Outsourcing Medicine/Rads

drboris · Jun 15, 2004

I was just wondering if all hospitals are outsourcing rads work only the ones that have too many films to read?

Also, do the doctors overseas who read these studies earn the same as US rads? If they earn less, wouldn't many hospitals realize this and start outsourcing everything?

Thanks
~Boris

hans19 · Jun 16, 2004

drboris said:
I was just wondering if all hospitals are outsourcing rads work only the ones that have too many films to read?

Yes!!! and they have also outsourced my residency! HELP!

drboris said:
Also, do the doctors overseas who read these studies earn the same as US rads? If they earn less, wouldn't many hospitals realize this and start outsourcing everything?

Thanks
~Boris

And there's a radiologist in Hyderabad driving my Porsche! :laugh:

-Hans

PS. THE SKY IS FALLING!!! THE SKY IS FALLING!!!

Gleevec · Jun 16, 2004

While there is nothing to worry about yet, oftentimes doctors are as reactionary in their politics as they are in their treatment regimens.

For example, ophtos and psychiatrists have both been hit by optos and psychologists getting privileges in OK and NM respectively. Perhaps if they had been as proactive as their optometrist and psychologist counterparts, these states wouldn't have adopted such legislation. Now, opthalmologists and psychiatrists are scrambling to make sure other states dont enact similar disempowering legislation. The problem is, now there is a PRECEDENT for other states to follow.

Sure, who the heck gives a crap about OK or NM, but lets say Cali wants to cut some of its healthcare costs. And lets say Vipro comes over and tells them Cali could save tens of millions a year by outsourcing their radiology studies to Bangalore, with high quality results and writeups. You dont think Cali will rewrite some of the laws protecting rads now?

I mean, this is a far-fetched scenario, so don't hold me to it, but do you think ophtos thought that suddenly optometrists could be shooting lasers at peoples eyes, or that psychologists would be prescribing drugs?

Its best to be proactive in politics, the problem is, doctors are typically a reactionary bunch. Maybe its the American mindset of treating problems AFTER they have erupted, but in any case, a good amount of political preventative medicine can only help. Otherwise, we will keep getting our arses handed to us by politicians, lawyers, and our medical turf stolen by non-medical practioners.

Id rather be overreacting to problems and perhaps be accused of saying "the sky is falling" rather than sit back smug leaving my field in the hands of greedy beaurocrats in Washington. I really feel medicine as a whole needs to be more proactive in policymaking, stoping things before they start. Perhaps stopping teleradiology is a good place to start. We've already experienced some defeats from the ophto and psychiatry, no need to give up any more ground than we already have.

Machiavelli · Jun 16, 2004

If I'm a plaintiff's malpractice lawyer, I'd be licking my chops at hospitals outsourcing the reading of radiology studies overseas. All it takes is one mis-read and the hospital could have really hung its butt out to dry. After all, it's letting people who aren't licensed to practice medicine in the US practice in their hospital (last I checked, radiologists did need a license).

thegasman · Jun 16, 2004

Yeah, the only way this would really work was if there were u.s. board certified radiologists out there in India or wherever to read the films. I could be wrong but I think most of the outsourcing happens at night in small hospitals for a prelim read and is reread by a us radiologist the next day. If there was a missed diagnosis by an overseas outsourcer there would be hell to pay financially.

drboris · Jun 16, 2004

So are the rads that are involved in outsourcing in India US Grads or not?

MacGyver · Jun 16, 2004

Gleevec said:
While there is nothing to worry about yet, oftentimes doctors are as reactionary in their politics as they are in their treatment regimens.

For example, ophtos and psychiatrists have both been hit by optos and psychologists getting privileges in OK and NM respectively. Perhaps if they had been as proactive as their optometrist and psychologist counterparts, these states wouldn't have adopted such legislation. Now, opthalmologists and psychiatrists are scrambling to make sure other states dont enact similar disempowering legislation. The problem is, now there is a PRECEDENT for other states to follow.

Sure, who the heck gives a crap about OK or NM, but lets say Cali wants to cut some of its healthcare costs. And lets say Vipro comes over and tells them Cali could save tens of millions a year by outsourcing their radiology studies to Bangalore, with high quality results and writeups. You dont think Cali will rewrite some of the laws protecting rads now?

I mean, this is a far-fetched scenario, so don't hold me to it, but do you think ophtos thought that suddenly optometrists could be shooting lasers at peoples eyes, or that psychologists would be prescribing drugs?

Its best to be proactive in politics, the problem is, doctors are typically a reactionary bunch. Maybe its the American mindset of treating problems AFTER they have erupted, but in any case, a good amount of political preventative medicine can only help. Otherwise, we will keep getting our arses handed to us by politicians, lawyers, and our medical turf stolen by non-medical practioners.

Id rather be overreacting to problems and perhaps be accused of saying "the sky is falling" rather than sit back smug leaving my field in the hands of greedy beaurocrats in Washington. I really feel medicine as a whole needs to be more proactive in policymaking, stoping things before they start. Perhaps stopping teleradiology is a good place to start. We've already experienced some defeats from the ophto and psychiatry, no need to give up any more ground than we already have.

Gleevec, I am proud of you my student. You have finally learned the truth of the scope of practice wars and how to battle them appropriately.

To the others, please read this response. Its exactly spot on accurate. What happens in Oklahoma or New Mexico has NATIONAL reverberations. For far too long, doctors have ignored whats going on in other states until it strikes them. As Gleevec pointed out, once a state precedent is established, the likelihood of it spreading to other states increases a hundred fold.

MacGyver · Jun 16, 2004

I guarantee you virtually all of the responses by established doctors will be something to the tune of "there are still plenty of patients" or "quit over-reacting."

Now I'm going to tell you why the opinion of these established docs is worthless.

1) They know that these things take awhile before reaching national scope. Therefore, they arent worried. Hell, they've already got their practice set up. Why would they care if medicine changes 30 or 40 years down the road. They'll already be retired by then, so they dont give a ****.

2) These doctors are PURELY reactionary. They only have an opinion AFTER the laws get changed. Their vision is totally myopic towards what happens in the next few years. Their view of the long term is totally inadequate.

MustafaMond · Jun 16, 2004

MacGyver said:
For far too long, doctors have ignored whats going on in other states until it strikes them. As Gleevec pointed out, once a state precedent is established, the likelihood of it spreading to other states increases a hundred fold.

For far too long, SDN has ignored the douchebag named MacGyver.
Once his precedent is established, the likelihood of his opinion spreading is zero.

Outsourcing is a dead issue.
There is no threat to the US.
The doctors reading films in India/Australia/Israel are USMGs!
Get your facts straight!

MacGyver · Jun 16, 2004

MustafaMond said:
Outsourcing is a dead issue.
There is no threat to the US.
The doctors reading films in India/Australia/Israel are USMGs!
Get your facts straight!

Australia? Yes.

India? Absolutely NOT.

Please provide a link showing the India rads docs are US, board certified radiologists.

hans19 · Jun 16, 2004

Is self-referal. IE an orthopod installs a magnet in his office and does his own knee or shoulder MRI's. Part of the big explosion in studies is those performed by non-radiologists and trying to get them read by radiologists and pocketting the technical fee.

Outsourcing is thus far a non-issue.
-Hans

zoolander · Jun 16, 2004

How it works at one Med Center ER:

Anyone getting a film at the NYU Tisch ER overnight gets the film read by a radiologist in Australia or Israel. These guys are board-certified in the US but live abroad, and read these during their normal business hours. Per one of the attendings, the hospital has been doing this for awhile. Not sure if it's a cost thing (can pay them less) or a scheduling thing (hard to get those busy radiologists to work overnight).

In one exception, MD's trained at Sackler Med School in Israel can currently practice in New York State w/out going through the US licensing process.

This is 2nd hand info, if you've got more current stuff let me know.

Gleevec · Jun 16, 2004

MustafaMond said:
Outsourcing is a dead issue.
There is no threat to the US.
The doctors reading films in India/Australia/Israel are USMGs!
Get your facts straight!

Hi,
I just wanted to reiterate, its not radiology persay that bothers me in terms of doctors delaying political intervention, but all the other battles where doctors have been blindsided in.

So the point of my post is more along the lines of a need to be more proactive politically, even on issues where we feel as if everything is OK, rather than waiting for a sudden, startling event to cause us to rise to action too late.

MacGyver · Jun 16, 2004

zoolander said:
How it works at one Med Center ER:

Anyone getting a film at the NYU Tisch ER overnight gets the film read by a radiologist in Australia or Israel. These guys are board-certified in the US but live abroad, and read these during their normal business hours. Per one of the attendings, the hospital has been doing this for awhile. Not sure if it's a cost thing (can pay them less) or a scheduling thing (hard to get those busy radiologists to work overnight).

As long as the docs are US board certified and forced to undergo residency training in the US, I dont have a problem with it. Lets face it. There are not very many doctors who choose to go this route, and there arent enough of them to pose a threat to the specialty as a whole.

What I DO have a problem with is the ABR or states making new laws saying that those who interpret radiology studies dont have to be US board certified or complete US residency training. This is the big threat. If that changes, then the floodgates will open and radiology as a specialty will crash and burn. There are literally millions of MDs living in foreign nations that would love to jump in and take advantage of this. No US med school, no US residency training, and no US board certification.

In one exception, MD's trained at Sackler Med School in Israel can currently practice in New York State w/out going through the US licensing process.

This program is open only to US citizens. Its basically a requirement that you have to learn Hebrew as well. The school is NOT recognized by teh LCME, and the website doesnt say whether Sackler grads have to go thru the ECFMG process or not. All it says is that New York state recognizes the medical degrees of Sackler, but that doesnt answer whether or not you are considered an AMG or IMG by the LCME and ACOGME residency programs.

I still think its a bull**** program that needs to be shut down. Its a money making ploy and nothing more. There should be a federal law which states that only schools recognized by the LCME can produce AMGs, and that campuses of american med schools on foreign shores are automatically excluded. That way, Cornell-Qatar and Harvard-UAE cant be used as shortcuts for practicing medicine in the US.

I also have a problme with the LCME recognizing Canadian med schools. The LCME should stick to med schools SPECIFICALLY WITHIN US BORDERS.

tofurious · Jun 16, 2004

hans19 said:
IE an orthopod installs a magnet in his office and does his own knee or shoulder MRI's.-Hans

Hmmm, can I order an MRI machine off Amazon.com now? Or perhaps buy a used one off Ebay? What world do you live in that an orthopod just buys an MRI machine?

As for who we are outsourcing TO, the correct answer is actually both non-US BC and US BC radiologists - it's just like the residents system here: there are many non-US BC radiologists reading these films, with one US BC radiologist supervising them and signing off on the films.

MacGyver · Jun 16, 2004

tofurious said:
Hmmm, can I order an MRI machine off Amazon.com now? Or perhaps buy a used one off Ebay? What world do you live in that an orthopod just buys an MRI machine?

As for who we are outsourcing TO, the correct answer is actually both non-US BC and US BC radiologists - it's just like the residents system here: there are many non-US BC radiologists reading these films, with one US BC radiologist supervising them and signing off on the films.

You have to buy direct from the manufacturer (Phillips, Siemens, General Electric, Bruker, etc).

Typical MR scanner setup is 2 million dollars. You have to build a special scanner room.

Its not a cheap capital investment, but the manufacturer will sell to ANYONE who has the cash. If Shaquille O'Neal wanted an MR scanner, he could easily get one.

hans19 · Jun 16, 2004

tofurious said:
Hmmm, can I order an MRI machine off Amazon.com now? Or perhaps buy a used one off Ebay? What world do you live in that an orthopod just buys an MRI machine?

I should have clarified. Groups of orthopods more so than individuals might buy a magnet. As an aggregate, they order a shizzload of MRIS. Sure an MRI machine costs 1-2 million. But when MRIS cost 1200 bucks a pop, and 1000 of that goes to 'technical fees' it doesn't take too many studies to pay for itself and start getting more than your money back.

Whats up with your attitude?

-Hans.

drboris · Jun 16, 2004

I agree with Gleevac that doctors need to become more proactive. Since not all of us are willing to lobby for rights, more doctors should donate their money to pool together enough funds to allow other doctors to defend the profession.

hans19 · Jun 16, 2004

The ACR (American College of Radiology) is, de facto, radiology's biggest/only lobbying group. Recently they have been successful in getting an increase in medicare funding for mammo studies.

They are currently working to get legislation passed to prevent self-referral for imaging studies by non-radiologists.

-Hans.

MacGyver · Jun 16, 2004

Update: NPR ran a story today about doctors who use e-mail and internet to treat patients without ever seeing them in person.

Here is an audio link:

http://marketplace.publicradio.org/.../16_mpp&start=00:00:20:38.0&end=00:00:24:11.0

This is very bad long term. Sure, it results in short cash increase for doctors who can see more patients, but how long do you think its going to take before HMOs realize that they can save billions of dollars by outsourcing this kind of medicine to cheap overseas labor markets?

Once again, doctors are our own worst enemy. The people INITIATING this practice are doctors, and it wont take long before the businessmen seize upon this and use it as an outsourcing paradigm.

This is getting ridiculous. I'm sick of a few doctors selling out our profession for temporary $$$ while the rest of us are sold down the river. These docs dont give a ****. Hell they will already be cashed out before it affects them.

Crap like this really pisses me off.

Rule #1 of outsourcing: Anything that CAN be outsourced, WILL be outsourced

Rule #2 of outsourcing: The likelihood of outsourcing is directly proportional to the salary gap between comparable labor positions in America vs 3rd world nation. There is no salary gap larger than that of doctors between nations.

Rule #3 of outsourcing: Anything that can be done via e-mail or internet is prime candidate for outsourcing.

Docxter · Jun 16, 2004

hans19 said:
I should have clarified. Groups of orthopods more so than individuals might buy a magnet. As an aggregate, they order a shizzload of MRIS. Sure an MRI machine costs 1-2 million. But when MRIS cost 1200 bucks a pop, and 1000 of that goes to 'technical fees' it doesn't take too many studies to pay for itself and start getting more than your money back.

Whats up with your attitude?

-Hans.

Orthopods will not go and buy a 2 million dollar machine. They will buy a low-field, low performance-gradient machine, which is likely open, or one of these ultra-low field "extremity" machines for $200000-300000 and then send every single one of their patients to get multiple MRIs and follow-up MRIs every couple months. It's pretty lucrative since the reimbursement for these low-cost, poor-quality (often nondiagnostic), low-maintenance, resistive MRIs is the same as the "real" MRI machines that may cost in excess of 2 million, and cost about $100000/yr to maintain and upgrade. Vendors love selling these low-field machines to orthopods and rheumatologists, since most radiology departments won't buy them.

Whisker Barrel Cortex · Jun 16, 2004

Have you seen some of the images from these scanners? They are horrible. No quality control at all it seems.

Although its a terrible example, the government intervened when woefully inadequate and downright dangerous mammography centers proliferated in the eighties. With onerous and strict quality control, those centers that popped up to make a buck off mammo or those in surgeons or OB/GYNs offices closed. A similar measure might be needed to assure the quality of other imaging. However, I hope it doesn't turn into the nightmare that is mammography. I think it won't since the lawsuit potential with knee MRIs is much less than with mammo.

hans19 · Jun 16, 2004

bente said:
And guess what imaging modality was the most costly last yr? MR?...no.
CT...no...
....
Echo.
Those are mostly self -referred.

Yeah... but rads gave that, as well as cardiac cath, away to cards a long time ago, and rads won't ever get it back.
Vascular surgery may have carotid dopplers, but radiology has the MRA and conventional angiography.

But what about cardiac MR, VC, CTA of the coronaries? Will radiology interpret these studies in the future? Who knows?

-Hans

zoolander · Jun 17, 2004

Saw that last night too... crazy.

Essentially there's a radioactive compound that images plaques. It can't yet correlate plaques to symptoms, or plaque resolution to symptom improvement. Sounds a lot like imaging for calcium in the carotid arteries (we can tell you it's there, not sure what to say about that).

Sounds like an exciting but untested research tool at this point. Can any neurologists describe a justification for imaging beta-amyloid plaques when it doesn't yet have relevance for prognosis or therapy?

All in, it's a long way off. The discussion of why the Alzheimers phase I vaccine trials were halted (T-cell mediated autoimmune encephalitis, sometimes fatal) reminded me that their compound ("the Pittsburgh compound- as exciting as when the Steelers get a touchdown") has a lot of testing to go.

RADRULES · Jun 17, 2004

The solution is simply not to read any studies performed at imaging centers or from offices that are not owned or operated by radiologists. They can read their **** studies themselves, take all the liability, and collect a few extra bucks. There is more than enough work to keep rads busy.

Smart rads are the ones who get involved in ownership of outpatient imaging centers. There are cash cows, and the radiologist is in the best situation to operate these places, in terms of knowing equipment, quality control, and of course interpretation of images. That is the way to go if you ask me.

tofurious · Jun 17, 2004

RADRULES said:
The solution is simply not to read any studies performed at imaging centers or from offices that are not owned or operated by radiologists.

Smart rads are the ones who get involved in ownership of outpatient imaging centers. There are cash cows

So let the radiologists flourish in the conflict of interest zone of "imaging centers" but restrict others' access to it. You obviously know how to milk this cash cow.

Why can't orthopods or neurologists own imaging centers? For that matter, why can't surgeons own outpatient surgical centers but anesthesiologists can?

The answer is not in what is ethical and what is free of conflict of interests. It's all a matter of who has the highest paid (most skilled?) lobbying group.

tinnsjo · Jun 18, 2004

I would think that the other specialties would eventually get a radiologist to read the films at their center. Some business is better than no business.
But it seems Radrules makes a good point...that if you are not a radiologist, you will be ordering more tests that are unwarranted. So, although radiologists may benefit from imaging centers, at least the imaging done there would be appropriate...but an ortho or neuro guy might order too many heads or backs.

Docxter · Jun 18, 2004

tofurious said:
So let the radiologists flourish in the conflict of interest zone of "imaging centers" but restrict others' access to it. You obviously know how to milk this cash cow.

Why can't orthopods or neurologists own imaging centers?

You don't get the point, do you? The issue at hand is self-referral. There is no conflict of interest here for radiologists. Radiologists are not the ones ordering the studies, and they only get referrals from others. But non-radiologists order the studies and then collect the money in their own imaging centers through self-referral. In a couple of studies, it was shown that if non-radiologists own imaging equipments , they are between 2 and 8 times more likely to get imaging studies than if they send them out to others (i.e., places they don't have a vested financial interest). The cost of this excessive self-referral to society from one of the medicare database studies was estimated to be, I believe, around 16 billion a year and is increasing in leaps and bounds. I have to double-check that number, but I think I remember correctly.

tofurious · Jun 18, 2004

Docxter said:
You don't get the point, do you?

I actually do get it (it's more of a rheotorical question), but thanks for the detailed explanation for all. The issue is: a family doctor can decide to take a sebaceous cyst out in his office and charge for it instead of referring to a surgeon, an internist can do shoulder injections instead of referring to a rheumatologist, a neurologist can charge for EMG he does himself without having to worry about self-referral, and a surgeon DECIDES when a person needs surgery without worrying about over-operating. If the same physicians who are most susceptible to self-referral are trusted with the autonomy to make other procedure-based decisions, why can't they decide for themselves to get the films they want? Besides, do you think a radiologist who is a part-owner would actually turn down profit-generating scan orders when they are ordered by these physicians? Probably not. The studies are interesting, but many other factors come into play - for example, I would personally not refer a patient to a radiologist-owned imaging center.

Whisker Barrel Cortex · Jun 18, 2004

tofurious said:
studies are interesting, but many other factors come into play - for example, I would personally not refer a patient to a radiologist-owned imaging center.

First, why the hell not. The images will be much better, more diagnostic (especially in high end studies such as MRI)

Second, the examples you give are much different than imaging. Self referral in imaging results in more imaging than otherwise required. Oh, your elbow still hurts, lets send you over for another MRI. The examples you give are doing a procedure that will be done anyway, but doing it themselves. A totally different situation.

It seems you have a deep seeded problem with radiologists. Too bad, we enjoy helping clinicians out. Good luck out there. If your attitude spills over in your real life don't expect any radiologist to go out of their way to be helpful to you.

MustafaMond · Jun 18, 2004

tofurious said:
If you want your MSc to be taken seriously for its scientific merit (or your training for that matter), you might want to consider going to an MD school instead of a DO school.

Whisker Barrel Cortex said:
It seems you have a deep seeded problem with radiologists.

Add to that list, IMGs, Caribbean medical grads, and DOs/
Tofurious is basically just a prick, trying to annoy and insult people.
His opinions mean squat.

hans19 · Jun 18, 2004

Tofurious said:
Hmmm, can I order an MRI machine off Amazon.com now? Or perhaps buy a used one off Ebay? What world do you live in that an orthopod just buys an MRI machine?

Tofurious, whats with your attitude?

MustafaMond said:
Tofurious is basically just a prick, trying to annoy and insult people.
His opinions mean squat.

Tofurious said:
I would personally not refer a patient to a radiologist-owned imaging center.

Tofurious:
Fine you can get a low quality KUB at YOUR own office.
But that will probably be low-yield, you'll probably need to end up getting a CT eventually.

So why not get a dual contrast CT Abdomen at OUR outpatient imaging center? Our fellowship-trained body imagers are well-versed in the protocols that render the highest quality images possible so you can get an interpretation you can actually use.

Maybe THEN we can find out what seems to be obstructing you? You're certainly acting like it.

Of course, if the CT's not diagnostic, I suggest clinical correlation... Did you happen to 'fall' ass-first onto something?
:laugh:

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