ACR Task Force Report: Relations Between Radiologists and Hospitals and Other Health Care Organizations

ACR Task Force Report: Relations Between Radiologists and Hospitals and Other Health Care Organizations

ACR Task Force Report: Relations Between Radiologists and Hospitals and Other Health Care Organizations Cynthia S. Sherry, MDa, Richard B. Gunderman, ...

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ACR Task Force Report: Relations Between Radiologists and Hospitals and Other Health Care Organizations Cynthia S. Sherry, MDa, Richard B. Gunderman, MD, PhDb, William T. Herrington, MDc, Leonard Berlin, MDd, Paul A. Larson, MDe, Lawrence R. Muroff, MDf,g,h

The vast majority of US radiologists are affiliated with hospital-based group practices, making professional relationships between radiologists and hospitals one of the most crucial factors for a successful practice. However, tensions between radiology groups and hospitals have been increasing and have led to some well-publicized breakdowns. The ACR Task Force on Relationships Between Radiology Groups and Hospitals and Other Healthcare Organizations was charged to identify key factors affecting these relationships and to make recommendations and propose positive steps that could improve relationships and benefit radiologists, hospitals, and patients. Key Words: Practice management, professionalism, hospital-based radiology J Am Coll Radiol 2010;7:410-418. Copyright © 2010 American College of Radiology

INTRODUCTION AND SCOPE OF THE PROJECT The vast majority of US radiologists are affiliated with hospital-based group practices, making professional relationships between radiologists and hospitals one of the most crucial factors in building and maintaining successful and secure practices [1]. But lately, tensions between hospitals and radiologists have been increasing, leading in some cases to well-publicized breakdowns [2]. In other less dramatic but more common cases, radiology groups and hospitals have not been collaborating as effectively as they might, a situation that can redound to the detriment of both parties. Recognizing the importance of this issue, the ACR established the Task Force on Relationships Between

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Texas Health Presbyterian Dallas, Dallas, Texas. Indiana University School of Medicine, Department of Radiology, Indianapolis, Indiana. c Athens Radiology Associates, Athens, Georgia. d Skokie Hospital Department of Radiology, Skokie, Illinois. e Radiology Associates of the Fox Valley, Neenah, Wisconsin. f University of Florida College of Medicine, Gainesville, Florida. g University of South Florida College of Medicine, Tampa, Florida. h Imaging Consultants, Inc, Tampa, Florida. Corresponding author and reprints: Cynthia S. Sherry, MD, Texas Health Presbyterian Dallas, Department of Radiology, 8200 Walnut Hill Lane, Dallas, TX 75231; e-mail: [email protected] b

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Radiology Groups and Hospitals and Other Healthcare Organizations. This task force was charged to identify key factors affecting these relationships, rank their relative importance, and make recommendations to the ACR, radiologists, and hospitals on actions that could improve these relationships. The task force’s goal was not merely to identify problems but to propose positive steps that would benefit radiologists, hospitals, and the patients and communities they serve. This document refers to radiologists in the broad sense of the term, and the usage is meant to be inclusive of all radiology subspecialties and member groups of the ACR, including radiation oncology, nuclear medicine, and interventional radiology. Also, the task force recognizes the significant and vital role played by medical physicists in promoting quality, ensuring accessibility, and providing support to radiology departments. This includes their facilitation of technical standards, their consultations regarding radiation safety, and their close linkage with radiation oncology, even though medical physicists may not in many situations be formal members of a radiology group or practice. The task force acknowledges that there are unique issues for each of the ACR constituencies and that an exhaustive exploration of all such issues is beyond the scope of this project. Therefore, the task force chose to focus on the most prevalent issues facing radiology groups today and to address specific constituency’s issues wherever possible. © 2010 American College of Radiology 0091-2182/10/$36.00 ● DOI 10.1016/j.jacr.2010.02.012

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Underlying Financial Trends As a result of recent economic trends, radiologists, hospitals, and other health care organizations have been operating under tighter financial constraints. Reductions in revenue have prompted attempts to extract new efficiencies that may prove unsustainable in the long run. Many hospitals are operating with very thin margins, and some are losing money at a rate that threatens their very survival. Faced with downward pressures on revenues, many hospitals are increasingly looking to radiology as an important source of income [1]. Likewise, many radiologists have experienced reductions in income, and many groups are under greater financial pressure than at any point in recent years. This has spawned efforts to increase per person productivity and to tap into outpatient business and the technical component of radiology payments to buttress declining professional revenues. Hospital administrators and radiologists may view each other as overpaid, or at least harbor uncertainty about the value the other adds to patients and the health care system [3]. Government policy plays a major role in the economic viability of radiology groups and hospitals. The recent Deficit Reduction Act increased downward pressure on revenues for imaging services, affecting both radiologists and hospitals. Current debates surrounding health care reform signal potentially sweeping changes in the future of radiology services and the entire health care system, with profound implications for both groups. Because imaging has been a rapidly increasing component of the health care budget, and many lawmakers are unfamiliar with the contributions it makes to patient care, imaging remains a target for further cost reductions. For example, current discussions concerning the bundling of payments have the potential to convert radiology from a revenue center into a cost center. Furthermore, in an effort to align incentives or gain greater leverage over imaging, hospitals are increasingly looking for opportunities to alter their relationships with radiology groups, such as converting independent radiologists into salaried employees. The following discussion delves deeper into some of the major issues affecting the relationships between radiology groups and hospitals today. Outsourcing Digital imaging laid the groundwork for teleradiology, which in turn has made possible the widespread distribution and potential outsourcing of radiology services. Radiology groups have benefited from the ability to outsource after-hours coverage at their hospitals and to obtain subspecialty-level service where none was locally available. By aggregating cases from multiple sites, tailored distribution models can also permit a more efficient

allocation of manpower, so that instead of a relatively large number of radiologists working only intermittently throughout the night, a smaller number can handle the workload and stay busy throughout their shift. When images are shipped across time zones, it makes it possible for even after-hours work to be done by radiologists during regular daytime hours. Yet despite these benefits, outsourcing can potentially open the door to financially driven business practices that are not necessarily in the best interests of local radiology groups, hospitals, or patients [4]. For example, in an effort to enhance financial returns, some radiology groups might be tempted to reduce on-site coverage to undesirable levels, compromising both referring physician and patient satisfaction. In other cases, hospitals have attempted to replace entire radiology groups with contracted teleradiology services [2]. In effect, such hospitals are ceasing to treat radiology as a professional service to be provided by their medical staffs and are instead treating it as a commodity to be contracted for, in some cases largely on the basis of cost, with quality patient care seemingly a secondary concern. Some entrepreneurial IT experts predict that outsourcing may entirely replace the current model of onsite radiology coverage. In particular, it has been said that PACS and equipment vendors view hospitals and radiologists as “mature” markets in a rapidly changing environment (P. Chang, personal communication, January 19, 2010). Shrinking revenues from these traditional markets will drive the development of alternative imaging pathways in which vendors, rather than hospitals or radiologists, become the primary contracting entities for future radiology services. These future vendors of radiology services envision a paradigm shift that will focus less on on-site coverage and more on leveraging software solutions to control imaging protocols, review clinical information, and conduct real-time interactions with referring physicians through automated systems of communication. Turf Issues Another issue that may negatively affect radiology– hospital relationships is the debate over which group of physicians, radiologists or nonradiologists, should provide particular types of imaging services. Often referred to as turf battles, these disputes arise in part because radiology groups typically do not own their hospitalbased imaging equipment, and other medical specialties have increasingly coveted imaging services as a means of maintaining and augmenting their own income streams [5]. Moreover, hospitals depend on their medical staffs for admissions and other patient-related services, and when physicians who make such decisions ask to provide more imaging-related services themselves, hospitals may

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feel that they need to accede. Recent examples of such disputes have included coronary CT angiography, peripheral angiography, CT colonography, and various interventional procedures. More remote examples have included obstetric and gynecologic ultrasound, echocardiography, cardiac brachytherapy, and nuclear cardiology. Many radiology groups may have supposed that “exclusive contracts” protect them against such disputes, but in fact such contracts often merely protect one radiology group from others, affording radiology little protection from other medical specialties [6,7]. Another challenge for radiologists in this arena is the dearth of robust quality indices for imaging services, which means that neither radiologists nor other medical specialists have data to support the contention that they provide more clinically effective, cost-effective, or safer service. Especially irksome to many radiologists is the practice at some hospitals of allowing nonradiologists to provide daytime imaging services but then expecting radiologists to provide after-hours coverage for the same examinations and procedures. Loyalty The mutual ties of loyalty that have traditionally bound radiology groups and hospitals have lately been under increased tension. For one thing, radiologists and hospital administrators often operate with different time horizons, with administrators tending to move from position to position more frequently than radiologists [3]. This can make the development of long-term relationships challenging. Moreover, the criteria for success for hospital administrators may put them at odds with radiologists. For example, an administrator might see short-term cost reductions as highly desirable, whereas a radiologist or radiation oncologist may think capital equipment investments in radiology are absolutely crucial to longer term quality of patient care. This means that radiology groups need to be circumspect about gentlemen’s agreements, which may not hold when one hospital administrator is replaced by another, and also to be prepared to make a persuasive case for medium-term and long-term perspectives in hospital strategy. These and other factors have tested radiologists’ loyalty to hospitals and have spurred some groups to pursue practice growth opportunities independent of the hospitals in which they work, such as outpatient imaging centers. This can lead hospital administrators to view radiologists less as partners and more as competitors. A related factor is the willingness of some radiology groups to enter into service contracts with competing hospitals, or even to open outpatient imaging centers in the hospitals’ backyards. If the relationships between radiology groups and hospitals are

to improve, it is vital that each attempt to understand the other’s perspective and that both begin to think more like partners and less like antagonists [8]. The Daily Impact Such economically motivated tactics manifest themselves in the day-to-day lives of health care systems in many different ways. Some of the more frequent and contentious examples include the following: 1. Hospitals may fail to ensure an appropriate environment of care conducive to high-quality radiology practice, as in the failure to provide up-todate imaging or therapy equipment, PACS, and voice recognition. Hospitals may attempt to hold radiologists accountable for departmental performance parameters that are not entirely in the radiologists’ control. In the case of examination turnaround times, radiologists clearly play an important role, but close scrutiny of the factors that prolong turnaround times often discloses that other personnel, such as technical and transportation staff members, represent the rate-limiting steps. 2. Radiology groups may fail to attend to the service needs of hospitals and other medical staff members, such as hours of coverage and the availability of subspecialty expertise [2,9-11]. When such issues lead to contract disputes, they can precipitate a vicious cycle of erosion in the relationship between radiology groups and hospitals, which in some recent cases has resulted in abrupt contract terminations. 3. PACS have improved the productivity of radiologists and medical staff members while naturally reducing the opportunities for direct personal interactions between the two. In an effort to enhance productivity and efficiency, some radiologists may exhibit a tendency to isolate themselves behind the closed doors of the radiology department. However, this undermines their place in the hospital by failing to build and maintain relationships with referring physicians, hospital administration, and patients. This lack of personal interactions tends to devalue radiologists while promoting the perception that radiology is a commodity rather than a professional service [12]. 4. Radiologists may not take as active a role as they should in optimizing radiology utilization patterns through the application of appropriateness criteria and similar tools, a pattern that has recently been augmented by the introduction of radiology benefits managers. 5. Far from seeking to undermine radiology leadership, some hospitals may long for more knowledgeable,

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skilled, and congenial radiology leaders who are empowered to make decisions on behalf of their groups [13,14]. In some cases, the failure of a radiology group to strategize effectively and speak with a unified voice undermines not only the group but the hospitals seeking to negotiate with it as well [15]. As noted above, conflicts may arise over the exclusivity clauses in contracts between radiology groups and hospitals, with hospitals claiming that such clauses apply only to other radiology groups but radiologists believing that they should apply to nonradiologist physicians as well. In academic settings, radiologists may become frustrated by an apparent lack of hospital understanding and support of academic missions such as research and education at the undergraduate and graduate levels. Furthermore, academic radiology must work within the added complexities imposed by medical school deans and professional promotion. In government environments such as the US Department of Veterans Affairs system, radiologists may become frustrated by wide variations in contract terms, payment structures, credentialing requirements, standards, background and security checks, and performance measures. Hospitals and health systems are showing more interest in moving to employed medical staffs or multispecialty group models to achieve greater alignment of incentives, to exert greater control, or to achieve improved profitability. Radiation oncologists often share many issues in common with diagnostic and interventional radiologists, but additional tensions may arise. Because of the smaller sizes of their groups, hospitals may have a tendency to integrate radiation oncologists with other services in cancer centers. Furthermore, radiation oncologists may feel their identity and security further weakened by advancing disruptive technologies, such as nanotherapy, that could potentially displace beam therapy. Some radiology groups are responding to the above trends and issues by aggregating into larger groups of subspecialized radiologists. These larger physician business entities often focus on preserving the independent practice of radiology governed by radiologists. They also allow better business management teams and economies of scale that can lead to better human resources support, IT investments, regulatory compliance, billing efficiencies, insurer negotiations leverage, political clout, and so on, though they are not immune to the traditional challenges inherent to group governance, culture and leadership issues.

INITIATIVES RADIOLOGISTS SHOULD CONSIDER Radiologists are usually best served when their goals are closely aligned with those of the hospitals they service [2]. Under this circumstance, radiologists are less likely to lose their tenure and are most likely to thrive. Through service quality and relationship building, radiology groups should endeavor to become indispensable to the hospital and medical staff. Radiologists should strongly consider the following initiatives: 1. Radiology is a service specialty. Radiologists must be responsive to the legitimate service needs of referring physicians and their patients [9,10]. It is also a consultative service in which being a good radiologist is necessary, but not sufficient, to retain a hospital contract. 2. Radiologists should strive to see hospitals’ perspectives and to deeply understand the needs of hospitals and clinicians. This is best accomplished through open lines of communication between hospitals and radiology groups. Hospital administrators perceive that radiology groups have been given a franchise for which they pay little in many cases. In return, hospitals anticipate that their radiology partners will be loyal and help grow the hospitals’ business [8]. 3. Radiologists must provide “value added” for referring staff members if they are to play a major role in the care of patients [16]. This can mean greater hours of coverage, more subspecialized expertise, attendance at tumor boards or grand rounds, and greater availability for consultations [17]. Radiologists become far more valuable when “speaking the language” of referring physicians [11]. Finally, radiologists must be willing and able to facilitate and optimize patient evaluations and therapies. 4. Radiologists should also provide value-added services for hospitals by working with administrators to help improve radiology departments’ cost-effectiveness, safety, and performance measures [17]. 5. Radiology practices must integrate themselves into the medical, political, and social structures of their hospitals and their communities. It is virtually unheard of for a practice to lose its hospital contract when a member of the group is a medical staff officer or serves as a member of the hospital board of directors. Radiologists should weave themselves into the local medical fabric by regularly attending medical staff meetings, serving on hospital and medical staff committees, and participating in local medical activities such as city, county, or state medical societies [2]. It is not sufficient simply to show up for work on

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time and provide timely reports, excellent patient care, and high-quality studies or treatment plans. Teleradiology and PACS have contributed to the commoditization of radiology by making radiologists more remote and less available for daily interactions with referring physicians, patients, and hospital administrators. Radiologists must make themselves more visible and more available [12]. Although this increased visibility might decrease productivity, failure to do this might easily cost a contract. Hospital administrators often express concern that radiologists do not have sufficient leadership skills to serve as active partners with the hospital. Radiologists must make a greater effort to provide appropriate leadership [13,14,18]. Not only will this benefit practices in dealing with hospital administrators, but such training is invaluable for leaders who manage the affairs of their practices. Radiologists must not only recognize the value of such training but demand that their leaders obtain these business-oriented skill sets. Although some tasks can be delegated to the nonphysician business executives in a practice, failure of physicians to provide input and oversight can prove disastrous. Practice leaders must continually strive to maintain effective relationships with hospital administrators. An adversarial relationship between hospital and practice leaders is very detrimental to the ongoing future security of the practice. Additionally, it is equally important for members of the group practice to be good team members by supporting their leadership and helping build the practice [9]. Whenever possible, radiologists should align their goals with those of their hospitals. This alignment of goals might entail participating in strategic planning sessions, helping establish and develop centers of excellence, and participating in joint ventures [2]. Although such opportunities are often not made available, when they do occur, radiologists should be prepared and eager to participate. Radiologists must carefully consider the negative impact on hospital relations when they enter into business arrangements that are viewed as competitive by their hospitals. Radiology groups should enter into competition with their hospitals only after fully considering the negative impact on their relationships. Conversely, jointventure imaging centers between hospitals and radiologists are one of the best examples of aligned incentives and represent one of the strongest binding ties that, if properly managed, will positively influence the security of ongoing relationships. Some radiologists are poor negotiators. Learning to discuss important issues in a constructive, rational,

and mutually beneficial manner will greatly aid radiologists in their interactions with hospital administrators, third-party payers, and community business leaders [19]. All parties benefit (and radiologists are accorded greater appreciation) when discussions pertaining to professional service agreements (hospital contracts) and business opportunities are conducted in an atmosphere of mutual understanding and respect. 10. Radiology groups should be aware that intragroup tensions or controversies, such as call inequities between or within interventional radiology and diagnostic radiology, can result in disharmonious clinical care disputes that may erupt and become problematic for the hospital administration and referring medical staff members [15]. Radiology groups should endeavor to resolve such disputes internally and expeditiously without involving their hospitals. 11. Radiology groups need to make sure their houses of business are in good order. It is critical for radiology groups to engage effective, well-trained, and highly qualified nonphysician practice leaders. Because of their unique talents and skills in radiology business issues, these experts should participate alongside radiologists in discussions, negotiations, and strategic planning with hospital partners. Equally important, radiologists should not unwisely abdicate their hospital business interactions to ineffectual office managers because a poorly chosen business manager can doom a group’s future with a hospital. INITIATIVES HOSPITALS SHOULD CONSIDER The goal for both hospitals and radiologists is to provide optimal, cost-effective care to patients. Hospital administrators are strongly encouraged to consider the following initiatives: 1. Hospitals should be supportive of radiologists’ incorporation of nationally recognized practice guidelines and standards in their hospital practices to ensure safe and effective patient care. They should encourage the implementation of programs such as the ACR Accreditation and Appropriateness Criteria® programs. 2. Hospitals should strive to provide a physical environment that is conducive to good patient care and accurate comprehensive radiologic interpretations and communications. This includes providing up-to-date imaging and therapy equipment, PACS, voice recognition technology and effective communication processes, radiologist support personnel, and quiet, ergonomic work areas with optimal lighting and efficient, comfortable workstations. Hospitals should be will-

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ing to work with their radiology teams to reduce medical–legal risk and ensure that continuous quality improvement processes are implemented. Hospitals should foster good business relationships by ensuring that radiologists are included on hospital committees such as hospital boards or various advisory committees. Hospitals should be willing to include radiologists early in discussions about strategic planning. It is critical that hospital administrators and radiologists see each other as allies, not as rivals. Hospitals should promote good clinical relationships between radiology and other clinical service lines by including radiologists as integral participants in disease-based planning (eg, stroke program) processes and process improvement efforts. Effective communication between hospitals and radiology practices is the cornerstone of an optimal relationship [2]. To this end, hospitals should schedule regular meetings (eg, weekly, biweekly, monthly) between designated spokespersons of radiology practices and hospital administrators, promoting good communication and a sense of partnership. Imaging has a central, integral position in today’s hospital environment, and radiologists should be viewed as essential players in the dissemination of efficient and appropriate patient care [20]. Hospital goals that affect radiology, such as 24-hour services, subspecialization coverage, and rapid turnaround, should be jointly discussed to determine appropriateness and feasibility [6]. Hospitals should be cognizant that granting imaging privileges or image-guided interventional procedures to nonradiologists may have longer term consequences, such as ongoing discord due to inequitable call schedules across multiple specialties. More important, hospitals should be aware that interventional radiology’s loss of caseload may affect the comprehensiveness of the hospital’s radiology service line by precluding radiologists from offering such services in the future because of a lack of ongoing proficiency and case access. Hospitals should place a high priority on nurturing a functional relationship with their radiology groups. A successful relationship will go a long way toward laying a sound bedrock for a radiology service that is optimal for patients, referring physicians, and the administration. Furthermore, hospitals should recognize the core strategic value of a strong foundational radiology service and the critical importance of onsite involvement by radiologists.

Although these steps cannot always ensure success, they will go a long way in ensuring a mutually beneficial relationship between a hospital and a radiology practice.

EXISTING AMERICAN COLLEGE OF RADIOLOGY POLICIES The task force undertook an exhaustive review of the many existing ACR policies that bear on the relationships between radiologists and hospitals [20]. All of the selected ACR policies originated as resolutions and were openly debated by the ACR Council before adoption. The policies have been routinely reviewed on the customary 10-year cycle for renewal, revision, or sunset. The relevant policies can all be found in the annually updated listing of the ACR Digest of Council Actions. There are more than 20 policies, not including ACR practice guidelines, that are germane to the current topic of radiologist– hospital relations, in testimony to the longstanding importance of this topic to radiologists. In its review, the task force concluded that despite some overlap, most of these policies remain appropriate and should remain in place. As a group, however, the task force notes that the policies fall short of addressing the core issues residing at the heart of radiologist– hospital relationships. For example, in some instances, the policies are weakened by a one-sided perspective that expresses solely the interests of radiologists. In other instances, the policies are not adequately reflective of the current reality in which radiologists broadly work. Highlights of the most relevant policies follow. One of the oldest policies dates back to 1976; it has been repeatedly renewed over the years, most recently in 2007, and broadly supports the independent practice of hospital radiology, which includes separate billing and open staff. The task force points out that the underlying tenets of this policy are sound, but the policy may not be a full and accurate portrayal of reality today. First, it neglects to acknowledge the viability of alternative models such as the growing number of radiologists who are directly employed by hospitals or as members of multispecialty clinics. Additionally, the policy supports an open-staff model even though a significant number of groups today participate in exclusive contracts within their hospitals. A later related policy (first passed in 1983 and last renewed in 2003) expounds again on the tenets of independent practice and concludes that “independent practice and separate billing serve the best interests of patients, referring physicians, and radiologists.” However, this later policy provides an update by stating that “the College recognizes that today the exclusive contract is a widely used method of establishing an administrative relationship between a hospital and an individual radiologist or group of radiologists” [2,6,7,21,22]. A few of the ACR policies attempt to address turf erosion within hospitals, that is, the trend for some hospitals to allow radiology interpretations and procedures to be performed by nonradiologist physicians. One note-

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worthy ACR policy states that “radiology is best practiced by radiologists.” The task force notes, however, that the policies do not adequately address the reality radiologists confront in hospitals: that more and more selected new and traditional imaging and interventional procedures are now being performed by nonradiologists in hospitals. Related to this issue, there is a specific and more pragmatic policy that addresses ultrasound in hospital emergency departments. Although it does not suggest that radiologists are the only physicians who should interpret such studies, it does “recommend that hospitals and medical staffs require physicians who perform and/or interpret sonograms on emergency department patients to apply for specifically delineated privileges to do so.” A lengthy policy addresses delineation of privileges in radiology and nuclear medicine, including a model privilege list that the task force believes is outdated. Several policies address issues of medical staff membership and credentialing. American College of Radiology policy states that “the same general criteria used for evaluating any other medical appointment should be applied to the applicant for privileges in radiology.” Another policy “vigorously opposes hospital efforts to curtail, without due process, medical staff membership and clinical privileges . . . without appropriate hearing under medical staff bylaws,” despite the fact that many radiology service contracts now in force include “clean sweep” provisions that automatically terminate medical staff membership upon the termination of an exclusive contract. A separate policy specifically addresses this issue and “expresses concern over hospital efforts to make changes in medical staff bylaws which reduce or eliminate fair hearing rights.” Another policy advocates for admitting privileges for radiologists. Overall, the task force recognizes significant limitations of the group of policies that affect radiologist– hospital relationships. First, the policies are appropriately written from a radiologist’s perspective, but if the goal is long-term successful radiologist– hospital relations, a “big picture” view that more broadly encompasses the hospital, health care team, and patient perspectives may be desirable. Furthermore, it is also worthy of mention that negotiations between entities require compromise from each side’s ideal position [19]. Finally, the task force recognizes that compliance with ACR policies is voluntary, even for ACR members and their groups. RECOMMENDATIONS TO THE AMERICAN COLLEGE OF RADIOLOGY It is the opinion of the task force that radiologist– hospital relations are indeed suffering today and that

improving these relationships is critical to the survival of high-quality imaging care for hospital patients. Furthermore, the quality of radiologist– hospital relations will have a large impact on the future stability, security, and success of radiology practices across the nation. The task force believes the ACR should take a multipronged approach to ensuring the enduring viability, strength, and quality of radiologist– hospital relations. The task force encourages the ACR to consider the following groups of recommendations. Data Gathering 1. A random survey of CEOs, chief operating officers, and chief medical officers of various hospital types should be conducted to assess their vision of the issues affecting their imaging, radiation oncology, nuclear medicine, and interventional radiology departments. 2. A focused survey of hospital CEOs, chief operating officers, and chief medical officers at hospitals where groups have been displaced should be conducted to assess their visions of what went wrong and what could have been done to save the relationships. 3. A group of leading hospital and health system CEOs and chief medical officers should be invited to join key leaders of the ACR in face-to-face discussions concerning the current and emerging trends in health care and how the ACR and radiologists can work together with hospitals to meet these challenges. If such a meeting proves fruitful, the ACR should consider using this group as an ongoing resource. Education and Communication 1. The ACR should develop a program to promote leadership development for radiology practices. There should be a focus on the current developing changes in health care, including the promotion of effective teamwork, professionalism, good citizenship, and a group culture of service. 2. The ACR should promote networking opportunities between practices, possibly through the Practice Leaders Web site (http://practiceleaders.acr.org/) and Practice Leaders meetings, to encourage learning through the experiences of others. ACR state chapter meetings can also incorporate these activities. 3. The ACR should use case-based learning opportunities (as currently used in business school curricula) for practice leaders online and in association with the Practice Leaders Web site and practice leaders meetings. Case material could be collected from real anonymized examples from across the country. A case of the month similar to Dr Leonard Berlin’s legal cases that were published monthly from March 1996 through December 2003, and

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intermittently since, in the American Journal of Radiology should be considered. The ACR should establish educational points and highlights for dissemination through the Resident and Fellow Section or the American Association of Academic Chief Residents in Radiology. Specific attempts to reach out to radiation oncology and medical physics residents should be made, as these individuals may not have strong contacts with either organization. The ACR should provide educational seminars on building strong relationships with stakeholders, including referring physicians, patients, and administrators. The ACR should continue its public awareness campaign and initiatives to educate the public and patients about the value added by radiologists. The ACR should help groups conduct a survey of their local hospital administrators and referring physicians to determine the best local indicators of quality, availability, and collegiality. The ACR should assess how a possible transition from a fee for service-based health care system to other value-based systems, including concepts such as bundled payments, accountable care organizations, and capitation, among others, might affect relations between hospitals and radiology groups, and the ACR should provide education and guidance to the members on these issues.

Consultation 1. The ACR should consider creating an anonymized collection of elements of hospital contracts and agreements to share among practice leaders to promote sharing of good solutions to common problems. An example might be a successful sharing agreement between cardiology and radiology for a coronary CT angiography turf dispute in which the hospital pays the cardiologist a stipend for interpreting the coronary portion, and the radiologist provides a complete report (including incorporation of the cardiologist’s findings, if available) and bills the patient (or insurance company). 2. The ACR should work to establish a consultant group to assist radiology practices by advising them on critical issues before they become divisive problems; the consultant might also possibly provide mediation when negotiations have stalled. A set of guiding principles and best practices for optimal radiologist– hospital relationships could be generated for reference. Collaboration 1. The ACR should establish a joint committee between the ACR, the ARRS, the American Society for Therapeutic Radiology and Oncology, the Radiological Society of North America and the Society of Interven-

tional Radiology to address professionalism in radiology and the potential impact on radiologist– hospital relations. 2. The ACR should continue to work to engage the American Hospital Association and establish improved lines of communication to develop mutually agreeable solutions to common problems and issues. 3. The ACR should encourage state chapters to engage their state hospital associations in dialogue on issues of common concern. 4. The ACR should consider collaborating with the American College of Physician Executives and other educational organizations to help provide and promote leadership training and development among radiologists and to foster closer alignment with the health care teams within hospitals. CONCLUSIONS Never before have so many hospitals and their radiology practices parted company. In a small percentage of cases, it is the radiology group that initiates the departure; however, in the overwhelming number of instances, it is the hospital that ousts the incumbents and seeks a new radiology group [2]. There are many reasons why this is occurring, but one major reason is that replacing radiology practices has never been easier. There are a variety of options for hospitals, and there is less reluctance for administrators to pursue these options. In some situations, the process is out of the control of the incumbent group; however, in most circumstances, radiologists can substantially influence their tenure. Radiologists must rededicate themselves to the concept of service [10]. Radiologists must be more visible to patients, referring physicians, and the hospital administration. It is imperative for the survival of the specialty for radiologists to provide added value to the clinical evaluations and therapies of patients [17]. This can entail expanded hours of on-site coverage, a greater number of available radiologists, more subspecialization, and greater opportunities for consultations with referring physicians and their patients. The ACR can play a vital role in improving the relationships between radiologists and the health care systems that they service. The College can provide leadership training and support, and it can fund campaigns to clarify and enhance the role of radiologists and radiology. The ACR can also develop relationships with organizations such as the American Hospital Association, and it can fund speakers at the meetings of those organizations so that the value and patient care contributions of radiologists can be presented to hospital administrators at “their meetings.” The development and expansion of the ACR accreditation programs are vital tools for radiologists and radiation

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oncologists striving to optimize patient care; RADPEER™ is a means for our members to demonstrate their commitment to the quality assurance and quality improvement processes. The Practice Leaders Web site can serve as a resource for networking dialogue, appropriate literature references, and lecture material, and practice leaders meetings can provide the leadership training that radiologists need and hospital administrators value. The development of a task force to study means of improving the relationships between radiologists and the health care systems that they serve (and to recommend solutions to the issues that exist) is a major positive action by the ACR. The issues are substantial, and the challenges that radiology and radiologists will face over the next decade are unprecedented. The ACR can and must take a lead role in the education and protection of its members. ACKNOWLEDGMENTS We wish to acknowledge the work and effort of the entire ACR Task Force on Relationships Between Radiology Groups and Hospitals and Other Healthcare Organizations for the helpful insight, timely diligence, and energetic analysis they contributed to this project. In addition to the authors, the task force and staff members are Charles M. Anderson, MD, Manuel L. Brown MD, Burton P. Drayer, MD, Cassandra S. Foens, MD, Lawrence A. Liebscher, MD, Reuben S. Mezrich, MD, PhD, Duane G. Mezwa, MD, Rodney S. Owen, MD, Christopher G. Ullrich, MD, Bradley W. Short, MLA, and Thomas R. Hoffman, JD. REFERENCES 1. Thrall JH. Changing relationships between radiologists and hospitals: part 1. background and major issues. Radiology 2007;245:633-7. 2. Muroff LR. Why radiologists lose their hospital contracts: is your contract secure? J Am Coll Radiol 2010;7:180-6. 3. Gunderman RB, Boland GW. Enhancing mutual understanding between radiology chairs and hospital CEOs. J Am Coll Radiol 2009;6:701-4.

4. Altman DJ, Gunderman RB. Outsourcing: a primer for radiologists. J Am Coll Radiol 2008;5:893-9. 5. Levin DC, Rao VM. Turf wars in radiology: challenges leveled at our specialty and how to respond to them. J Am Coll Radiol 2007;4:492-3. 6. Thrall JH. Changing relationships between radiologists and hospitals: part 2. contracts and resolution of issues. Radiology 2008;246:343-7. 7. Portman RM. Exclusive contracts in the hospital setting: a two-edged sword. part 1 legal issues. J Am Coll Radiol 2007;6:305-12. 8. Lee F. If Disney ran your hospital: 9 1/2 things you would do differently. Bozeman, Mont: Second River Healthcare Press; 2004. 9. Muroff LR. Taking your practice to the next level. J Am Coll Radiol 2008;5:986-92. 10. Lexa FJ. 300,000,000 customers: patient perspectives on service and quality. J Am Coll Radiol 2006;3:346-50. 11. Pressman BD. ACR presidential address: distinction or extinction. J Am Coll Radiol 2008;5:1036-40. 12. Reiner BI, Siegel EL. Decommoditizing radiology. J Am Coll Radiol 2009;6:167-70. 13. Gunderman RB, Weinreb J, Hillman BJ, Moore AV, Neiman H. Leadership in radiology: the 2007 ACR Forum. J Am Coll Radiol 2008;5: 92-6. 14. Gunderman RB. Seven leadership fallacies and how to correct them. AJR Am J Roentgenol 2005;184:1065-8. 15. Muroff LR. Dealing with the problematic partner. J Am Coll Radiol 2007;4:527-32. 16. Gunderman RB, Boland GW. Value in radiology. Radiology 2009;253: 597-9. 17. Patti JA, Berlin JW, Blumberg AL, et al. ACR white paper: the value added that radiologists provide to the health care enterprise. J Am Coll Radiol 2008;5:1041-53. 18. Muroff LR, Williams C. Apathy in radiology: we have met the enemy and he is us. J Am Coll Radiol 2007;4:512-3. 19. Berlin JW, Lexa FJ. Negotiation techniques for health care professionals. J Am Coll Radiol 2007;4:487-91. 20. American College of Radiology. ACR Digest of Council Actions. Available at: http://www.acr.org/SecondaryMainMenuCategories/mbr_chapter/ FeaturedCategories/CouncilResources/DigestofCouncilAction/2009DCA. aspx. 21. Sunshine J, Chan WC, Kassing PJ. Radiology practices and their contracts with hospitals, 1989-1990: a representative sample survey. AJR Am J Roentgenol 1991;157:1341-7. 22. Portman RM. Exclusive contracts in the hospital setting: a two-edged sword. part 2 pros and cons, avoidance strategies, and negotiating tips. J Am Coll Radiol 2007;6:401-5.

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