Sunday, July 05, 2009


Jamie Farr, MASH's "Max Klinger," Number One Fan of the Toledo Mud Hens (photo courtesy

There's some mud of a different sort being slung around in Toledo these days. As documented in the longest thread in history, a company called Imaging Advantage was hired to cover radiology at the three hospitals of the Mercy System in Toledo. Imaging Advantage, IA, displaced Consulting Radiologists Corporation, whose radiologists had served Mercy for 50 some-odd years. But this isn't just a simple business deal, and everyone in private practice radiology needs to hear the story. I'm exposing my small but loyal and extremely intelligent readership to the situation in hopes that they will spread the message even further. Since the Aunt Minnie thread has reached over 2000 posts, with almost 90,000 hits, I'm going to do you the favor of attempting to distill the story down to manageable length. This is a very long story, and I'm sure you don't want to read about every last little detail. Still, what happened in Toledo has repercussions for all private practice radiologists, and the word needs to be spread. I've been reading and participating in the Aunt Minnie thread, and I've been in touch with the radiologists involved, thanks to the organizational skills of AuntMinnie user Dr. Sardonicus.

Let's start with the timeline of events. Sometime last October, a consulting firm was brought in to the Mercy system to look at radiology. No one seems to know precisely the name of the consulting firm, but the few faces seen by radiology at the time seem to belong either to IA personnel or to members of RCG, the latter a consulting group run mainly by radiologists from the Massachusetts General Hospital. Keep that connection in mind.

Fast forward to May. "Spartandoc," the head of CRC (I'll keep to the AuntMinnie nicknames where possible, although real names have been published), was called into the office of the Mercy CEO, Dr. Imran Andrabi, a family practitioner by trade, and told that IA was taking over.From "T. J. Lewis," a member of CRC:

We were told by the administration on Tuesday morning 5/19/09 that we were out on 6/8/09. If we wanted we could become employees of IA. No contract was seen and no details of call or compensation have been given. We are a group of 19 rads in Toledo OH. We staff(ed) 3 hospitals in a system, one of which is a 550 bed inner city teaching hospital and trauma center.
Depending upon whom you believe, IA has either made a go of it, or has blown the deal completely. From the Toledo Blade, 6/28/2009:
To date, Imaging Advantage has about 15 radiologists, all of whom have at least 90-day contracts, at Mercy's three Toledo-area hospitals, and it is working to permanently fill positions by early September, Dr. Andrabi said. More radiologists are working at Mercy now than before, he said, and all off-site test-reading is done in the United States.
There were rumours, which were unsubstantiated, that there would be off-shore reading, or ghosting. This apparently is not the case. But the rads on the ground are apparently all from locums services, at least those that were mentioned in the Blade article, and don't work directly for IA. A significant amount of work is apparently being performed by NightHawk Radiology, although it is impossible to tell just how much is being read, and how much is transmitted out.

How things are going on the ground at Mercy is difficult to determine. You see, there was a gag-order placed on all personnel within the radiology departments, supposedly to avoid HIPAA violations. Somehow, I don't find that believable. But word has trickled out, and it isn't encouraging for IA or MHP fans. Various reports, mainly posted on Aunt Minnie, tell of lots of misses, interventional cases backlogged to a terrible degree, radiologists unavailable for consult, and so on. This is to date anything but a success story.

What happened here? Why was the existing group, CRC, ditched in favor of an unknown? The reason that is circulated is turn-around-time, in essence, it is implied that CRC couldn't get the reports out fast enough. Dr. Andrabi was quoted on this topic in the Radiology Business Journal:
He says that MHP signed with Imaging Advantage believing that radiology report turnaround times needed to be lowered to serve both patients and referring physicians. “We needed to go to a different management model to enable us to do that. For the concept we looked at, we needed teleradiology as an adjunct to on-site physicians to meet turnaround times. From the time something is performed in radiology until the referring physician has it in hand should be no more than 4 hours,” he says.
But even Dr. Andrabi, as quoted in the Blade, realized that there were reasons for CRC having TAT's that appeared to be longer:
One key difference is that Imaging Advantage radiologists working at Mercy will not reread interpretations done overnight by the teleradiology firm it uses. That saves time, although it eliminates a second look, said Dr. Imran Andrabi. . .
The turn-around-time argument is lame at best, and appears to have been rigged at worst. Houdini-Rad, another CRC member posted this:
TAT at MHP was from order entry to signed report. At St. Anne Mercy ave. TAT was less than 24 hrs. Administration broke down TAT's by modality and whined about TAT for speciality MRI, msk, breast, etc. and for CTA's. The problem with CTA's with over 1000 images the PACS would crash. I was once trying to go over a stat CTA of the aorta with a cardiovascular surgeon at the level 1 center and had to load the case on 5 reading stations and as one would crash we would go to the next. He couldn't believe we had this problem and that it was allowed to go on even after our complaints. This surgeon left Toledo last fall. We were given no slack if we were waiting for appropriate outside studies or path reports. As you know getting this info can take days. Thus increased TAT.
I have learned that the PACS in question was an older Kodak Carestream, for whatever that's worth. This is a PACS blog, after all!

The conclusion most will reach is that the MHP administration wanted to get rid of CRC, and replace them with IA, and used TAT as an excuse to do so. The only question now is, WHY?

From what I can gather, the radiologists of CRC have an excellent reputation, and there were no service problems. They were working with some problem equipment, such as the PACS noted above. The only demand I can document is the request for TeraRecon or a similar system, and CRC even offered to buy this themselves. But to no avail.

We do know that a consultant appeared at Mercy in October, 2008, and it is thought to have been RCG. This is important. While Imaging Advantage theoretically has no relation to RCG or Mass General, there were several principals who seemed to have their feet in both camps. IA does tout their use of Tele3DAdvantage (note the rather similar name) which is the "retail" 3D lab from . . . Mass General. I find it very interesting that Tele3D uses Visage, a fine, but significantly less-expensive system than TeraRecon. From ImagingBiz:

One company that has built its advanced visualization platform from the ground up on thin-client technology is Massachusetts-based Visage Imaging, a subsidiary of the Australia-based informatics organization Pro Medicus Ltd. Early on, Dreyer was named head of the medical advisory board at Visage. He says that he quickly began to stress the importance of scalability . . . For two years, Dreyer says, MGH worked with Visage in clinical trials to achieve functionality that would meet the hospital’s needs.

And now we start to understand. . . From the Blade article:

But Dr. Andrabi said that by contracting with Imaging Advantage, Mercy not only will get test results more rapidly but also will have access to other advanced technology.
For example, Imaging Advantage has a contract with Massachusetts General Hospital for three-dimensional radiology rendering services, with images from other hospitals sent there to be converted, he said.

Imaging Advantage plans to extend the service to Mercy, where radiologists will read images converted into 3D at Massachusetts General, Mr. Hashim (CEO of IA) said.
The arrangement will allow Mercy doctors to tell more quickly what problems patients have without the Toledo system having to invest money and time in technology, Mr. Hashim said.

Interesting. Did Mercy dump CRC to avoid buying a system that costs less than $200,000?

Imaging Advantage touts their relationship to Mass General, something that an administrator might find appealing. What else do they offer? Their website tells us:

Imaging Advantage is a market leader in providing comprehensive radiology solutions to hospitals, imaging centers and radiology groups. We focus exclusively on two goals: enhancing existing radiology services in local communities (by introducing 'best in class' services and incorporating local groups and radiologists into our program) and achieving excellence in patient care.Our solutions include: practice management, radiologist staffing, day and night final read teleradiology, subspecialty and quality control programs, and uniquely tailored programs to increase patient throughput, reduce costs and increase market share.

Our team members are graduates of Harvard, Yale, Stanford, Cornell, Columbia, Wharton and other excellent institutions.

Imaging Advantage managers are advised by luminaries in business and medicine including former Cendant CEO and Chairman Henry Silverman and Dr. Alexander Margulis, one of the most respected and acclaimed radiologists in the world. Our Medical Advisory Board consists of a select group of the country's leading radiologists.

Imaging Advantage has a contract with Massachusetts General Hospital (MGH) Radiology to provide 3D rendering services. MGH has representatives on the Imaging Advantage Medical Advisory Board and a separate Oversight Board for 3D. This reflects MGH's interest in promoting the 3D work where MGH has 10 years of experience delivering centralized services.

Imaging Advantage is 100% US-based and all teleradiology exams are read domestically by US board certified radiologists.

Imaging Advantage assists clients in competing during difficult economic times. We market our clients' radiology department services through symposia and through our nationally recognized Public Relations firm.

From the Radiology Business Journal article:

Imaging Advantage CEO M. Naseer-Uddin Hashim says, however, that there is a lot of excitement attached to thinking another way. “Radiology, the way it’s practiced, is very static,” he says. “I think it should be dynamic; that’s our model. Give the local physicians the tools, the technology, and the resources to serve the patient better. I believe you, [the radiologist], are part of a dynamic system throughout the United States. I’m going to put you into that network.”

Hashim describes himself as a former practicing attorney turned entrepreneur. Imaging Advantage began in 2006, he says. He was reluctant to discuss Imaging Advantage’s clients other than MHP, but agrees that the number could be called “several dozen.”

Imaging Advantage, Hashim says, might partner with a radiology group, take over the group, or (as in the case with MHP) take over the radiology service contract with the hospital. Whenever it has taken over the contract, he says, it has always offered jobs to the radiologists in the existing group, which it tried to do with Consulting Radiologists Corp in Toledo. He says that it was unusual for radiologists in the existing group to turn Imaging Advantage down cold, as the Consulting Radiologists Corp physicians did. “This is the first time this has ever happened, where the whole group has decided they’re going to hold off,” he says.

Interesting. If CRC was so bad, why were they worthy of being hired back? And, more important to the wider question, where does IA make its money?

Hashim denies that what Imaging Advantage was doing amounted to a predatory commoditization or corporatization of the practice of radiology. “We’re exactly the opposite,” he says. “I start by working with the local radiologists and saying, ‘Let me make you indispensable.’” Adding teleradiology into the mix, he says, eases the burden on the local radiologists and improves turnaround times on reports. “When you improve turnaround times, you serve patients better,” he says. “The other thing is that you’re removing stress because radiology is a bottleneck, so you’re improving the entire hospital system.”

Hashim says that no payment was made by MHP in the Imaging Advantage takeover. Asked how Imaging Advantage makes money, he mentions efficiencies. “In certain cases, we may also participate on the technical side of the deal,” he adds. “If we increase the volume and efficiency, everybody wins.”

Word that escapes the gag suggests that no one is winning, least of all the patients of the Mercy system.

But what of this "new paradigm"? AuntMinnie user "Jerry Goler" posted a great analysis:

This business model is nothing new. RSJ (Reich Seidelman and Jannicki) and Team health were doing it in the late 90's. Pretty simple...put up booths at hospital administration conferences promising hospital administrators radiology services. There are a large group of administrators who just want power and control...easiest to do with the so called hospital based specialties. Then put out an RFP, which is rigged. The new group gets the contract, gives the old members a chance to keep their jobs. Pretty good chance one or two people will do so, because they have kids in school, etc.

RSJ did this in Sioux City Iowa in the late 90's, destroyed a group but one radiologist had just finished building a customized home to care for...had to stay. Then they rotate locums in and out, and use telerad while trying to entice people to move there and keep 40% of what they make. Of course, it doesn't work, but they walk out a million dollars ahead. Optimal (a group similar to IA) does same thing.

Reason this model works, by the way, is that enough radiologists are out there willing to look the other way and step into these contracts. And they are not competitive ...exclusive contracts are anything but.

. . . As for the rads in Toledo. . .don't know the market, might not be practical, but now would be a good time to build outpatient imaging centers and take the business back. It will be a couple of years, but the hospital will fail because this model sucks. But it will take that long and that much money loss until the board figures it out and dumps this administrator. . .

Goler goes on to say (concerning TAT):

Sure and begorrah, it's blarney. But this is just part of the script. Bet that the rate limiting factor for radiology reports was not the radiologists,but the hospital's fault. They make up something that sounds good to board members, and the uninformed. Then they start slamming the local rads. The consulting group says it's just trying to help, make it a win win situation.

The game is lost at this point, and it will be a minimum of two years before that becomes evident to the general hospital board and employees. The administrator bet his reputation on this working, and using the model right now to see what other docs it can be applied to. The business plan is akin to a pimp, a prostitute turned madam, and a stable of prostitutes. There are about 4800 hospitals in the United States...or a pool of 4800 administrators trying to climb their way up the food chain to the next bigger paycheck. They can do two things to show their value . . . building projects, and getting control of doctors. Madam's make their cut from a big slice of the girls working on their backs and knees. Very profitable business model...service oriented.

Nice visuals.

I would urge you to read as much of the AuntMinnie thread as you can, as there are even more details.

I still don't know what the underlying cause of CRC's ouster really was. There has been all sorts of speculation ranging from a friendship of the principals involved, to kickbacks from IA to MHP, to "arrogance" of Spartandoc ruining a 50-year relationship. There have been at least 5 "new" posters on AuntMinnie supporting IA/MHP, which were so laughably done as to make most of us certain that they were created within the offices of IA itself.

My personal guess (and Mr. Lawyer, it is only a guess, based on my own craziness, and not supported by any fact) is that IA promised some form of return of professional fees back to MHP couched in terms of "savings", as well as the "savings" on 3D rendering. Certainly, the administrators liked the idea of contracting out radiology with better "control" than they had over the group on the ground. Throwing around the Mass General name certainly helped IA's case. The TAT thing was simply an excuse to get in the door, and we know that TAT numbers are easy to manipulate, based on how you actually calculate them anyway.

The Mass General does keep coming up in the conversation:

Imaging Advantage touts a relationship with Massachusetts General Hospital (MGH), Boston, Massachusetts, to provide 3D rendering services. Andrabi says that the MGH service is not yet up and running at MHP. (Spartandoc) says that the MGH connection was used repeatedly during the transition to reassure clinicians at MHP of the quality of Imaging Advantage.

“I think that’s scary for the entire field of radiology", (Spartandoc) says. “The name MGH evokes top-notch, cutting-edge radiology. It’s one of the shining stars. I think it’s frightening that this shining star is leading the way to the commoditization of radiology services.”

But isn't this "just business"? (And typical academic behaviour?) No. A good group was tossed out in what appears to be an unscrupulous manner. I think most of us have good relationships with our administrations, but. . . It is all too easy for those in the C-Suite to be swayed by fast-talking, slick operators with JD's and MBA's. IA is simply the latest example of a bunch of enterpreneurs who think they are smarter than the rest of us. The plan is simple: find radiologists who will work cheap, become the middle-man, and pocket the difference. All the better if the original rads feel compelled to stay on, working harder than they did before for less money. Consider this the Enron-gambit of radiology. It is an unsustainable model, because the guys on the ground get burned out very quickly, but by that time, IA will have made a million or so for its efforts. It can then just walk away from the whole thing.

Thwarting such little Madoff's isn't easy. To do so, we have to perform at our best (a given), and we need to have good relations with our administrations. They need to know how hard we work to add value to the patients' care. There will always be a rogue administrator here and there who falls for the patter of a company like IA. The only defense there is to make sure all rads are aware of just what the IA's of the world actually are, and how they operate. Would you want to work for them? I wouldn't, and I would look askance at someone who did.

CRC is landing on its feet, more or less:

In the end, (Spartandoc) says, Consulting Radiologists Corp decided to downsize, and none of its radiologists signed with Imaging Advantage. Some have left for other jobs, two have gone on sabbatical, and two took early retirement, Cervantes reports. Volume at Consulting Radiologists Corp’s imaging center has gone up 50% since Imaging Advantage took over at MHP, and hospitals competing with MHP are seeing volume increases too, he adds. “They are still without radiology directors at all three Mercy hospitals,” (Spartandoc) says. “I know because I have filed a complaint with the Joint Commission.”

(Spartandoc) thinks that Consulting Radiologists Corp, in its downsized version, will survive. He says that the response to its loss of MHP business from the radiology community has been surprisingly strong. He says, “I’ve had phone calls from all over the country.” His callers realize that the corporate takeover/teleradiology business model, he says, “is bad for patient care, and they’re trying to stop it as soon as they can.”

I wish them well. But for the grace of God go we all.


Neoavatara said...

Good synopsis, Sam. I have been following this as an observer. I have close connections to Toledo, as my family lived their a long time. My sister in fact was born at one of the MHP hospitals. My cousin, MISTRAD, has been getting a lot of information through me regarding the situation. Right now, the conditions are bad in radiology, and despite protestations, patient care has seriously suffered. One can only hope hospital administrators won't be stubborn in facing certain realities of the situation.

Sardonicus said...

I would add a few things. First - the current Chairman of the Board of Chancellors, James Thrall, is the head radiologist (their phrase) at MGH. It is beyond belief that his faculty members could be so deeply involved in this without his approval. And of course, he is one of the leaders of RCG. I have written a letter to the president of the ACR, Carol Rumack, asking her to review the propriety of his being involved in commoditizing radiologists.

Also, there have been communications with those on site regarding how it is going, and the picture is entirely different than Andrabi paints in the press releases (of course). They speak of, in particular, failures in the IR operation, with cancellation of many cases. The first guy on site was signed up for 3 weeks and left after one. The techs indicate that there have at times been no person to go to to get problems worked through, and they apparently flatly refuse to review cases done at night, even if there are questions. There have been some grievous misses. Can't say if the number is statistically significant, but, when you replace a subspecialty oriented group with those who aren't familiar with all the studies that are done there, you expect problems.
Another interesting sidelight is that Nighthawk is supplying the night work. Paul Berger, the founder, resigned from the company on the very day that they took on the contract, citing deep philosophical differences. The timing could be coincidence, but knowing that Berger was constrained in what he could put out publically, and knowing that the timing would be viewed as being linked to the IA contract, I feel certain that he was trying to communicate his unhappiness with the way Nighthawk had been used to remove a good group the only way he could.