As we looked at the numbers, one thing was perfectly clear: Whether a low-surge or high-surge academic medical center or a private radiology practice, the economic impact of Covid-19 was felt deeply and widely within the specialty of radiology during the first 21 weeks of the year. We all will need to work hard to safely re-engage patients who have deferred health care.
If you are wondering whether other radiology practices experienced the precipitous volume declines that yours did, an article in press at the Journal of the American College of Radiology suggests the affirmative for practices operating in both the academic and private practice settings.
Norbash et al looked at the experience and response of 6 academic practices—three experienced high Covid-19 surges, and three experienced low surges—as well as a comparable collated dataset from the independent private practice members of Strategic Radiology (SR) in their paper, “Early-Stage Radiology Volume Effects and Considerations with the Coronavirus Disease 2019 (COVID-19) Pandemic: Q2 Adaptations, Risks, and Q1 Lessons Learned.1” Arl Van Moore Jr, MD, FACR, SR chair and CEO, was the paper’s second author.
The study analyzes volumes for 14 imaging modalities experienced by the practices during the first 21 weeks of 2020 compared to the corresponding weeks of 2019. Total volumes were compared, as were inpatient-only, outpatient-only, and ED volume numbers.
“Dr. Norbash, the paper lead author, wanted to include, examine, and compare the experiences of both academic and community-based radiology practices and the impact of the pandemic,” Dr. Moore explains. “Strategic Radiology was able to quickly and efficiently provide the required data by tapping a centralized accounts receivable database that provides the foundation of the coalition’s business intelligence service.”
Pervasive Volume Declines
The authors noted that not all markets experienced the onset of Covid-19 with the same intensity during the time period of the study, the first 21 weeks of 2020. While some health care markets such as New York City and Boston experienced early high surges of Covid-19 patients, the West Coast academic practices had a lesser intensity by comparison. The dynamics are changing now that other markets are experiencing similar surges. The effect of shelter-in-place orders and delaying imaging and admissions to preserve capacity also contributed to decreased volumes.
The data suggest that volumes for all practices were seriously impacted during a six-week period, with large volume declines starting at week 11 and persisting into week 16, and showing a slow recovery beginning around week 17. The maximum volume decline among the low-surge academic medical centers was 52% in week 14; among the high-surge academic medical centers, the maximum decline was 65% in week 15.
Volume decline and recovery curves seen in the data from the private practice coalition paralleled the changes seen with the academic medical centers and tracked most closely with the low-surge academic medical center trends, according to the authors. To avoid double taxation of profits under the current IRS Tax Code, most private practices have adopted a business model that entails disbursement of earnings at year-end. Given the penalties placed on retaining corporate earnings and building operational reserves to meet and deal with such contingencies, private practices had relatively limited resources on hand to ride out the economic trouble without significant interventions. Large academic practices had the option to use reserve accounts for salaries.
Breast modalities saw the largest modality declines, with screening experiencing the greatest drop. The lowest declines were seen in PET-CT and interventional radiology (IR), modalities in which cancellation had the highest perceived adverse consequences “The modalities with greatest initial drops, such as breast screening mammography and DEXA scanning, also showed the greatest delays in trending toward volume recovery,” wrote Norbash et al. “Similarly, earliest recovery trends were seen with modalities demonstrating lower drops.”
For the six academic medical centers, breast screening exams dropped by 99 percent in week 16; diagnostic breast exams also reached their nadir at week 16 with an 80% decline. DEXA declines were slightly greater than breast screening declines. CT experienced its greatest decline (56%) in week 15; and MRI dropped 76% in week 15. In comparison, PET/CT’s greatest decline was 45% in week 16.
A series of uncited figures provided further insights into the ebb and flow of volume during the pandemic. When all six academic medical center volumes were aggregated and viewed by category of service (ED, inpatient, and outpatient), outpatient volumes dropped most dramatically, followed by ED volumes. Inpatient and outpatient volumes in weeks 17 through 21 showed the greatest recovery, with ED volumes lagging.
A figure illustrating breast screening exams showed a similarly precipitous drop in volume for high-surge academic medical centers, low-surge academic medical centers, and the coverage sites of the private practices. High-surge academic medical centers were slower to establish a recovery trend.
Adaptations, Lessons Learned
In addition to providing transparency into the impact of Covid-16 on the study participants, the paper also offered insights into measures taken to manage the impact on the practice’s human and financial assets. They also speculated about the lasting impact of implementing various interventions and their durability.
Practices responded to sudden slowdown in volumes with radiologist and staff bonus holdbacks and reductions in compensation and retirement matches; lay-offs for part-time and academic contract faculty and, in private practice, radiologists; furloughs as time-off with and without pay; halting open recruitment searches; and reducing unfunded academic research and administrative time in all settings. The authors speculated that modality-specific staffing may be considered as at-risk volumes are better understood.
Having learned that non-clinical staff can work remotely, practices may reduce their pre-pandemic footprints in an effort to manage the overall costs supporting imaging interpretation on an ongoing basis. Most practices redeployed some percentage of the clinical staff remotely to depopulate reading rooms and preserve the clinical workforce. The authors recognized the potential that radiologists be perceived as using nurses and technologists as human shields and suggested that hazardous duty pay be offered to frontline staff, including interventional radiologists.
The authors hesitated to extrapolate a straight-line recovery of pre-Covid volumes at week 33 indicated by the 21 weeks of data, due to possible future second waves or regional outbreaks as currently experienced by Florida, North and South Carolina, Texas, Arizona, and California.
The authors also observed that the pandemic had uncovered financial fault lines in the current health care system, including vulnerabilities associated with fee-for-service versus closed vertically integrated systems that continued to collect subscription fees while incurring reduced operating costs. The nature of the U.S. health care system itself as a collection of somewhat clinically isolated entities and systems could be a vulnerability in itself, and the authors speculated that more interconnections among providers could create efficiencies that would “blunt downside challenges.”
On the other hand, they also observed that a highly decentralized system could provide some measure of protection in offering individual entities the ability to respond quickly, but also to better prepare for a pandemic by negotiating more favorable contracts in individual markets.
“As we looked at the numbers, one thing was perfectly clear,” Dr Moore observes. “Whether a low-surge or high-surge academic medical center or a private radiology practice, the economic impact of Covid-19 was felt deeply and widely within the specialty of radiology during the first 21 weeks of the year. We all will need to work hard to safely re-engage patients who have deferred health care.”
1. Norbash AM, Moore AV, Recht MP et al. Early-stage radiology volume effects and considerations with the coronavirus disease 2019 (COVID-19) pandemic: Q2 adaptations, risks, and Q1 lessons learned. 2020. J Am Coll Radiol. In press. Published online: July 9, 2020.
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