Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy ■ Clinical Practice Management ■ Training & Education ■ Leadership
Health Services Research & Policy
■ Clinical Practice Management
■ Training & Education ■ Leadership

Is Radiology Too Big to Fail?

Is radiology a house of cards threatening to collapse upon itself?

You probably first heard the phrase "too big to fail" during the 2008 financial crisis. Large financial institutions were deemed so critical to the U.S. and worldwide economies and their possible failure so potentially disastrous that it took a taxpayer bailout to avoid a second Great Depression. Whether you think these banks were deserving beneficiaries of government largesse or should have been left to fail for their inexcusably inept risk management, the whole episode remains a cautionary tale.

If they're too big to fail, they're too big.

by Alan Greenspan, former chairman of the Federal Reserve

Bibb Allen Jr., MD, FACR, chair of the ACR Board of Chancellors, rightly hails radiology as being central to contemporary medical diagnosis and management in a recent JACR® article: "Imaging prevents needless surgical procedures, reduces the length of hospital stays, and detects deadly diseases in their earliest stages," Allen writes. He is confidently optimistic that we are entering the "golden age" of radiology. But he acknowledges that in the past "the growth of imaging services led to an increased financial drain on our health system."

Watching a re-run PBS program about the bank bailout, I wondered if something like this could ever happen in health care, particularly in radiology. Radiology has been changing, for better or worse, largely driven by technology advances that improve efficiency, such as round-the-clock interpretation via teleradiology and rapid reporting with voice recognition technology. Increased efficiency has brought with it increased productivity and revenue. As such, radiology is low-hanging fruit when it comes to identifying easy targets for large health care cost savings. Because of declining reimbursements, radiologists are competing for a shrinking piece of the health care pie.

Small radiology groups are coalescing into larger ones since large groups can negotiate better reimbursement rates from insurers and enjoy cost savings from economies of scale, but unfettered mergers and acquisitions can result in over-consolidation in an attempt to preserve profitability. Such over-consolidation ("too big to fail") contributed to the 2008 near-collapse of large financial institutions.

So, technology-enabled increased efficiency led to reduced reimbursement which led to group consolidation. Technology might be, paradoxically, the best way to avoid succumbing to the siren song of over-consolidation. Large radiology groups collectively handle and store lots of electronic imaging data, but what can they do with it? IBM knows. IBM Watson Health has jumped on the big data bandwagon to pioneer the next wave of population health innovation (and generate new revenue streams, of course). Watson will test the boundaries of real-world application of artificial intelligence.

JACR editor-in-chief Bruce J. Hillman, MD, FACR, in his most recent editorial, only one page after Allen's article, reminds us that "the advance of knowledge is unstoppable." He paints a less rosy picture, cautioning that Watson may be biding its time as a tireless apprentice before completely supplanting us, so "radiologists will have to continually reinvent themselves."

Watson may help radiologists churn through an ever-larger stack of imaging studies, but such hyper-efficiency may lead to self-reinforcing downward-spiraling reimbursement. Whether you like this vision of the future or not, it's coming. With billions of dollars spent acquiring the companies Phytel, Explorys, Merge and Truven for their vast troves of healthcare data to feed the voracious super-computer Watson to prepare for its debut, Watson is too big to fail. Radiologists have no choice but to figure out how best to use this burgeoning technology. Will Watson be radiology's bogeyman or BFF? Regardless which it turns out to be, the fates of Watson and radiology may be inseparable.

Further reading: 

Allen B. Radiology's golden age: Our best years are ahead of us. JACR 2016; 13: 233. 

Hillman BJ. Big data. JACR 2016; 13: 234.  

Van Moore A. ACR Presidential Address: With change inevitable, can we survive? JACR 2009; 6:749-755. 

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Wednesday, 22 May 2019

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