Editor’s Introduction: Is the Radiology Model of Ultrasound Working?

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As we move from fee-for-service in ultrasound and all other radiology examinations toward a quality of service-oriented, patient satisfaction–based reimbursement, we find ourselves at a crossroads within radiology, and especially within sonography. Do quality and patient satisfaction depend on the rapidity of our scheduling and throughput, or do they still depend on the quality of the imaging, the interpretation of the images, and thoroughness of the examination? All of us are performing and interpreting more examinations each day than we ever would have imagined possible just a few short years ago, and these examinations are being done remotely at sites far away from the building in which we work without any opportunity to actually speak with the patient or scan for ourselves.
In the past, quality ultrasound meant going into the room and scanning every patient to confirm abnormal findings and to ensure that nothing was overlooked. If the patient pointed to the pelvis as the site of pain, we looked in the pelvis even if the requested examination was an abdominal ultrasound examination. The goal was to answer the question what is wrong with the patient, not only to perform the examination that the insurance company had preapproved.
None of that seems to matter anymore. How quickly we generate reports, how fast we can schedule an examination, and how convenient we can make it for the patient are the new measures of quality that the administrators quantify. The expectation is that the actual health care won’t suffer, and we all try, but are we succeeding? If a patient has a hernia ultrasound examination done on the other side of the state, is that examination as good as the one where I have the patient in Valsalva or stand up while I scan myself? I don’t think so, but I also don’t think anyone really cares any more.
I really envy the model for ultrasound other departments now use, especially obstetrics and maternal-fetal medicine, where they scan maybe 5 or 10 patients a day. The obstetricians have their patients come into their clinic where they consult prior to the ultrasound examination. The patients get their examination, and the obstetrician reviews it and then scans the patients himself/herself while discussing the findings, then the patients get a genetic counseling consult to further discuss future appointments, intrapartum and postpartum care, delivery planning, and postnatal treatment options for the child. The obstetricians are reimbursed for every step of the process, and they are not depending on the ultrasound reimbursement alone to cover their salaries and expenses, unlike us radiologists who have to scan more than 100 patients a day to satisfy the RVU requirement we’re expected to produce each day in order to justify our faculty staffing.
And it’s not only the volume of examinations performed, it’s the rapidity with which the results are expected throughout the institution that concerns me. The expectation is such in our institution that we now give faster report turnaround times for nuchal translucency measurements than for emergency room examinations. We scan neither anyway, but as long as that report is immediately available when the patient returns to the clinic or the emergency room, then it’s a quality examination, and it certainly is great service. However, to make the speed of the information exchange be the major focus quality metrics seems absurd, yet this is the very metric being assessed by the administrators who see this level of service as equivalent to an improvement in ultrasound quality. It is as if the diagnostic accuracy and image quality are a given, which in effect turns us into a commodity.

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