Thinking Outside the Pie

January 27, 2020

Stick to your strenghts to safeguard -- and increase -- your slice of the pie.

In my accumulating years in this field, I’ve had occasion to observe and, indeed, be part of, rad groups of drastically differing size. Once in an outpatient center where I could literally count the number of docs on one hand, and at the other extreme a telerad juggernaut with a headcount exceeding 400.

It’s not uncommon to think that, as in a lot of other businesses, bigger equals better. In multiple ways, that’s correct. But, from my perspective as a working rad who has (yet) to significantly climb any chains of command, I’ve found myself contemplating whether the size of my employer’s operation really means anything to me, personally, when it comes to my bottom line.

That is: Each rad has a realistically finite amount of work he can get done in a given amount of time. The vast majority of our work is done with outside entities (CMS, insurers, etc.) dictating monetary values for it. Multiply those two factors together, and you have what the rad is prospectively bringing to a rad group that takes him on.

Multiply that by the number of rads in the group, and there you have the entirety of what the group has for making ends meet, including paying the rads. From this perspective, there shouldn’t be a whole lot of difference whether the group has one rad or a thousand (assuming for the sake of simplicity that all rads are treated equally). Yes, a 10-rad group will have a compensation-pie 10 times the size of a solo rad, but each of the 10 rads only gets a slice amounting to a 10th of the pie. Add an 11th rad, and now everyone gets 1/11-individually, the other rads don’t experience much, if any, change.

Now, of course, there are a bunch of marginal ways at which that this can be nibbled, both positively and negatively. There can be a few partners or otherwise-elite rads (or corporate owners) skimming off the top, such that each working rad gets a little less of his slice so the muckety-mucks get that much more. Or, more constructively, a group can leverage economies of scale, or other efficiencies, to boost individual rads’ contributions.

If, of course, medicine were like other professions, where the professionals were at liberty to determine their own professional rates (for instance, lawyer A being worth $100/hour and lawyer B, $400), the pie would be much more elastic. For whatever reason, however, that’s not a realistic thing to discuss in healthcare-as long as your operation depends on whatever third-party payors are willing to give it.

The thought has, thus, occurred to me that, if you really want your operation to be free of such limitations, your best bet might be to develop sources of revenue outside of the pie-from places that the government and insurance companies haven’t (yet) gotten under their control.

I’ve heard of a few approaches to this in the past: One group local to my area bought a building far larger than they needed, for instance, with the notion of renting out the excess space preferably to other docs-clinicians, who would, then, be in a perfect location to refer patients for imaging to the landlord. (Does that count as a kickback? With this particular group, I would not be surprised by any infractions of the rules.) I even knew of a rad or three who took fly-by-night classes so they could do cosmetic Botox injections in their offices.

All of which might be financially successful, whether or not particularly passing ethical “smell tests.” Most of this stuff I’ve seen takes a risk above and beyond the routine entrepreneurial variety: It ventures beyond the stuff that the investing rads know best.

That is, we are in our element when it comes to performing and interpreting imaging and imaging-guided procedures. This, and stuff directly related to it, is what we know best. If we can play to our strengths, our chances of success should be greater.

I believe such thinking was what led my current rad group to develop what is now a small suite of software products and support-services. Initially aimed at boosting the efficiency and efficacy of its own rads and related personnel, these were developed to the point that they can now be marketed to other rad groups (and related healthcare facilities).

One, for instance, is a neat productivity-tracker that runs parallel to a rad’s RIS/PACS. At a glance, the rad can tell how much he’s done thus far today-or in other increments of time. Stats regarding case-mix can be mined, and longer-term trends, such as how much the new hire’s productivity has improved during his first year can be reviewed. I’m told this item, when rolled out, resulted in something like a 15-percent productivity-boost across the practice almost immediately.

While developing such discrete, marketable products, a group tends to get a better overall sense of its operation. Inefficiencies and potential trouble-spots can be identified, and smoothed out. Somewhere along the way, the folks working on this within the group evolve into experts on the subject-and, next thing you know, they are viable as consultants, themselves readily marketed to other groups that might be seeking similar optimization.

This column not being an ad for the products and services in question, I won’t go into further detail on the specifics-but, if anybody out there wants to hear more, I can be contacted via this website. And, as a bit more of a shameless plug, I’ll remind readers of the Facebook page I once detailed in this column (“Good Rads”)-I can also be messaged there.