‘How Did That Happen?’: Course Correction Versus Consternation in Radiology

Every now and then, circumstances arise that one would never have imagined, let alone predicted. One of those circumstances just crossed my path this past week.

If you have invested in stocks much, you are probably accustomed to receiving occasional proxy-vote mailings from this stock or that. Most of us hold such infinitesimal fractions of the stock that we don’t expect our votes to do much. Many immediately toss the notices in the trash.

Meanwhile, you might have heard of these things called “index funds,” which hold far greater volumes of stock than any of us ever will. They are a lot busier with the stocks than we are, but even they can’t always be bothered to keep track of all the issues that result in votes. Instead, they outsource the voting. Theoretically, the third-party entities they hire look into the votes and push for whatever is in the index funds’ (and theoretically their shareholders’) interests.

The big revelation (for me, at least, and a couple of big deal talking heads who reported the story) was that two proxy advisory firms dominate the entire industry. Between them, they control about 97 percent of the market for advising institutional investors (outfits like Vanguard and BlackRock) on how to vote their shares. That covers trillions in United States assets — a big chunk of our economic engine — influencing board elections, executive pay, and corporate policy.

It turns out that one is wholly owned by a foreign company and the other also has substantial non-U.S. stakeholders. To borrow from the late, great Norm Macdonald, don’t call me a cynic but they might not have our best interests in mind. Even if the foreign influence thing doesn’t bother you, you might not like the idea of just a couple of entities having such control over our steering wheel.

(By the way, I describe this as big news for me, and a bunch of other people in the past several days...but what’s news to one person can be old hat to others. The Wall Street Journal, for instance, ran an editorial a couple of years ago calling for breakup of this “duopoly.” Sometimes, it takes a certain critical mass sounding off in the right public forum before things catch fire.)

Confronted with such news out of left field, folks react differently. How could this be allowed to happen? What nefarious forces caused it and how have they been benefiting? We need investigations and probably punishments!

On the other hand, sometimes things just evolve without a mastermind to guide them. What if a bunch of people just didn’t want to be bothered with proxy votes (let alone attend stockholder meetings in person)? That created a vacuum and some enterprising folks moved in to fill the void. If we just discover an undesirable situation has evolved now, maybe the most productive thing to do is correct it without torches and pitchforks.

There is a third option that puzzles me. There are folks who size up their “How did this happen?” situations and conclude that, well, this is just the way things have been for X number of years, and there is no changing it now no matter how unpalatable the state of affairs.

That seems to be the most common reaction in health care, radiology included. It is not too hard to imagine why. Any individual cog in the machine, no matter how capable a physician or brilliant an administrator, doesn’t have a whole lot of control over things. Pointing out that something is inefficient, let alone stupidly self-defeating, is often a way to waste energy and/or get in trouble rather than a means of fixing things.

Another rationalization for maintaining the status quo, especially if you are in a position of leadership, is the embarrassment of admitting that stupid or inefficient conditions happened on your watch. It might feel more face-saving to pretend you think they aren’t stupid, inefficient, or corrupt, and stand behind them instead. It is a move reminiscent of Pee Wee Herman falling off his bike and telling onlookers, “I meant to do that.”

Still, there are things we can and do control. If some of them hamstring our work, harm our colleagues (or employees), and especially degrade patient care, it is careless, if not evil, to not even try setting things right.

We have the best chance of doing that if we couple vigilance with an awareness of just how common unintended consequences can be, consequences of our own actions as well as those of peers, even superiors. Upon detecting things that shouldn’t be, we might still indulge in some consternation. It might help fuel our “How did we come to this point?” inquiry for instance. Rather than wallowing in that, however, we should very swiftly set about course correcting.

That includes being receptive to others who are trying to course correct while one is still indulging in consternation.

The Centers for Medicare and Medicaid Services (CMS) just put out their final rule to yet again chip away at RVUs for radiological studies. Suppose that’s just enough to pull the rug out from under a per-click individual or a rad group that was just barely operating in the black. We are entirely justified in ranting about the unfairness of it all but that won’t fix things for us. If someone in the team starts saying sensible things about our next move, we shouldn’t let our raging drown him or her out.

Instead, we have got to figure out options are for staying afloat. This may involve finding new efficiencies, getting better subsidies from hospitals we are covering, or reexamining the case mixes we handle for a better RVU profile. After poring over the situation, if we find no solutions, we have to decide whether we can find ways to endure the “new normal” or concoct outside-the-box moves we might not have considered before.