Quality, speed, and “productivity”

The Tension

There is an inherent tension in radiology between quality and speed. Obviously, there are faster radiologists and slower radiologists. And there are better radiologists and worse radiologists. It is not even that you are either fast or slow in all contexts. It is also not a false dichotomy in that you are either slow but good or fast but bad. Everyone exists on a continuum for both.

In general, an individual will experience a decrease in quality past a certain increase in speed, which may be compounded by case mix, complexity, time of day, and number of interruptions. But also: we are unlikely to realize meaningful gains in quality past a certain decrease in speed. You only need so much time reviewing a study before experiencing diminishing returns.

The Incentives

Because groups are comprised of individuals, and individuals fall on a spectrum, it is challenging for a group to incentivize everyone to perform at their optimal point on their speed/quality curve. For one thing, some people, when incentivized in a productivity system, are perfectly willing to churn out garbage if it earns them more money. However, in a completely flat structure where everyone earns the same regardless of the number of work units produced, there is also no incentive for individuals to work hard if their natural pace would lead them past a predetermined watermark. A fast reader has the perverse incentive to slow down and watch streaming video instead of continuing to crank while a slowpoke in the cubicle across town is agonizing about sub-grading neural foraminal stenoses and measuring nonactionable cysts or something else in their report with at most borderline helpful, exhaustive detail.

What is “fair” and how do we achieve it?

A small practice may recruit such that personalities mesh across all partners and democracy works without much effort. Everybody knows everybody. Everybody is accountable to everybody. Everybody puts in the work lest they be publicly shamed or ostracized or simply because it’s part of being on a team. If there is a productivity component, then ideally everybody is equally interested in putting up numbers and making lots of money. It explains why some small groups can be so successful.

Conversely, a larger practice may resort to relatively strict productivity, controls, and incentives because social dynamics play less of a role.

When you are creating a large machine full of cogs, what’s easiest to measure (and to some also most important) is how many widgets that machine can produce. Especially if quality is secondary–and clearly some outfits believe it is–it’s just so much easier, trackable, and profitable to incentivize volume.

And if your practice is designed for maximum profitability–doubly so if that practice requires that profitability in order to meet shareholder expectations or service large debt obligations–then it’s not hard to see how that becomes the dominant paradigm.

The Complications

Where things become more complicated are in medium and large independent practices and academics. These larger groups often used to be smaller groups and they had a legacy culture that may or may not have become diluted or strained with the growth and/or consolidation that many markets have seen over the past 15 years. Sharing the pie equally may have been an easy solution in old times but now increasingly becomes untenable in the setting of enlarging worklists, high volumes, delayed turnaround times, and difficulty recruiting.

Democracy may be desirable but that doesn’t make it easy.

You want a way to discourage loafing and shirking responsibilities but you also don’t want to promote negative behaviors that often arise from RVU-based performance. One big one that many groups face is cherry-picking. The other is a push away from important practice-building but non-remunerative tasks. If you are being paid extra to produce more numbers then why would you want to talk to a clinician on the phone if you could have read another scan during the same amount of time? Why would you want to read plain films or thyroid ultrasounds if there are screening mammograms or negative headache brain MRIs ripe for the taking? And–hardest to measure–quality.

The Solutions

There are ways to mitigate everything but no clear one-size-fits-all solution. There are trade-offs to all choices, and not all practices need complex systems to function. The practical reality is that when pursued these kinds of changes are hard, require much thought and buy-in, almost invariably involve infighting, and are probably best solved via IT solutions that streamline workflows, prevent individually negative behavior, and potentially incorporate ways to reward all desired tasks–even when those don’t generate billable RVUs (e.g. automatic case assignment ± customized internal RVUs to better account for effort ± “work” RVUs for nonbillable tasks). As former Intel CEO Andy Grove said: “Not all problems have a technological answer, but when they do, that is the more lasting solution.”

But it’s not easy, and it requires deliberate choices and strong solutions. An ideal practice doesn’t build itself.