Threat from India?

This is crazy, but my med school already does this. The ER uses some firm overseas (dunno where) and some rads people there read 'em, and beam 'em right back. They wer testing this last year, and I believe that all CT/MRIs done after 4pm are getting beamed. At least the ones ordered up by the ER docs (which is a sh*tload).

5 years from now, I'll bet that every hospital will either be doing this if it turns out that they can save ca$h.

The other thing that I would be wary of is the fed govt. slashing reimbursements for MRI/CT. Right now, it's nuts because the reimbursement rates for CT and especially MRI are freakin' GREAT cos these rates are from just a few years ago (1995ish) when getting an MRI was a big deal. Now we have MRI machines in podunk hospitals and they're ordering up a storm. It would be soooo easy for the fed govt. to simply cut reimbursement for MRI, thereby wiping out a major component of rads' income overnight. Don't think that can happen? Ask the nearest pathologist.

Its not just MGH. Stanford, Penn, Yale, and UCSF are all starting to send their rads films overseas.

This trend is not going away anytime soon. I hear there are many public state institutions (Univ of Florida - Shands) that are thinking about doing telerads overseas also.

This is the most serious threat to rads. Its not going to stop because there is simply too much money to be made. You're talking about a cost differential of over 170k-200k per year (radiologist salary vs foreigner). Theres no way hospitals or academic medical centers are going to choose to pay more money. This is a simple decision for them.

There will be some slight resistance to this trend, but ultimately I dont see anything stopping it. They will put some safety measures in place (i.e. foreigners getting board-certified) but that wont raise their salary up to american counterparts.

This topic was beaten to death on aunt minnie.

ANY imaging study performed in the US must be billed by a US certified physician. Every state has different requirements. Here is Illinois you need two postgraduate years of residency training.

Many night hawk services are popping up all over the place. One noteworthy one is a group of american trained rads who live somewhere in Australia and cover US hospitals. I know there are others.

Just to clarify to the above posters, apart from the MGH setup, all the other "foreign" radiology groups employ US board certified radiologists who are often Americans sent to e.g. Australia to read night films by day. They are paid very competitive salaries in US dollars and actually can become partners in either the night read practice or the firm they cover. Also, remember that incomes in Canada and Australia do not lag that far behind the US. In Canada starting salaries without fellowship are well over 300K CDN (>200 US) and the buying power of 300K is about the same here as 300US in the states. And once someone is BC'd, it is quite easy to move to the US. Trainees from Canadian radiology programs are all fully ABR-eligible so we lose tons of radiologists every year to the US!! BC'd doctors, like in any other specialty, will not come cheap even if they are situated overseas.

The MGH thing is different because the proposal is to use non-board certified physicians with a state license. The sham residency will presumably equip them to write the steps but not enough to let them get BC'd in Rads (hence 3 not 4 yrs of training). This will keep them prisoners to the staff radiologist who will cosign all their reports, and ensure that they can not immigrate to the US and start earning $$$$$ like their boss. This "cosigner" will take all the liability -- the model is more like PAs, but it makes us very uncomfortable because the guy setting this up sounds like he has no interest in actually checking the foreign "non-BC'd" reads, except to sign the invoice!! This is like the neurosurg patient seen by only a PA in the emerg--> result--> lawsuit!! I doubt this will be accepted by many/any institutions... er except MGH I guess!

Though if it turns out that hospitals can save a lot of ca$h, they will likely follow the "MGH model". It would be very easy for podunk hospital CEO to say, "well look at Harvard...they're doing it so I will too".

I still think the biggest threat for rads income is the fed govt. cutting reimbursements for MRI/CT. As soon as that happens, the insurance companies will follow suit, and viola... Suddenly rads becomes a lot less appealing.

Originally posted by Celiac Plexus
I still think the biggest threat for rads income is the fed govt. cutting reimbursements for MRI/CT. As soon as that happens, the insurance companies will follow suit, and viola... Suddenly rads becomes a lot less appealing.

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Medical reimbursement is constantly changing regardless of what specialty you're in. CT/MR rates will likely be cut at some time and so will PTCA rates and colonoscopy rates and open AAA repair rates and EEG rates and annual physical exam rates and everything else. The point is that it doesn't make much sense to go into GI (for example) instead of rads because of this since their cash cow can be slaughtered just as easily by the feds.

Actually, Celiac, the threat from MGH applies to all specilties. Basically they are thumbing their noses at the American Board of Medical Specialties/ABR. The danger is this: the States have never cared whether you are BC'd or not. It has always been "voluntary" with an arm-twist form medicare/insurance companies/lawyers. This sets a precedent that could see for. e.g foreign trained surgeons with a state license working in huge pools under one BC'd surgeon (or none eventually).

It is obvious why this is bad for physician salaries, but the public won't care about that. However, what they should care about is the fact that the training of non-BC'd "specialists" does not have to follow any standardized curriculum. There need not be any controls on case volume, and there need be no exit exam. What kind of "standard of care" is that?

As for declining reimbursement rates, the same thing can and does happen to all specialties. How much do GS's get for an appy these days? or a lap chole for that matter? And radiologists can and do lobby just like any other group. One should choose a specialty based on what one likes, however, we all have to stand up to ensure a high standard of training -- it is in the public's and the profession's best interest.

Originally posted by eddieberetta

As for declining reimbursement rates, the same thing can and does happen to all specialties. How much do GS's get for an appy these days? or a lap chole for that matter? And radiologists can and do lobby just like any other group. One should choose a specialty based on what one likes, however, we all have to stand up to ensure a high standard of training -- it is in the public's and the profession's best interest.

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True, the general surgeon has been hit by unsympathetic government regulators. In the surgery world it is well-known that GS has hit the bottom as far as reimbursement goes for things like appy, choly... Probably a significant reason for the declining interest in GS in the period of '99-02. Rads is just the opposite with # of applications to residency mirroring the rapid increase in rads' salaries.

My point was not to diss the field of radiology. I was just pointing out that the fed govt. will eventually (probably by the time those just entering the pipelin emerge) slash reimbursements for MRI/CT reading. And although the fed changes reimbursement rates for just about all things medical, I would think that the likelihood of MRI/CT reimbursement getting slashed would be of high interest to us med students since the high financial rewards of the field seem to be driving so much interest in the field right now.

Furthermore, in a field like GS there are so many procedures to be done, that changing a GS salary anymore (as in lower than it laready is) would be very hard to do. The fed govt. has already hammered the bread and butter procedures, and most of the more esoteric cases as well. To lower GS incomes anymore it would have to start making them practically free. Rads on the other hand seems to have one big financial gun (at the moment) that is driving incomes higher and higher: the almighty ability to read MRIs and CTs... When that rate for this service is "adjusted", those 20 week vacations are gonna be the first thing to go.

As far as extrapolating that using non-BC Indians to read images will create a situation for non--BC foreign surgeons to operate on the "supervision" of an US-trained BC surgeon... That's a pretty weak thought. Reading an MRI is a little different than performing an operation from the patient/doctor standpoint. Most people never even know the radiologists name, much less his nationality. A surgeon/patient relationship is intimate, and extremely important. It's one of the reasons why I chose surgery over everything else. Further, I doubt that patients would go for the kind of set-up that you imagine. Just put yourself in their position... Would YOU go for that? At any rate, surgeons go in to surgery to OPERATE on his/her patients. I can't imagine a surgeon who would be comfortable delegating his patient's surgery to another surgeon so completely and on the scale that you describe.

Good luck in your career. Irg has it right though... letting the financial picture drive your decision-making process at this point would not be prudent.

Peace.

CP,

Cheers man, I would want a BC'd surgeon and a BC'd radiologist as well. I just think we are sliding down a slippery slope on a lot of fronts and it is up to us as (future) physicians to maintain standards. BTW I didn't think you were dissing rads -- I think your comments were interesting and thought provoking and I'm glad you put in your 0.02.

Good luck to you too!

BTW I don't think that nationality matters -- I am talking about credentialing only.

Here goes, correct me if I am wrong:

1.) BE generally means you are in or have completed a residency in a program acceptable to the respective specialty board. For the ABR, this generally means you have completed a 5 year residency in the US (ACGME-approved) or Canada (FRCPSC-approved). These residencies follow a structured program providing x hours in each area and yz number of cases etc. etc. The use of the term BE is widespread but discouraged by the boards. US and CDN residencies are both accepted because, apparently, they were developed together and the syllabi are nearly identical. BC means you are BE and have passed the board exam.

2.) In many countries, (like Canada, the one I know most about) specialists do indeed need to be "boarded" (in this case becoming a FRCPSC, after passing the equivalent of the ABR exam) to call themselves specialist X. In the US, BCtification is "voluntary" meaning that as long as you have a state medical license (usu required MD and Step1-3) you can practice any kind of medicine you like. However, most hospitals and insurers will only reimburse you if you are BC'd (the VA is the big exception, apparently). And of course if you screw up and have not done a residency and are not BC'd, you are toast. As a side note, BC'd docs are usually eligible for the respective FRCPSC exam, if you decide to move to our peace-loving utopia

3.) Most eventually pass but they are hard exams. Some do fail.

4.) Fail and you can take them again. Some hospitals/insurers may not care as long as you graduated from a board eligible residency...

5.) I would prefer a BC'd specialist. In Canada you cannot practice as a specialist without being "BC'd" (FRCPSC)

6.) Yes depending on specific item, specialty and insurer.

7.) Just do all your steps. Hell, even I'm doing them. State licensure can be a major hassle without them.

Originally posted by GeneralTso

If thats the case, I think I'll cross off Rads from my list since Ive seen what cheap labor from india has done to parts of Silicon Valley.

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What a ******ed racist comment. You clearly have no idea what Indians have done for the Hardware/Software Industry in the US. Do us all a favor and keep your prejudiced generalizations to yourself. Unbelievable....

Originally posted by firebreather3
What a ******ed racist comment. You clearly have no idea what Indians have done for the Hardware/Software Industry in the US. Do us all a favor and keep your prejudiced generalizations to yourself. Unbelievable....

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as a former ******, i find your comment very offensive

Originally posted by GeneralTso
As a former financial analyst, I have more than a good idea of what the outsourcing movement to India has done to the US Hardware/Software industry. It has allowed companies to shave their expenses at the expense of white collar jobs since the well educated indian workforce is willing to work for a fraction of the wages here. Great for India and Silicon Valley companies and lousy for the software engineer who lost his fomerly high paying job. Its not a leap of logic to see that the same threat is facing US radiologists if MGH's plan gains any traction and they are able to sell it hospitals with their bloated cost strutures.

My comments were not intended to be an ad homium attack on FMGs from India so your charges of racism is far off the mark. My indian buddy is the one who brought this to my attention and he is just as concerned on the impact of this plan on the rads profession as a soon to be Rads.

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Yes and as a former Software Engineer I can tell you that Indians have made invaluable intellectual contributions to the overall Software Infrastructure in this country. These contributions have increased profit margins and are largely responsible for the high level of Enterprise software we all enjoy today. To use the H1-B problem as a way to ostracize Indians for the loss of jobs is not only ignorant but minimizes their diligent efforts. You would have had better luck with the buzz word "corporate greed". Indians are not cattle herded around for the cheapest price; they are decent, hard working, intelligent people who happen to have an aptitude for Software Engineering.

Originally posted by GeneralTso
You have misconstrued my comments and the purpose of this thread. When I was referring to the effect of Indian outsourcing on Silicon Valley, I was referring to companies like Wipro that contract with companies here. Nowhere in my comments did I talk about rallying against Indian nationals that come here to be residency trained so your comment on H1-Bs is somewhat curious and puzzling since that has nothing to do with outsourcing. Cheap indian labor is apt because the same work is farmed there at a fraction of the cost that it an American would do here. I did not make any value judgementts such as lower quality or less productive which is where your comments were going at. If anything, the companies are gettting a better product at a cheaper price considering the workforce in india is so well educated and are willing to be paid far below their true value because the standard of living is lower there than northern cali.

Unlike tech workers, however, MDs have state regulations and licensing guideliness that protect our jobs and controls who gets paid for doing medical work. The plan that is transpiring at MGH flouts all these rules and regulations so that a few MGH docs can become filthy wealthy at the detriment of all the others in the profession and the Indian nationals they are using are just pawns in their masterplan.

Please be better informed and get your facts straight before you fly of the handle and call people racist and ******ed.

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This grows tiresome...it's just one ambiguous statement after another followed by a lengthy qualification. Given your original quote, which by the way was "....since Ive seen what cheap labor from india has done to parts of Silicon Valley", I think anyone with my background would have reacted similarly . Especially since in my opinion the disparity between Radiology and Software Engineering negate any possible context for such statements to be made. Therefore I stand by the assertion that those comments are ******ed and racist. I made no such assumptions about you as person. That should be a sufficient concession to leave our t?te-?-t?te on relatively amiable grounds.

Actually, firebreather3, I think your responses are growing tiresome and annoying. We are talking about remotely outsourcing image reads to non-credentialed physicians. We are talking about billing the insurer under the name of a BC'd radiologist for the interpretation, and then paying someone else who is not BC'd to do the job for a lot less money, without any oversight. We are talking about greedy doctors pocketing the difference, in the process placing patients at risk. We are taking about the possible impact on the practice of radiology. We are not talking about the "H1B problem", whatever the hell that is. The "disparity" you speak about is exactly what concerns us, since unlike IT, medicine requires uniform credentialing as people's health hangs in the balance. The "context" that you have summarily "negated" is the Mass. Gen Hospital, where this may be happening.

Please read before posting.

(Back to the original topic, I doubt this will actually spread beyond night reads by BC'd MDs because of the additional liabilty incurred by the BC'd radiologist doing all the billing (although MGH can do whatever they want) In addition, you need radiologists in house for a lot of reasons, so GeneralT, I would pick your career based on whatever turns your crank)

Originally posted by eddieberetta
Actually, firebreather3, I think your responses are growing tiresome and annoying.

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In that case, feel free not to read or respond to my posts. That might be more effective than the repetitive drivel you wrote. In any case, I understand the issue at hand and only object to the stereotypical generalization of using Indians as "cheap labor". This occurs far too often, is accepted readily and I can't tell you how demeaning it is. That's the last I'm prepared to say on this obscenely lengthy, clearly off-topic and unpleasant part of the discussion.

Originally posted by firebreather3
In that case, feel free not to read or respond to my posts. That might be more effective than the repetitive drivel you wrote. In any case, I understand the issue at hand and only object to the stereotypical generalization of using Indians as "cheap labor". This occurs far too often, is accepted readily and I can't tell you how demeaning it is. That's the last I'm prepared to say on this obscenely lengthy, clearly off-topic and unpleasant part of the discussion.

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Indians are "cheap labor" compared to equivalently trained US labor. Jeez. Wake up. The only thing "unpleasant" about this discussion is your accusations that another poster is racist.

Clearly eddieredbarchetta's were NOT racist. I don't know what posts you were reading, but it's clear to me that eb was making a (pretty good) comparison between the outsourcing of computer labor to India whith the outsourcing of radiology work to India. Why do you think India was chosen? Because the food is tasty? Nah man... it's because US companies save money with relatively cheaper labor. Damn man, how coud you not understand that?

Maybe I'm wrong about this, but I think the impetus for outsourcing radiology film reads overseas comes directly from hospital management, not directly from rads themselves.

After all, why would the hospital approve this plan if their own rads make a lot more money so that the net result is the same?

I think the MGH rads people will make slightly more, but pressure from above will force them not to get too greedy. If MGH ends up spending exactly the same amount of money they do now with in-house rads interp, then why would MGH want to go overseas for increased liability risk?

the fact is that MGH plans on spending VASTLY less money on rads as a result of outsourcing; this will preclude the MGH rads from becoming overly greedy or making substantially more money than they are now. MGH will monitor their rads incomes closely under this new plan; if it turns out that the in house MGH rads people are jacking up their income, they will put cost controls on them to bring it down.

the amount of money MGH stands to make on outsourcing rads is ABSOLUTELY PHENOMENAL. I think some people still dont understand how much money you could save by going this route. A typical American rads costs upwards of 250k per year; the Indian counterpart would be very comfortable with a 80k per year salary. There are some overhead costs involved with outsourcing, but still thats a huge chunk of change to be saved.

The bottom line is that this trend will grow and continue unless new regulations are brought down from above. Clearly, hospitals are not going to walk away from a 170k per year windfall per radiologist. They'd be crazy to.

I don't think the admin even understands what is going on. This is being set up by one MGH radiologist. If it was the admin, they would have to deal with the liability they would be taking on by themselves by not providing MGH patients with the standard of care (a BC'd radiologist). The current scheme skirts these sticky issues because the BC'd radiologist is the one taking responsibility for the reads. The rads dept. (not admin) gets the money, freeing them up to do other things with their time...

To be honest, I suspect it has a lot more to do with MGH's difficulty in recruiting radiologists to do any actual reading -- they all want to spend 90% of their time on research.

I agree, however, that people doing medical procedures should be certified to do so, and this scheme does not guarantee high quality care for patients. At the same time, I doubt many radiologists would be comfortable letting someone else read films for them. But as I said, MGH can do whatever they want...

Well, I've said everything I know about this issue, so sadly, I must bid farewell to this thread. May it rest in peace

I guess the proof will be in the pudding with this experiment. It's either going to succeed wildly and provide needed assistance for image interpretation (as well as a financial windfall for the partners @ MGH as their billing productivity goes up presumably)or collapse under an avalanche of liability issues. If they have good quality control (a BIG if) on the other end, there's no reason to think it won't do well.

I don't know whether or not its worth worrying about just yet as far as it affecting the market here. There are just sooo many imaging studies being ordered these days (with many new technologies on the horizon) with the price per study falling which should keep everyone more then busy for our lifetimes. Now a reliable computer program for interpreting films......that's the real threat to sustaining the current market for radiologists

Interesting about the potential for a computer to interpret images (although I realize this has been discuss on SDN before) - I guess the same could be said for clinical medicine where symptoms, signs and patient demographics could be entered into an algorithm and a differential diagnosis given as an output with the work up and management protocol that could be followed by any physician. You could even use NP/PA's to gather the signs thus further lowering the costs - Indeed, maybe those in IM should worry since there role in the more complex cases would be moot!

Seriously though, there is always someone somwhere, whether it be in India, Australia or a between medical fields in America looking for the same procedue (ie rhinoplasy and ENT vs. plastics) - I wouldn't stress about it.

Airborne

A computer will not interpret images accurately within our lifetime. The complexity of imaging and the liability involved will not make this happen.

I know a couple of Indian Radiologists who have joined Radiology fellowships @ excellent institutions like RIT and Mayo in the past couple of years. I am sure these guys are not permanent residents or US citizens and did not go through any kind of an IMG match. They just started these fellowships which do not seem to span more than 2-3 yrs. I dont see how they are going to be able to live in the US after their fellowships and work as Radiologists. I wonder if these programs are giving them some amount of training hence creating a workforce abroad to meet US specs.

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sorry I meant Rochester NY

Originally posted by AMMD
I know a couple of Indian Radiologists who have joined Radiology fellowships @ excellent institutions like RIT and Mayo in the past couple of years. I am sure these guys are not permanent residents or US citizens and did not go through any kind of an IMG match. They just started these fellowships which do not seem to span more than 2-3 yrs. I dont see how they are going to be able to live in the US after their fellowships and work as Radiologists. I wonder if these programs are giving them some amount of training hence creating a workforce abroad to meet US specs.

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I am sure they are applying for permant resident status in the USA.

I am pretty sure there is no such devious plan to train them and send them back to India as pawns (as someone stated) for US graduated MDs.

ok so lets say you are finishing your rads residency and suddenly they cut reimbursement for readings or the indian labor thing pans out and rads salaries plummet...

you could still just take a year to do a fellowship in interventional/angio or nuc. medicine and then follow that route. Are most revenues in interventional or nuc. derived from reads?

Based on what happens in a supply-demand system, I predict the outsourcing will be successful, assuming the liability issue is resolved. The originators of the program will get obscenely wealthy (nothing wrong with free enterprise) while the program operates in obscurity.

God forbid anything bad were to happen as a result of the lesser qualified Doc's and the potential for rubber stamping their work. The BC'd reviewer may be tempted by bigger $$ or drawn to the golf course in less than honest situation. It happens all the time in other industries. Nobody will get caught till someone is seriously neglected in the process. Then a relatively small judgement will be awarded, maybe a country club prison sentence, and less work sent down this path. Just ask Michael Milliken, Kenneth Lay & co., that WorldCom CEO, ....

They kept most of their money, while the small people were hurt.

Income in specialty fields will continually change due to the government reimbursement involved. I have a good DO friend leaving FP after 30 years due to declining income, going into hyperbaric medicine with better payments.

The liability issue that everyone is bringing up as a potential impediment to this idea is overblown.

Why?
1. States (Cali, etc) are slowly limiting medical tort awards.
2. The federal gov't has also considered limiting awards on medical tort.

The only major hindrance to this idea is to continue letting doctors face major liability, which the AMA opposes.

You can't have the cake and eat it. You either support pts having unparalleled rights to sue docs (maybe good for the future of radiology) or pts having these rights limited (good for the future of the medical profession).