamline when acquiring other health care providers. In terms of radiology, the idea at Jefferson was to organize the radiology service line to create scale, provide excellent patient safety, and develop new opportunities such as AI-enhancing workflow and subspecialty interpretations driven by a powerful group.

New Directions
There are four divisions at Jefferson, each with a director and a chief of radiology as well as an enterprise physician and administrative leader—Tomlinson’s role at Jefferson—who act in a “dyad” capacity. Given that structure, the questions became where to start and how to arrive at decisions; what the process of governance, protocols, and procedures should be; and how to get everyone on the same page.

“Who loses something and who gains something vs what then becomes the enterprise platform?” Tomlinson says. “Everyone has to work in the same direction. You have to get folks to give up some of their local control for the greater good.”

Of course, change doesn’t always go down easily, especially given that individuals are highly accustomed “to doing things their way,” he notes. “But that’s what it’s all about. You set up the governance structure and you have councils (processes and procedures, quality and safety, and IT) that represent all the constituents, in order to make decisions and recommendations.” From there, he continues, “You then have a ‘Chairs’ Counsel’ including physicians and administrative leaders that serves as the final decision-making authority around all of it.”

Within that framework, it’s necessary to define the process for making decisions as a large group that ensures continuity of care in all parts of the operation. “Every patient has to have the same experience, and those studies have to be congruent,” Tomlinson says. “The ability to support hospitals and care pathways is enhanced by having both community radiologists and subspecialized radiologists operating out of the same practice.”

Furthermore, coordinating activities inherent to radiology service lines can be daunting, he adds. “There are 2 million studies in our enterprise, and other groups will be joining us, which will put us at about 2.5 million. Think about organizing for around 2 million studies with 130 radiologists, when most hospitals do a couple of hundred thousand. You have to organize that, rationalize assets, and build the infrastructure to accomplish everything.”

Service lines—especially cardiology, obstetrics, and radiology, all of which involve a heavy capital outlay—are prime for rationalization because they reduce equipment and staffing costs while allowing facilities to repurpose space, according to Steven Shill, a partner at the BDO Center for Healthcare Excellence & Innovation, as quoted in Crain’s Chicago Business.

Significant Opportunities
While there’s no such thing as a typical radiology department, there are certain common characteristics among most departments, according to The internal structure, disposition, and management of personnel and fiscal resources impact a radiology department’s organization. Arranging employees into working groups based on their work functions falls under management goals. The efforts and skills of employees toward reaching departmental objectives in a cohesive and satisfying fashion are guided by administration.

On the operations side, implementing best practices and protocols throughout the health system at scale improves the system’s ability to buy and negotiate contracts, which leads to improved and less costly patient care, Tomlinson explains. Increasing the size of the system, however, can prompt a sense of wariness.

“I think everyone’s worried that, ‘Oh my gosh, these big health systems are going to raise the rates,’” Tomlinson says. “But, really, they’re able to deliver better care at a lower price point, with highly subspecialized resources.”

That’s what they seem to be doing at Jefferson, where most of the infrastructure is in place, and the majority of radiologists are employed by one group there, Tomlinson says. An ongoing question, however, is how to mix specialists, such as academic subspecialists, while ensuring that the best care is being provided “regardless of where patients enter your health system, so that my best musculoskeletal, breast, or abdomen radiologists can read a subspecialized study from my farthest outpatient location.”

In addition, he says, “I want to ensure the local relationships our community radiologists have with their referrers are also balanced when distributing studies.”

As arduous as the streamlining of radiology service lines may be, the effort is certainly worth it, considering that, at most hospitals, radiology is one of the largest spending categories. Medical imaging represents nearly 10% of annual commercial health care spending in the United States and, for many hospitals, imaging represents the largest source of outpatient profit—fattening the coffers by as much as 35%, according to Becker’s Hospital Review. The department’s potential economic value stands out.

Radiology’s abundant growth obviously yields a significant opportunity for hospitals to upgrade their critical metrics while swelling profitability. That said, when it comes to efficiency, quality standards, and even service effectiveness, radiology has much room for improvement.

Of course, patients are highly invested in what unfolds following a merger or acquisition since such deals affect many each year. To gain a better sense of whether system expansion can compromise safety, where safety issues arise, and how they can be minimized, STAT interviewed more than 70 clinicians, most of whom were physicians, as well as business staff associated with network development. In one instance, late at night, an anesthesiologist was in the basement of a hospital that had just merged with the one in which he typically worked. Unfamiliar with his surroundings, he had difficulty locating the room in the radiology suite where a patient’s breathing had stopped, necessitating the immediate insertion of a breathing tube.

Do or Die
Despite concerns, most in the industry recognize the need for consolidation. According to Tomlinson, “The whole idea of consolidation is to scale up and become more efficient to deliver care in a better and more standardized way because people know that they can’t do it alone anymore.” The potential consequences of failing to appropriately deal with consolidation? “Survival,” he says flatly.

Consolidation also can help breathe life into a health care facility that might otherwise be hanging on the edge. “When you’re larger, that’s the imperative; otherwise there’s no reason for the market to consolidate,” Tomlinson says. “If we don’t streamline, everyone continues with 10% to 12% increases in their health care spending, and the percentage of health care spending of GDP just continues to get bigger. What have you accomplished?”

If a health system decides to forgo consolidation anyway? “You’re going to be a big health system that’s very inefficient, doesn’t have good contract agreements, doesn’t provide good service, can’t move into population health and risk-based models because you’ve never scaled, and just did everything inefficiently at scale,” Tomlinson says. “If that’s your direction, you’re not going to be around very long.”

— Chuck Green is a freelance writer based in Chicago.