What does radiology's long-term future hold?

Radiology is capital-hungry and labor-intensive. In this era of healthcare reforms and budget restrictions, long-term planning is required to manage it.

Radiology 2020 is a future scenario developed with input from almost 300 German radiologists, referring physi-cians, and industry experts. It has been revised several times since its initial publication in 2004. The project, supported by the radiology services com-pany Curagita, of which I am CEO, was developed with reference to the German healthcare setting. Its approach and several of its findings, however, may be applied to an international context. Radiology 2020 identifies four megatrends: a progressively older, smaller population; the redefinition of health as "well-being," a status enjoyed by those who can afford to pay; increasing healthcare costs at the same time as decreasing healthcare budgets; and the globalization of medical technology. Considering these trends with-in the context of a market economy, 10 key challenges can be identified that will shape radiology services in 2020.

• Differentiation. The type of radiology service provided will depend on the company providing that service. The role of radiologists will depend on the specific delivery structure (see table). Radiology services will be provided by disease-oriented imaging physicians, service-oriented traditionalists, and subspecialist technocrats.
• Integration of inpatient and outpatient services. Specialized hospitals will actively outsource radiology services to highly skilled supertechnologists and teleradiologists. Local hospitals will arrange radiology provision together with other hospitals and private radiologists, using shared equipment. A combined laboratory and radiology portal at the entrance will steer patients into cost-effective clinical pathways. Large hospital hubs or university centers are likely to use in-house radiology services. They will open subspecialty departments and use standby radiologists in the OR. Turf battles will intensify.
• Patient segmentation. High-quality healthcare will be provided to paying patients or those with additional insurance. This will be complemented by simple radiology services (think Ryanair) for patients with standard insurance. The use of secondhand equipment and generic contrast agents will be normal for this group. (All major patents covering contrast media will have expired by 2012, and existing products will not have been replaced by innovative agents.)
• Redefined division of labor.A growing proportion of radiologists' existing workload will be performed by IT systems, technologists, and teleradiologists. Radiology services will be provided by referring physicians and partially qualified radiologists. Managers, suppliers, and investors will work together on the management side. The result will be radiology cooperatives or companies.
• Greater emphasis on cost and customers. The number of patients and care providers will remain stable, but incomes will diminish. Insurance providers will contract directly with radiology brands and discounters (managed radiology services). Radiologists will increasingly use consumer marketing and industrial business development tools. Future heads of department will receive variable com-pensation packages based on physician satisfaction, market share, and profits.
• New, innovative radiology modalities or examinations subject to certification or assessment based on health economy criteria. Cost-benefit ratios will become the weapons in turf battles. Evidence-based imaging will be a prerequisite for reimbursement. Standardized clinical pathways will be enforced in radiology.
• Medical and financial diagnostic responsibility. Radiologists may earn a fee for optimizing the radiology budget. They will be coresponsible for therapy decisions and forced to indicate probabilities and give guarantees. Diagnostic errors will become as important as surgical errors.
• Radiologists will take on primary care or gate-keeping functions secondary to an increase in preventive healthcare and screening. Screening results will be used to direct patients to general practitioners or specialists, or straight to therapy.
• Competition in molecular theranostics. Most panelists remain unclear about the likely time frame, direction, and intensity of this predicted turf battle. The exact role that radiologists will play in molecular imaging is also uncertain.
• Fragmentation of radiology into subspecialty areas such as neuroradiology, pediatrics, etc.

This 10-point scenario does not consider what would happen during a war, global economic crisis, pandemic, or energy shortage. Alternative scenarios have, however, been identified. These include multiclass radiology, centrally planned imaging services, provision of molecular imaging outside radiology, resistance to x-ray examinations and high-tech medicine, and Europe-wide harmonization. Radiologists should prepare for 2020 by taking action in their hospitals and clinics and at the scientific and political level.