outsourcing radiology

[ashahdc]

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Recently 6 radiologists in NYC were laid off, supposedly with the jobs being sent overseas for tele-radiology. Comments?

 

[Law2Doc]

Recently 6 radiologists in NYC were laid off, supposedly with the jobs being sent overseas for tele-radiology. Comments?

Your source for this?
While the technology exists, someone still needs to provide oversight and likely would need to reread the films in the US. Because if a mistake is made and the practice is hailed into court, it is pretty indefensible to say that no one licensed in the US ever read the film, I would think.

 

[FizbanZymogen]

Hmmm......there has always been speculation surrounding this possiblility but I would really need to see evidence that this occured.

 

[TexPre-Med]

Easiest specialty to outsource. I would question a residency in radiology if you are thinking about it.

 

[TexPre-Med]

Your source for this?
While the technology exists, someone still needs to provide oversight and likely would need to reread the films in the US. Because if a mistake is made and the practice is hailed into court, it is pretty indefensible to say that no one licensed in the US ever read the film, I would think.

With capping of malpractice suits, could the saved money by outsourcing outweigh the cost of a few lawsuits here and there?

 

[DocHoliday]

Jim Cramer on Mad-Money suggested investing in NIGHTHAWK (NHWK) its an Austrailian company that does this. Instead of paying doctors to work late night shifts, they electronically send the images to NHWK becuase its day time over there. Pretty neat, but unfortunate for us. 👎

 

[Law2Doc]

With capping of malpractice suits, could the saved money by outsourcing outweigh the cost of a few lawsuits here and there?

This isn't a state with capped malpractice suits, I don't believe. And local insurance isn't going to cover non-licensed people practicing medicine on US patients. So no, I don't think so.

 

[OncoCaP]

Here are a few public stories that I could find. Given that there is supposedly a shortage, I'm not sure why a radiologist would lose a job and not immediately find another in radiology:

http://www.msnbc.msn.com/id/6621014/
http://www.blonnet.com/2003/12/19/stories/2003121900980400.htm

Considering how easy it is to outsource and considering how this works in other industries such as technology, I would fully expect there to be radiologists with offices here in the U.S. who have several people doing work behind the scenes (consulting?) in India. A certain amount (most?) of the radiology work is probably routine, and I wouldn't be surprised if Indian physicians were reading images.

How much of an issue this is or will become is anyone's guess. It would be extremely naive to think that the radiology field is somehow immune to outsourcing for liability reasons. Hospitals doing outsourcing aren't necessarily going to do this themselves (they might do it through a local radiology group or just keep it secret some other way). If the physicians in India reading the images are very good at what they did (or the work was routine or low-risk), the liability would not necessarily be an issue if the radiologist in the U.S. declared that s/he reviewed the images.

Outsourcing has affected technology in mostly a positive way (better quality and much cheaper technology products), and I would expect a similar positive impact on the quality and cost structure of radiology. It looks like outsourcing is just easing the shortage of radiologists a little bit right now. Down the road it could have more of an impact. I'm not sure how much of an impact automation and radiology software would have on that profession or increased responsibility of various radiology techs and other mid-levels. It's really hard to predict what is going to happen 10 or more years from now.

 

[TexPre-Med]

This isn't a state with capped malpractice suits, I don't believe. And local insurance isn't going to cover non-licensed people practicing medicine on US patients. So no, I don't think so.

non-licensed? you mean no M.D. or no U.S. license? While I do not think we are at the point to make this common practice, I could see this springing up in the next decade. Insurace companies just want to make a buck and the savings could be astronomical.

Could you have a U.S. company operating overseas with foreign M.D.'s? They wouldn't necessarily be practicing in the U.S. but working on U.S. cases? Not sure on legal issues, but I would think that it could be done. Maybe drop most radiologists and have 1 quick checking everything "consulted" overseas.

 

[Gut Shot]

If you check out the Nighthawk Radiology website, indeed the radiologists are all US board certified, and every one I looked at trained in the US (med school as well as residency). This isn't exactly a third world radiology sweatshop.

 

[Law2Doc]

non-licensed? you mean no M.D. or no U.S. license? While I do not think we are at the point to make this common practice, I could see this springing up in the next decade. Insurace companies just want to make a buck and the savings could be astronomical.

Could you have a U.S. company operating overseas with foreign M.D.'s? They wouldn't necessarily be practicing in the U.S. but working on U.S. cases? Not sure on legal issues, but I would think that it could be done. Maybe drop most radiologists and have 1 quick checking everything "consulted" overseas.

No US license means no license to practice on US people located in the US. Doesn't matter what degree they have conferred by another country. Insurance companies specify licensure as a condition to coverage as it helps them manage risk -- they know what they are getting into. To open it up to other countries with maybe differing standards of education and quality would surely require significantly different calculations, and likely much higher premiums for most of the nations where you would get substantial cost savings (which tends to negate the cost savings). A US company operating overseas with foreign MDs is not helpful -- the issue is did someone who meets US licensure and its accompanying standards read the film. Thus you certainly could send a US doctor overseas, or train someone from overseas here and try to have him move back and read your films after residency, but again, that doesn't get you the cost savings. Or sure, you could have someone US licensed supposedly checking everything consulted overseas, but he would be the one on the hook for every mistake, would be repeatedly and regularly sued, and few people are so foolish to risk their own livelihood on countless mistakes on films he never read and yet signed off on.

I agree that the kinks may be worked out eventually, but probably not at enough cost savings to make it worth it in the near term.

 

[OncoCaP]

If you check out the Nighthawk Radiology website, indeed the radiologists are all US board certified, and every one I looked at trained in the US (med school as well as residency). This isn't exactly a third world radiology sweatshop.

I would be more concerned about what is not printed than what we find in (electronic) print. Think about it: if someone is not using U.S. licensed radiologists (using radiologists from another country for example), would they advertise it where the general public could Google it?

Also, other than their conscience (which isn't always perfect) and risk of prosecution (also not a perfect deterrent) what prevents someone from having routine work consulted out to a less expensive country? I worked with companies that outsourced substantial fractions of their technology work and they made sure that those activities were not published where the public had access to the information. They would have 100 engineers working in other countries and ~30 locally checking their work (in addition to doing work locally).

 

[Taurus]

On the surface, the outsourcing of IT work and film reading doesn't seem that different. Technically, both are straight-forward to implement these days. However, there is one big difference. On the one hand, if the foreign worker screws up the work in IT, it's called a bug. Bugs can be fixed. There are QA processes to verify that the code works according to expectations. No harm done. On the other hand, if the foreign radiologist misses that diagnosis, e.g., cancer or pneumothorax, it's not harmless. Someone will get hurt or die. Negligence + damages = malpractice = lawsuit. How much in damages are we talking about? I estimate $10-20 million per case if the person is severely hurt or dies. Ask yourself if the hospital or insurance company would dare to take on that kind of liability. Very unlikely.

One other thing. Nighthawk uses Australian rads to do preliminary reads. Those get sent back to this country to get a final read. Medicare will pay for final reads only if you're physically in this country. It won't pay if you're overseas, even if you're US board-certified in rads.

 

[Gut Shot]

I would be more concerned about what is not printed than what we find in (electronic) print.

Every film that is read has someone's signature attached to the interpretation. Having unlicensed proxy readers would still require signatures from US licensed radiologists. Doing what you are proposing would likely involve multiple levels of fraud, much of it perpetrated by people with little to gain and everything to lose.

 

[Wrigleyville]

Have you ever called dell.com to get tech support and gotten a highly intelligent but unintelligble person from Bombay to help you through your problems? Do you think clinicians who are used to strolling into the radiology reading room to go over films will be satisfied with a similar "solution"? Add HIPPA issues to this and the problem becomes insurmountable.

UCSF tried outsourcing some work to foreign countries a few years ago, and the docs on the other end threatened to release confidential patient information unless they were paid more. That experiment ended in a hurry.

You need a medical license in the state where the exam is done to do the final reads on the films. Good luck finding people with NY state medical licenses in India willing to working for peanuts (Rupees?). There is not a single person with such a license who would not, at this very moment (8:17 CST) drop eveything they have to move to the U.S.

 

[dutchman]

For as long as defensive medicine exists, radiology will continue to rule.

 

[QuantumMechanic]

I despise the "the sky is falling" attitude" on SDN. If the assertions made on SDN were true, nurses will be higher paid than physicians, who will be lowered to the level of indentured servants in the American economy. Sorry kids, not going to happen.

 

[helpfuldoc2b]

For as long as defensive medicine exists, radiology will continue to rule.

I heard they are laying off Pharmacists as well because they decided to use vending machines as a more cost effective method of dispensing drugs. Also they are outsourcing the Psychiatry field to 1800-numbers, for the cost of 1.99 per minute. Seriously though, this outsourcing thing is getting out of hand, its crazy how money oriented our nation is. I want to see the malpractice insurance coverage on any medical speciality outsourced.

 

[glp]

One other thing. Nighthawk uses Australian rads to do preliminary reads. Those get sent back to this country to get a final read. Medicare will pay for final reads only if you're physically in this country. It won't pay if you're overseas, even if you're US board-certified in rads.

this is the point i think a lot of people don't get. all nighthawk reads are prelimary and every film they read must be reread by a state licensed radiologist. in the u.s. licensure is done on a state by state basis and laws for practicing can also vary state by state. but at this time i believe that all final reads must be done by a radiologist licensed in the state in which the film was taken. if radiologist are vigilant in their lobbying, there is no reason that state legislatures would be moved to change this policy. they just need to be smart and proactive and can easily do so under the auspices of patient care.

 

[Taurus]

this is the point i think a lot of people don't get. all nighthawk reads are prelimary and every film they read must be reread by a state licensed radiologist. in the u.s. licensure is done on a state by state basis and laws for practicing can also vary state by state. but at this time i believe that all final reads must be done by a radiologist licensed in the state in which the film was taken. if radiologist are vigilant in their lobbying, there is no reason that state legislatures would be moved to change this policy. they just need to be smart and proactive and can easily do so under the auspices of patient care.

Laws are not written in stone. They can be changed, especially with the help of highly paid lobbyists.

Even if the laws are changed, I don't see outsourcing as a threat. Liability is just too great. They would need to prove that the accuracy of foreign rads is equal or better than US-based ones before I would start to worry. Furthermore, rads is more than just reading film. Make yourself indispensable and you control your own destiny.

 

[Droopy Snoopy]

Even if the laws are changed, I don't see outsourcing as a threat. Liability is just too great. They would need to prove that the accuracy of foreign rads is equal or better than US-based ones before I would start to worry. Furthermore, rads is more than just reading film. Make yourself indispensable and you control your own destiny.

Hence the rise of interventional and the like. I don't see the big deal, the medical profession is just getting a small taste of what the IT and manufacturing industries among others have been getting for years. Don't think we'll be seeing oodles of rads residency programs shutting down any time soon.

 

[Taurus]

Hence the rise of interventional and the like. I don't see the big deal, the medical profession is just getting a small taste of what the IT and manufacturing industries among others have been getting for years. Don't think we'll be seeing oodles of rads residency programs shutting down any time soon.

Speaking of technology, can you just imagine the impact technology will have on all aspects of medicine in the next few decades? Patients will see their provider from 500 miles away via teleconferencing from the comfort of their homes for routine care. Surgeons will operate remotely using robots on patients across the globe. Change is constant so keep one step ahead of the changes and you'll be fine.

 

[Droopy Snoopy]

Surgeons will operate remotely using robots on patients across the globe. Change is constant so keep one step ahead of the changes and you'll be fine.

That's what I tell myself every time I start playing some Halo - it's not procrastination, it's preparation for my future life as a robotic vascular surgeon 😎

 

[OncoCaP]

Laws are not written in stone. They can be changed, especially with the help of highly paid lobbyists.

Even if the laws are changed, I don't see outsourcing as a threat. Liability is just too great. They would need to prove that the accuracy of foreign rads is equal or better than US-based ones before I would start to worry. Furthermore, rads is more than just reading film. Make yourself indispensable and you control your own destiny.

First, let me say that I'm positive about medicine overall. I also agree that it is certainly probably that radiology will only get better with time. I'm only talking about risk, not guaranteed impending doom.

I also agree that laws can be changed. Projections are that with the current rate of health care increase (even before the baby boomers "boom" in healthcare), Medicaid and Medicare will take up the *entire* budget by ~2050 (I realize it's hard to predict the future). Given the enormous pressure that government at all levels is under (a pressure that is projected to increase), we will find lawmakers trolling for cost savings -- very much more so than they are today.

International outsourcing of reading images is going to come up and if the pressure is significant enough, it will be allowed ... legally. Outsourcing something like surgery is more difficult and would require expensive robots that must be maintained locally at great expense. Even before legal changes, it's also illegal to defraud Medicare and Medicaid, and it happens more often than most people would like to see.

I also agree that outsourcing is not a threat to radiology jobs. However, I could see it affecting the lifestyle (number of hours worked?) and income of radiologists be affected 10 years from now, perhaps sooner. Keep in mind that most international outsourcing projects that I was aware of early on were a complete and total disaster. Despite numberous facts showing they were not a good idea in many cases, more and more projects were being started. The reason they occurred and continue to occur today is that MBA's sitting in a board room somewhere thought it was a great idea to make more money. That's it. Convince a few powerful people, and it happens. Once a few do, it no one else wants to be left out. Even now, the value of many outsourcing projects is questionable ... but that is not stopping them. Logic does not always prevail.

In terms of where this outsourcing is going to happen ... I could see it happening at the more cost-sensitive sectors of healthcare first. Have you been to a community clinic recently ... you know, the kind that helps people who don't have health insurance? I went to one recently, and it strongly smelled like feces when I walked through the lobby. Then there were the lines just to check in and large number of people milling around. Many of the patients in this clinic don't speak English and couldn't care less as to who reads their radiology images. The care they receive is sometimes questionable and pretty much whatever there is money to do. They don't care whether their radiology images are read here or in China; what these patients care about is whether someone is going to help them at all, preferably within 5 hours so they don't need to come back tomorrow. As the number of uninsured increases, they will put increasing pressure on lawmakers to reduce costs, and outsourcing radiology to low cost countries will be one of the proposals considered and seriously considered.

My intent is not to suggest doom & gloom here. My intent is simply to discuss pressures and potential changes, including potential motivations behind these changes. From what I can tell, the image reading aspect of radiology is at risk of some big changes, although I don't expect widespread unemployment of radiologists. At the same time, it's not out of the question that such changes could affect the lifestyle (more work expected) and income of radiologists.

 

[Taurus]

Projections are that with the current rate of health care increase (even before the baby boomers "boom" in healthcare), Medicaid and Medicare will take up the *entire* budget by ~2050 (I realize it's hard to predict the future). Given the enormous pressure that government at all levels is under (a pressure that is projected to increase), we will find lawmakers trolling for cost savings -- very much more so than they are today.

You don't have to wait til 2050. The cost savings pressure is on right now. If you have worked, you know that healthcare premiums have been increasing at double-digit rates for many years now. Compound that annual increase over years, it won't take long before the cost of the premiums will be more than the paycheck of most except the highest paid workers. Businesses, who pay most of the premiums, are balking too. So, healthcare costs have to come down. The two largest healthcare costs are 1) hospital costs 2) physician fees. The government tries to cut reimbursements to those two things all the time before the healthcare lobbyists step in to save the day. More likely than not, the cuts will win out in the end. First, all physician reimbursements by Medicare and insurance will decrease in the future. Not just in radiology. Across the board in all fields. Why do you suppose cash only practices are so attractive? Or why some physicians are going into cosmetics where it's cash only? Second, hospitals and practices are using more and more midlevels to reduce costs. Heck, even the state and federal governments are promoting midlevels because they see the cost-savings associated with using them. Midlevels are good because they increase access to care and are cheaper. In the long run though, they devalue physicians because they tip the supply and demand curve. NP's and DNP's who will soon replace them are the biggest threats. CRNA's in anesthesia. Just wait and see what happens when they enact some form of universal healthcare in this country. It won't be pretty for physicians.

I also agree that outsourcing is not a threat to radiology jobs. However, I could see it affecting the lifestyle (number of hours worked?) and income of radiologists be affected 10 years from now, perhaps sooner. Keep in mind that most international outsourcing projects that I was aware of early on were a complete and total disaster.

Change is constant. You can't expect the status quo to not change for 30 years in this era of high tech. Medicine is becoming more and more like every other industry in the world where change is the norm. Medicine is a business, like it or not, and those business decisions may adversely affect you in some way. However, outsourcing of other industries like IT, accounting, business functions, etc. are different than in medicine. Those industries don't have such heavy regulations by the state and feds. Furthermore, the liability issue isn't there with those industries. In those industries, workers can screw up (that happens a lot). QA processes will catch the mistake or it can be cleaned up easily later. Not a big deal. Those workers are also anonymous. They could have been picked off the street yesterday (happens more often than you think). They don't have to sign their name to anything and be held accountable if they screw up. But outsourcing of medicine is fraught with tons of pitfalls. I have no doubt that some will try to outsource, but it will be very difficult and in the end may prove to be not worth it.

I'm probably one of the most paranoid people on SDN regarding outsourcing. If I truly thought that outsourcing was a possibility in rads, then rads wouldn't be on my radar screen. But my senses are telling me that it won't, at the moment anyways.

 

[Law2Doc]

That's what I tell myself every time I start playing some Halo - it's not procrastination, it's preparation for my future life as a robotic vascular surgeon 😎

I'd rather pass on than have folks playing WOW in my guts.

 

[Sol Rosenberg]

Keep in mind that most international outsourcing projects that I was aware of early on were a complete and total disaster.

Bingo. In my career as an Electrical Engineer (which is a field, if you believe the gloom-and-doom on the news, that has already begun to be outsourced to the far east, and will continue, to a greater degree to be in the future) I have seen firsthand, with a 100% failure rate, attempts to outsource engineering (to India in these cases) fail. Keep in mind that with these outsourcing projects there were essentially no legal/liability considerations, and no one's life was at stake. Some outsourcing projects at other (competing) companies have been "successful," (meaning that they still exist) at tremendous cost in both capital and productivity to those companies.

I have no reason to believe that outsourcing of radiology will be significantly different, even ignoring all of the legal issues. I agree with you that there will be some experimentation with the outsourcing, but even without any misreads, etc I think that these experiements, based upon my prior experience will also fail. But, throw in the lawsuits from the misreads and that "party" will be over.

Thus, I have not ruled out Radiology as a potential specialty, and if it suits your personality, I think that one would be foolish to rule it out because of outsourcing. Both the IT and High-Tech job markets are hot right now, and those have supposedly already been outsourced. 🙄

 

[8744]

Bingo. In my career as an Electrical Engineer (which is a field, if you believe the gloom-and-doom on the news, that has already begun to be outsourced to the far east, and will continue, to a greater degree to be in the future) I have seen firsthand, with a 100% failure rate, attempts to outsource engineering (to India in these cases) fail. Keep in mind that with these outsourcing projects there were essentially no legal/liability considerations, and no one's life was at stake. Some outsourcing projects at other (competing) companies have been "successful," (meaning that they still exist) at tremendous cost in both capital and productivity to those companies.

I have no reason to believe that outsourcing of radiology will be significantly different, even ignoring all of the legal issues. I agree with you that there will be some experimentation with the outsourcing, but even without any misreads, etc I think that these experiements, based upon my prior experience will also fail. But, throw in the lawsuits from the misreads and that "party" will be over.

Thus, I have not ruled out Radiology as a potential specialty, and if it suits your personality, I think that one would be foolish to rule it out because of outsourcing. Both the IT and High-Tech job markets are hot right now, and those have supposedly already been outsourced. 🙄

My company flirted briefly with outsourcing drafting (AutoCAD) overseas but nothing ever came of it. It may have been cheaper by the hour but it cost a lot more in managerial oversight, reworking, and checking. Same with engineering work.

 

[OncoCaP]

The companies I worked with that did outsourcing eventually did get results ... after tremendous time and expense. This does serve as a significant barrier in terms of achieving results. While this should serve as a barrier, I have found that consequences often do not prevent stupidity and pain to many in the first place. There are companies that are making outsourcing work, even though the results can be really bad initially.

The initial failures had more to do with the get-immediate-results mentality rather than the quality of the people in other countries (who were very capable, just not given an adequate chance to learn their jobs or subjected to management by remote control). Now that these companies have invested in it and figured out how to make it work, they are making enormous sums with it. It took about 10 years to make these systems work. I suppose if medical outsourcing had a similar timescale we should have some warning.

It is my understanding that a sizeable fraction of radiology is defensive medicine (cover-your-tail stuff when nothing is wrong) or obvious (look, the bone really isn't broken as any child can see), and to that extent it does appear to be vulnerable to outsourcing. If and when radiology outsourcing did take place, the quality might be really bad but politicians would claim "... look we have made healthcare more accessible by reducing the cost and our outsourcing partners have a 100% success rate on checking off items on the quality checklist. Wait times are much better than they were before and, while yes, there are isolated instances of problems, overall, quality is actually better (with appropriately choosen data to back the claim)."

While politicians could claim victory and get votes, true cost could easily go up; true quality could go down, and radiologists here in the U.S. may not be better off because it. Maybe it would not eliminate radiology jobs, but it might make them less fun due to job requirements related to outsourcing (having to correct other people's mistakes, etc.). I certainly remember it stressing engineers and managers out to have to supervise work from other countries. We shall see what happens in medicine ....

 

[Law2Doc]

It is my understanding that a sizeable fraction of radiology is defensive medicine (cover-your-tail stuff when nothing is wrong) or obvious (look, the bone really isn't broken as any child can see), and to that extent it does appear to be vulnerable to outsourcing.

I think this understanding is not something most radiologists would agree with you on.

 

[OncoCaP]

I think this understanding is not something most radiologists would agree with you on.

Ok, then Law2Doc, in your understanding, what fraction of radiology is "routine/straightforward" and what part of it is "complicated/dangerous"? Also how are we measuring the accuracy of radiologists right now? I'm really curious....

 

[Taurus]

the quality might be really bad but politicians would claim

If the only thing that healthcare decision-makers cared about were what politicians thought, nearly all of medicine would be outsourced or insourced. In other industries that outsource, management only cares about shareholders. In healthcare, you have that additional threat of huge litigation costs and damages. No business that wants to stay solvent should overlook their liability exposure.

 

[Law2Doc]

Ok, then Law2Doc, in your understanding, what fraction of radiology is "routine/straightforward" and what part of it is "complicated/dangerous"?

I'm not sure "defensive medicine" and "obvious" are really the same concepts as "routine", which is why I suggested your prior "understanding " is off. Most medicine is routine, in that you tend to see and do the same kinds of things more than the rarities, (more horses than zebras) but you don't write it off as something so obvious that anyone can do it, or that it is just follow-up to make the lawyers happy. Medicine doesn't work that way and people expect their doctors to have the ability to know when something isn't routine. Every radiology case, as well as pretty much any specialty study, biopsy or procedure can become dangerous if you miss something. Some things need the rapidity of response someone thousands of miles away cannot provide. And you don't run for luck with the hope that you don't see that many zebras. You need people with the expertise to catch them too.

 

[OncoCaP]

If the only thing that healthcare decision-makers cared about were what politicians thought, nearly all of medicine would be outsourced or insourced. In other industries that outsource, management only cares about shareholders. In healthcare, you have that additional threat of huge litigation costs and damages. No business that wants to stay solvent should overlook their liability exposure.

At the present time there are already a certain number of medical errors (done by U.S. radiologists). Not every error results in an injury or fatality, especially if a sizable fraction of the patients are healthy or have something that isn't detectable on an X-ray, MRI, or whatever. Many conditions are never even diagnosed correctly the first time. Many medical errors are never caught by the patient and even when the patient is aware of an error, don't necessarily result in a lawsuit. In fact, many physicians will argue that a fair number of lawsuits involve cases where the physician did nothing wrong but the patient is hurting and someone has to pay. A considerable fraction of the outsourcing that I saw involved extremely dangerous processes, where an error would result in a loss of life, limb, and property. There were other safeguards that usually caught the problem (akin to other physicians checking things out) or the problem didn't necessarily set off a fireball. When a problem did occur, the company just took it as a cost of doing business because the savings of outsourcing were so large that they paid for any liability many times over. Suing a large company is not like suing a lowly physician. They have legal teams that can make life tough for plaintiffs, dragging things out for years or just settling for a nominal sum. Many companies were very good at finding someone else to blame as well and not disclosing "unhelpful or irrelevant" information that would make them uncomfortable.

 

[Taurus]

And you don't run for luck with the hope that you don't see that many zebras. You need people with the expertise to catch them too.

Agreed. In complicated, emergency situations, you can't say, "I'll refer you to a specialist". You are the specialist. You can get away with deferring to someone else with more expertise than you in primary care or general practice. That's the reason why midlevels have success in that area even with 2 years of training. If a zebra comes along, they just defer.

 

[Law2Doc]

When a problem did occur, the company just took it as a cost of doing business because the savings of outsourcing were so large that they paid for any liability many times over.

Medicine is a more regulated industry, subject to licensure, than the kind of thing you are describing. Some of what may fly in engineering/IT type matters will not fly in healthcare, in which government has a direct stake and involvement. No radiology department can decide -- we are going to outsource and just budget for the additional mistakes (even assuming that "cost of doing business" would result in a savings, which I tend to doubt, because of the lawsuit and insurance issues I mentioned above). You don't get to decide that some percent of mistakes (deaths, severe injury complications etc) is fine.

 

[Taurus]

At the present time there are already a certain number of medical errors (done by U.S. radiologists). Not every error results in an injury or fatality, especially if a sizable fraction of the patients are healthy or have something that isn't detectable on an X-ray, MRI, or whatever. Many conditions are never even diagnosed correctly the first time. Many medical errors are never caught by the patient and even when the patient is aware of an error, don't necessarily result in a lawsuit. In fact, many physicians will argue that a fair number of lawsuits involve cases where the physician did nothing wrong but the patient is hurting and someone has to pay. A considerable fraction of the outsourcing that I saw involved extremely dangerous processes, where an error would result in a loss of life, limb, and property. There were other safeguards that usually caught the problem (akin to other physicians checking things out) or the problem didn't necessarily set off a fireball. When a problem did occur, the company just took it as a cost of doing business because the savings of outsourcing were so large that they paid for any liability many times over. Suing a large company is not like suing a lowly physician. They have legal teams that can make life tough for plaintiffs, dragging things out for years or just settling for a nominal sum. Many companies were very good at finding someone else to blame as well and not disclosing "unhelpful or irrelevant" information that would make them uncomfortable.

Remember what the definition of malpractice is. Malpractice is negligence by the physician + damages suffered by the patient. If there is negligence but no damages, then the patient won't win. However, if the radiologist misses that nodule in the lung or that pneumothorax, the patient can get severely injured or die as a result. That's a clear case of malpractice.

 

[OncoCaP]

I'm not sure "defensive medicine" and "obvious" are really the same concepts as "routine", which is why I suggested your prior "understanding " is off. Most medicine is routine, in that you tend to see and do the same kinds of things more than the rarities, (more horses than zebras) but you don't write it off as something so obvious that anyone can do it, or that it is just follow-up to make the lawyers happy. Medicine doesn't work that way and people expect their doctors to have the ability to know when something isn't routine. Every radiology case, as well as pretty much any specialty study, biopsy or procedure can become dangerous if you miss something. Some things need the rapidity of response someone thousands of miles away cannot provide. And you don't run for luck with the hope that you don't see that many zebras. You need people with the expertise to catch them too.

You're great at dodging the original questions, but I can appreciate your points anyway. While I'll be the first to admit that physicians work should not be done by idiots, keep in mind that radiologists in other countries are not necessarily bad at what they do. In fact, many are very good and could hold their own, particularly when it comes to routine work. Even so, physicians in the U.S. are making a fair number of human errors that don't result in lawsuits and somehow outsourcing is supposed to result in a large increase in the number of medical lawsuits. It doesn't follow. There are plenty of physicians out there that frighten me and they don't get sued for reasons such as patients who don't know any better, like the physician anyway, don't want to mess with it, etc. On the other hand there are excellent physicians that do get sued. When it comes to radiology, there are likely "high risk" cases and "low risk cases" that can be handled with different procedures. The "low risk cases" that are easy to diagnose 👍 👎 for patient populations that don't have a significant history of lawsuits might be outsourced first. Legal liability is not always tied to the job performance of the group getting sued.

 

[OncoCaP]

Medicine is a more regulated industry, subject to licensure, than the kind of thing you are describing. Some of what may fly in engineering/IT type matters will not fly in healthcare, in which government has a direct stake and involvement. No radiology department can decide -- we are going to outsource and just budget for the additional mistakes (even assuming that "cost of doing business" would result in a savings, which I tend to doubt, because of the lawsuit and insurance issues I mentioned above). You don't get to decide that some percent of mistakes is fine.

Engineering is subject to licensing as well. Liability is actually higher in some cases because you're not only talking about injury to people but also significant property, operations, and environmental damage.

When it comes to cost, we have decisions like that being made right now. Some physicians don't do a good job, but accept Medicare & Medicaid in a rural area and get patients out the wazoo. They (or their PA's) seem to make a very large number of mistakes but never get sued because their patients just don't know that an error is ever made. Even when they do find out it's an error, they don't always sue.

Here are factors leading to malpractice lawsuits (notice job performance or accuracy is not prominent):

http://www.findarticles.com/p/articles/mi_m1272/is_n2607_v124/ai_17862984
* The most frequent reason respondents gave for contacting a specific attorney's office was television advertising (73%); next highest was an explicit recommendation from a health care provider to seek legal counsel (27%).

* Fifty-three percent reported an unsatisfactory relationship with their provider preceding the alleged injury.

* Forty-eight percent mentioned difficulty with finances during their complaint. Of those who had a steady income, 45% had outstanding medical bills; one-third of these individuals had medical bills that were 50% or more of their annual earned income.

* The five physician specialties most often sued were obstetricians, family practitioners, orthopedic surgeons, emergency medicine specialists, and general surgeons.

* Nurses were named in allegations almost twice as much as any other medical specialty or professional group.

* Private hospitals, offices, emergency care centers, and/or nursing homes were named more frequently as the site of the alleged injury than were state, county, and Federal facilities combined (83% vs. 17%). Forty percent of alleged injuries occurred in outpatient settings.

"What is very significant is that most of these respondents had strained relations or difficulty relating to medical personnel prior to the alleged malpractice," the Huyckes point out. "How many really suffered substandard care isn't clear from our study. What is clear is that health care providers, including clinics and hospitals, should more closely examine why patients become dissatisfied with medical care." Providers who want to protect themselves from malpractice charges more effectively must learn to ask explicit questions about their patients' understanding of and expectations for medical care and its cost.

http://jama.ama-assn.org/cgi/content/full/287/22/2951
Conventional wisdom holds that a physician's malpractice experience is determined by factors associated with the physician, caseload, and unpredictable circumstances. One risk factor for lawsuits is area of specialty, a belief confirmed actuarially in the setting of malpractice rates.1-2 Even within a given discipline, however, some physicians are sued more often than others. Sloan et al3 observed disproportionate malpractice activity among internists, obstetricians, and surgeons, with 2% to 8% of these specialists accounting for 75% to 85% of their group's award and settlement costs.

Factors associated with physicians' experience with claims appear stable. Bovberg and Petronis4 found that a physician's malpractice risk did not fluctuate appreciably over time. Their finding is not surprising given that insurers typically handle claims one at a time, seeking to resolve individual claims, not necessarily to provide prevention-oriented feedback. Because suits are relatively infrequent even for physicians with high claims rates, physicians with the highest risk may not be aware that they generate more suits than their colleagues. Furthermore, physicians at high risk may dismiss individual claims simply as a cost of practicing a high-risk discipline, an especially litigious population, or even bad luck.

Research has forced reconsideration of these traditional explanations of claims experience. Risk seems not to be predicted by patient characteristics, illness complexity, or even physicians' technical skills.5-6 Instead, risk appears related to patients' dissatisfaction with their physicians' ability to establish rapport, provide access, administer care and treatment consistent with expectations, and communicate effectively.7-11

 

[OncoCaP]

Remember what the definition of malpractice is. Malpractice is negligence by the physician + damages suffered by the patient. If there is negligence but no damages, then the patient won't win. However, if the radiologist misses that nodule in the lung or that pneumothorax, the patient can get severely injured or die as a result. That's a clear case of malpractice.

Yes, sure. Maybe reading images for nodules in the lung might be a higher risk (I'm really unsure) and might not be outsourced to the same people that double checking X-rays on a jammed finger might.

 

[Law2Doc]

You're great at dodging the original questions, but I can appreciate your points anyway. While I'll be the first to admit that physicians work should not be done by idiots, keep in mind that radiologists in other countries are not necessarily bad at what they do. In fact, many are very good and could hold their own, particularly when it comes to routine work. Even so, physicians in the U.S. are making a fair number of human errors that don't result in lawsuits and somehow outsourcing is supposed to result in a large increase in the number of medical lawsuits. It doesn't follow. There are plenty of physicians out there that frighten me and they don't get sued for reasons such as patients who don't know any better, like the physician anyway, don't want to mess with it, etc. On the other hand there are excellent physicians that do get sued. When it comes to radiology, there are likely "high risk" cases and "low risk cases" that can be handled with different procedures. The "low risk cases" that are easy to diagnose 👍 👎 for patient populations that don't have a significant history of lawsuits might be outsourced first. Legal liability is not always tied to the job performance of the group getting sued.

I'm not dodging questions, I'm just selectively reading and answering threads that interest me the most; Sorry if I missed something. At any rate, first, you never get to know what is a "high risk case" until you look at it, and once you look at it, you lose the value of having it read elsewhere. The biggest catastrophes tend to be initially innocuous. Tiny things, easy to miss, get bigger or spread -- you want to catch things early. Second, while there are fantastic doctors abroad, when you are talking about huge cost savings, you are generally not talking about these doctors. You are talking about poorer nations where the state of medicine and requirements of licensure are sometimes not on par with the US. You pay for quality everywhere, not just in the US.

 

[Law2Doc]

Yes, sure. Maybe reading images for nodules in the lung might be a higher risk (I'm really unsure) and might not be outsourced to the same people that double checking X-rays on a jammed finger might.

I'm guessing but I would think a jammed finger is not a film that tends to be outsourcable. The patient is there in the ED/office and will generally be put in a cast on the spot if a break is seen. (At least that's the way its always worked when I broke bones). The stuff that tends to get outsourced would be things that would be done overnight, rather than on the spot.

 

[dutchman]

All this will be irrelevant when the government socializes medicine and malpractice becomes a non-issue. They will email those images to india, and if they misdiagnose you, the worst you can do is lodge a complaint with some "regulatory body".

BTW, I know this because I experienced it first hand in Europe.

 

[OncoCaP]

I'm guessing but I would think a jammed finger is not a film that tends to be outsourcable. The patient is there in the ED/office and will generally be put in a cast on the spot if a break is seen. (At least that's the way its always worked when I broke bones). The stuff that tends to get outsourced would be things that would be done overnight, rather than on the spot.

Depends on the situation. If you see your FP doc and he thinks it's ok, but "just in case" let's get some X-rays done and sends you to Radiological Associates of Anytown, USA. They could transmit the images and get the results in short order.

 

[FizbanZymogen]

Nighthawk is used that is true but in general most individuals want to have their images explained and so you will always have a radiologist around in person. Second Nightwahk isn't something that just gets used to save money etc....it is used "at night" like the name implys when an American radiologist isn't right there in smaller community hospitals like mine and almost always nighthawks readings are double checked by another local radiologist for completeness. Rads aren't going anywhere and are actually their demand is increasing, especially for specialist trained to read specific images. Don't listen to people saying, "I would think twice about Rads" they either don't know what they are talking about or are trying to thin the field for themselves. It is perhaps one of the most exciting fields in modern medicine with many branches, Interventional Rads, Diagnostic Rads etc......

 

[turkleton]

People talk about outsourcing radiology as though there was just a huge technological breakthrough to make this possible. While broadband communications is amazing now, it has existed for the better part of a decade, and to a lesser extent even in the mid to late 90's. Yet at no point during this stretch did the radiology outsourcing scare take form, for many of the reasons which have already been mentioned. If there was a problem, new radiology graduates would have a hard time to find a job- and that's absolutely not the case. Until you're able to implicate foreign firms/physicians in domestic malpractice suits, no physician in their right mind would predicate major decisions on data from someone who is not liable for their work- additionally, I think the importance of actually talking to the radiologist is underestimated.

 

[OncoCaP]

I appreciate the info & discussion. It is quite impressive how radiologists have protected their field.

Personally I'm not considering radiology because I heard that it involves minimal patient interaction (a lot of "sitting in the dark reading images"); although I reserve the right to change my mind, right now I'm more interested in something like heme/onc that involves a lot of patient interaction. Also, my dermatologist advised me against radiology (unsolicited advice) due to outsourcing. If the radiology outsourcing is just a rumor, it's certainly a often repeated one ... doesn't make it true, of course.

 

[Law2Doc]

Personally I'm not considering radiology because I heard that it involves minimal patient interaction (a lot of "sitting in the dark reading images");

I think you probably need to talk to a radiologist or two and see what they actually do these days. Lots of interventional/procedural stuff, significantly more patient contact than the olden days thanks to real time scanning, as well as equipment and staff in most of the EDs.

 

[OncoCaP]

I think you probably need to talk to a radiologist or two and see what they actually do these days. Lots of interventional/procedural stuff, significantly more patient contact than the olden days thanks to real time scanning, as well as equipment and staff in most of the EDs.

I'll be sure to check it out. I certainly like high-tech toys .

 

[Taurus]

If the radiology outsourcing is just a rumor, it's certainly a often repeated one ... doesn't make it true, of course.

I actually like the urban myth about radiology. It scares off people from rads and makes it easier for me to match. Ooh, rads won't have jobs 10 years from now. Keep spreading it!!