Radiology in 2020 - Aaarad.org

Radiology 2020A Guiding Look AheadNorman J. Beauchamp, Jr. MD MHSProfessor and ChairmanDepartment of Radiology and Imaging SciencesProfessor of Neurological Surgery andIndustrial EngineeringUniversity of Washington

When Chris and I were firstcontacted to delineate thefuture… our next step seemed• Ask THEInternationalopinion leader!!!“already workingwith anotherspeaker”clear….

“Study the past if you woulddefine the future. “ConfuciusChinese philosopher & reformer(551 BC ‐ 479 BC)

Look back to 1996

Technology in 1996EV1 - first modern production electric vehicle from a majorautomaker and also the first purpose-built electric car produced

Healthcare 1996“Managed care willreduce health carecosts… by controllingaccess to resources.”

Healthcare & Radiology 1996“Cost imperative can bemet through leveragingIT and improvingefficiency.”

1996 Predictions of the Future"Health Care Cybervision: TheRole of the Internet in HealthCare," - co-sponsored by Internettechnology leaders SunMicrosystems, Ernst & YoungLLP, Sybase, Inc., SprintInternational and 3Com.

Healthcare & Radiology 1996“Radiology departmentswill demonstrateefficiency, quality controland cost-effectiveness.”

Healthcare & Radiology 1996“New imaging technology willchange the educationalrequirements andemployment status ofradiologic technologists.”

1996 Predictions of the Future“The future of radiology will be inintegrated systems asinterconnectivity anddigitalization contribute to anetwork of compatible andcommunicating modalities likethose made possible throughPACS.”

“Study the past if youwould define thefuture. “Lesson not the expectedone….did not uncoverclues to determine thefuture of Radiology

“Study the past if youwould define thefuture. “The stated strategic plansmade backthen…remain unrealizedNot due to a lackof importance

Predictions and StrategyDid not inspire the necessary response

Predictions and StrategyDid notmotivate asustainedresponsethe first purpose-built electric car produced byGeneral Motors (GM) in the United States..made 1100

Predictions and Strategy“Managed care willreduce health carecosts by controllingresources.”

Predictions and Strategy“Radiology departmentsmust demonstrateefficiency, quality controland cost-effectiveness.”R and D: Outcomes and Operations Research, Tools forCommunity of Researchers

Predictions and Strategy“New imaging technology willchange the educationalrequirements andemployment status ofradiologic technologists.”

Predictions and Strategy“The future of radiology will be inintegrated systems asinterconnectivity anddigitalization contribute to anetwork of compatible andcommunicating modalities likethose made possible throughPACS.”

Healthcare Cybervision(one year later)• Despite the potential of the Internet andthe feverish application of Internetrelatedtechnology - in healthcare largelyin a holding pattern.security issues as the major reasonfor holding back.

When it comes to makingpredictions for the purposesof strategic planning, we arepretty much wasting ourtime...The Strategy ParadoxM. Raynor

Change Happens*

Punctuated Equilibriumpunctuationchangetimeequilibriumnot no activityHow Nature Works

Depends on the “slice” of time• Fuel efficient vehicles• Managed Care– Quality, safety and access as a primary focus– R and D– Outcomes– Technologist and Physician Training• Healthcare CybervisionWe ebb and flow in our resolve

Change is a “Step‐Function”

Challenge is one of Timing• Are we on the “riser” or the “tread”?

And One of Prediction• When does the current “tread” end?

The future is a range of possible outcomes, not a specificset of circumstances that will inevitably come to pass.The Strategy ParadoxM. Raynor

It would be a mistake,however, to concludethat we have no insightinto the future…The Strategy ParadoxM. Raynor

Prepare for Change

Environmental Influences• Healthcare costs continue to rise– Societal obligation– Global responsibility• Technological advancement• Information technology pervades– Continued avenue to gain efficiencies• Role of regulation and government• Role of consumerism in healthcare– Balance of quality, productivity and value

The existence of strategic risk is a function of theunpredictability of the future. Consequently, managingstrategic risk cannot hinge on improved prediction.However, it is possible to bound the range of possiblefutures that one might face. This is best done withscenarios.By creating a number of scenarios that define the“possibility space” over a relevant time horizon, one cancreate a framework for discussing the future withouthaving to stake future success on guessing right.The Strategy ParadoxM. Raynor

Scenarios• The goal is to define a few scenarios thatmake a difference to decision makers• A good scenario will lead us to betterquestions• A good scenario will lead us to sustainedappropriate action and reaction“STORIES STICK”

Radiology 2020• “Use the Forces” ” (Free Market)• “Moving on up” (Governmental Control)• “Reverse Polarity” (Institutional Controls)NOTE THE CATCHY NAMES

Scenario I“Use the Forces”• The government, facinghealthcare costs consuming23% of the GNP, hasdecided under PresidentRoss Perot that free marketcapitalism will reign and thata new era of deregulationwill commence.

Scenario I“Use the Forces”• The ubiquitous internet hasbroken down many protectionistbarriers, including those erectedby medical licensure.• Google’s health record has beena smashing success having beenadopted by 85 million people andsecurity concerns have beenassuaged.

Scenario I“Use the Forces”• The internet’s record ofreducing prices has beenimpressive.• The new mantra ishealthcare information andservices are only a “clickaway”.

Scenario I“Use the Forces”• Physicians will now be licensedacross state lines and provision ofmedical services is nowunencumbered between all statesand U.S. Territories• Internet-based services arereimbursed and some are currentlyselectively even outsourcedglobally.

Scenario I“Use the Forces”• Since the FDA has begun to piggybackon EU approval of drugs, Medicare isconsidering the same for physicianservices.• There is talk of further reduction inbarriers to English speaking physiciansin Europe providing services in theUnited States.• Interventional procedures abroad arereimbursed for selected, approved sites.

Scenario I“Use the Forces”• E-Bay type markets have begun topop up for the provision of diagnosticservices, including lab and radiologicservices.• Ultrasound has become cheap, andlarge, flexible arrays are beginning toreplace some CT and MR studies.• These inexpensive, new devices arebeing installed in doctors’ offices andhigh risk patient’s homes…linked tothe internet.

Scenario I“Use the Forces”• In-vitro testing is available onlineand has become popular because ofnew capabilities in not onlydiagnosing cancer, but in evaluatingthe predisposition to cancer.• Scanners in supermarkets can beaccessed using optical diagnostictechniques and the results areavailable online in a secure fashion.The tests cost $9.99.

Scenario II“Moving on up”• The political heat is on, the numberof uninsured has soared, andmedical care is increasingly difficultto find, and when found, it is tooexpensive.

Scenario II“Moving on up”• With national healthcareexpenditures being at 23% ofGNP, President Chelsea Clintonand her administration havedecided to import the Canadianhealthcare system.

Scenario II“Moving on up”• Government imposes immediatewage and price controls as it drawsup plans to migrate into a singlepayer system starting with seniorsand children and moving rapidly toencompass the entire population.

Scenario II“Moving on up”• The goal is to better supportdirect patient care and to deemphasizeancillary servicesand high technologyequipment, which havebecome the “disgrace” ofhealthcare.

Scenario II“Moving on up”• The internet is facilitatingcentralization of paymentsystems and acceleratinguniformity of medical recordsdriven by Medicare’s adoptionand dissemination of the VAelectronic medical recordssystem.

Scenario II“Moving on up”• To get paid, use of this systembecomes a must in the Medicarepayment system in the next 18months.• All physicians will be expected to beonline for medical records and billingin the next 18 months.

Scenario II“Moving on up”• The guidelines will beevidence-based and new andinnovative technology mustshow efficacy prior to beingincluded in these clinicalpathways.

Scenario II“Moving on up”• While viewed as a crisis atthis time, the mechanisms,institutions, and rules andprocedures being put in placewill all form the basis of thefuture single payer system inthe United States . . .

Scenario IIIReverse Polarity• University Health System Consortiumstates that two departments requirehospital subsidization: Radiology andAnesthesiology• Radiology Department Chairs balancediversifying sources of income versuscollecting their due from the hospital

Scenario IIIReverse Polarity• Hospital administrators note thatneurologists, vascular surgeons and GIInternal Medicine Doctors have lowersalaries than radiologists

Scenario IIIReverse Polarity• Dean decides to move imaging sciencesinto pathology department combiningmolecular diagnosis with molecularimaging

Potential Futures…not future• Leadership consists of the design of settingswhich provide tools for and stimulateconstructive, productive individual actions.• Common sustainable responses indicated across allscenarios– Operations and Outcomes– New Skills Development– Information Handling

Strong chairWeak chairWealthy deptPoordepartmentPACsQuantitative measures of performance

End with questions not answers• What are the factors driving our future?• What are the plausible scenarios?• What are the strategic directions that arerelevant across all scenarios?• What are the indicators that let us know anew scenario is emerging?

Acknowledgement• Chris Laubenthal• Dieter Enzmann• Alex Norbash

Questions• What should our strategy to be to get rid of inefficiencies caused bylack of integration, disincentives, and duplication.• Competition would drive toward providing greater value (qualitydivided by cost).• Government regulation and licensing would control totalexpenditures ‐ so that the integrated system which produced morevalue for the capped cost would tend to thrive.• To design such an integrated delivery system and to make ithappen, government predictably would turn to its own resources:academic medical centers.• In turn, those academic medical centers would be motivated tobuild their own vertically and horizontally integrated healthcaredelivery system to compete with the few successful non‐academicsystems which got a license in each district.• In fact, over time, the academic/private distinction would blur ‐since research data would be needed by any system to map a pathto sustainability, and academic systems would need to incorporatethe business models and actual practices of private practice.

Central Conceptdecisions are based on consequences of aneventnot based on the probability of the event

The future is a range of possible outcomes, not a specificset of circumstances that will inevitably come to pass.The Strategy ParadoxM. Raynor

Most commitment-intensive strategies generate the highestreturns, but they also suffer the highest mortality rates.The Strategy ParadoxM. Raynor

modern portfolio theorydiversification to reducerisk

Most strategies are built on specific beliefs about thefuture. Unfortunately, the future is deeply unpredictable.Worse, the requirements of breakthrough success demandimplementing strategy in ways that make it impossible toadapt should the future not turn out as expected. Theresult is the Strategy Paradox: strategies with the greatestpossibility of success also have the greatest possibility offailure…Therein lies the strategy paradox: the same behaviors andcharacteristics that maximize a firm’s probability of notablesuccess also maximize its probability of total failure.The Strategy ParadoxM. Raynor

Leadership therefore consists increasingly of the design ofsettings which provide tools for and stimulate constructive,productive individual actions.The Change MastersR. Kanter

The existence of strategic risk is a function of theunpredictability of the future. Consequently, managingstrategic risk cannot hinge on improved prediction.However, it is possible to bound the range of possiblefutures that one might face. This is best done withscenarios.By creating a number of scenarios that define the“possibility space” over a relevant time horizon, one cancreate a framework for discussing the future withouthaving to stake future success on guessing right.The Strategy ParadoxM. Raynor

Strong chairWeak chairWealthy deptPoordepartmentPAC no matter what…what are the thirty factorsdrivers no matter what; politics turfQuantitative measures of performance

Raiology is a cost…in patient radiology works without a workflow….call the flooAnd see if the patient can come. We do not know…..if we short length by six ho25 hillions

Jon covers IT and we should be the leader therefore. We may need to drop that ….Prediction missing reality…healthcare cybervision….this builds off….ten years ago we said something that was wrong then and weare talking about it again…why won’t we be wrong…..the more we study the past it may confuse it again…..

Raiology is a cost…in patient radiology works without a workflow….call the flooAnd see if the patient can come. We do not know…..if we short length by six ho25 hillions

Marty says since 1988 marty has said look at films going away in two years… he was long for at least twenty years…so its not aboutbeing right or wrong….its about being ready is marty’s point…..so how do we get ready…

How big and how much influene to each of these things have and drive us in different directions…

the healthcare states a directions that costs will continue to rise..on some of these filters the bigger slice we get the predictionincreases in probability….

Wisdom of the crowd to illicit paths of change…how do we get out to future…IT internet gone lead us in a directions…..

Scenario IIITides Turn• the government legislates how healthcaregets DELIVERED• toward much greaterefficiency/productivity/impact.• there is a rejection of unregulated, nonintegratedcottage industries clustered arounda random number of hospitals, all of whichare independent corporate entities.

Tides Turn• Government divides the country up into 14 districts and declaresthat there will be only 2 or 3 vertically and horizontally integratedhealthcare delivery systems in each district.• Each of these systems will own a full spectrum of healthcaredelivery facilities from single offices to full blown hospitals. Allhealthcare facilities will be owned by one of the integrated systemand they will compete in each market.• These systems will be either monumentally effective privatepractice systems or very innovative and effective academichealthcare delivery systems.• In large markets, the 2 or 3 systems would compete head‐on. Insmaller markets, only one would be present – and which one wouldbe a competitive process.