The landscape of the local medical community shifted several degrees last week with the announcement that three clinics – Family Practice Medical Center, Janning ENT Center and the Willmar Asthma and Allergy Specialty Clinic – have formed a medical imaging joint venture with the Center for Diagnostic Imaging.
It’s not the first time the players have rearranged themselves on this particular chessboard. In fact, medical imaging services have been at the center of a series of moves and countermoves among local health providers for at least the past seven or eight years.
For years, medical imaging was dominated by Rice Memorial Hospital, which provided most of the services and also had Kandiyohi County’s only CT and MRI scanners. Then, inÂ 2001,Â Affiliated Community Medical Centers acquired its own CT and MRI. For the next six years the two organizations operatedÂ their medical imaging services more or less independently of each other. Late in 2007 they decided to cooperate, signing an agreement to fold medical imaging into a newÂ joint venture known as Willmar Medical Services and ownedÂ by the hospital and ACMC, which share the profits and losses 50-50.
And that’s how the picture looked untilÂ now, with the arrival of the WillmarÂ Center for Diagnostic ImagingÂ this fall. Construction is already under way in the Lakeland Health Center building to accommodate a new CT scanner, ultrasound, X-ray, bone density imaging, digital mammography and interventional radiology. The partners in Willmar CDI say they might add MRI services at some future point, if there’s enough need or demand.
So what does this mean for patients? What does it mean for the community? The answers, as it turns out, are notÂ at all easy to pin down. In fact there seem to be more questions than answers.
On many levels, it’s hard to argue with the decisions that have been made. In each case,Â providers have seemed sincerely motivated by a wish to provide good care for their patients and to ensure there’s local access to high-quality imaging technology. Given the importance of medical imaging as a diagnostic tool, it’s not inappropriate forÂ them to want to make it available to their patients.
But we’re now going to have three CT scanners in Willmar, and maybe three MRIs as well. If you do the math, this works out to one CT unit for every 6,000 city residents. Is this adequate? Or is it too much for a rural community of 18,000?
People come to Willmar’s medical facilities from a much larger geographic area, of course. If you look at Kandiyohi County as a whole, the ratio increases to one CT scanner for every 14,000 or so county residents – the equivalent of a good-sized town. Is this a better, more accurate yardstick?
How do we know when enough is enough? There doesn’t seem to be any objective way to measure this because, as far as I know, no one has ever determined what the ideal, most cost-effective ratio should be.
And let’s not forget the region’s small rural hospitals. Several of them – Benson, Litchfield and Olivia, to name a few -Â haveÂ CT units of their own,Â manyÂ within a 30-mile radius of Willmar. Is this a reasonable investment on behalf of the communities they serve? Or is it good enough to sendÂ their patientsÂ somewhere else if they need a CT scan, or for smaller rural hospitals to rely on mobile imaging services that come once or twice a week?
What should the expectations be forÂ rural health care?Â Is the cost of buying and maintaining high-tech medical imaging equipment a worthwhile tradeoff for having it readily available in rural communities?
For rural Minnesota, the Willmar medical community is somewhat of an anomaly. There are two dominant players: a regional referral hospital and a regional multi-specialty clinic system. There’s one medium-sized player, theÂ family practice clinic. In recent years a handful of smaller, independent specialty clinics also have sprung up.
What should the relationships among them look like? Should they compete in some areas and cooperate in others? Compared toÂ many towns, there’s a good track record of cooperation among Willmar’s medical providers. At times they have disagreements (who doesn’t?), but for the most part they’ve worked well together – until something comesÂ along that reveals the underlying faultlines.Â
For better or worse, the local medical community is highly interdependent. When someone makes a strategic decision, it tendsÂ to reverberate.
Here’s an example:Â When ACMC started its own CT and MRI service in 2001, hospital officials worriedÂ the market wasn’t big enough to sustainÂ two such services. They feared Rice Hospital would lose patientÂ volume – and revenue – for these two types of imagingÂ and, as it turned out, that’s exactly what happened. Rice also found itself competing in a tight employment market for qualified technologists. TheÂ hospital’s high-tech imaging programÂ never really recovered until the joint venture went into effect at the beginning of 2008.
How much do we value the ability of medical providers toÂ make strategic decisions they believe will benefit their patients and their business? ShouldÂ smaller clinics be forced toÂ refer patients to services that financially benefit their competitors? Is there a benefit to offering services that are locally owned and help keep money in the local economy?
How much do we value choice? There’s an increasing push for consumers/patients to participate more in the decision-making and to “shop” for their care on the basis of cost and quality. How is this supposed to work in a rural market with a limited number of providers? Are we willing to accept that there might be only one game in town?
For that matter, what role have consumers/patients played in the medical technology arms race? Have we contributed to it by having expectations of easy, convenient access and aÂ whole menuÂ of options?
How should we view medical technology? There’s no question that medical imaging helps save lives and effectively treats disease. But it’s also expensive; the price for a new CT scanner, for instance,Â starts at around $1 million. It’s easy for patients, and sometimes health care professionals as well,Â to be wowed by the gizmos and high-tech trappings. Is it desirable, though, to have the best and latest? Does it mean we’re getting better care? Or do we need to be more skeptical and less credulous?
Overall, the use of medical imaging has been on the rise.Â The majority of these tests are probably appropriate but some of the time they are not. There’s some evidence thatÂ as high-tech medical imaging and other services become more widely available, they’re alsoÂ used more often, which pushes up overall costs. As for competition, in the health care industry it generally has not led to lower costs; in fact, the oppositeÂ is usuallyÂ true.Â
We might not want government telling us how to do health care, but it’s not clear whether the private sector has been any better or more effective at holding down health care costs and expensive duplication of services and technology. If we value a market-driven health care system, are we prepared to acceptÂ what this entails? Are we OK with the competition? Are we OK with the fact that at times there will be winners and losers?
Finally, when do we say no? To whom do we say it? Who gets to decide? How should these decisions be made?
I don’t have any answers. Maybe these questions are impossible to answer, or impossible for achieving any kind of consensus. ButÂ the questions need to be asked. Nationally, we’re on the brink of health care reform. All the key issues – cost, access, quality, effectiveness – are playing out right here in our own back yard. We can’t afford to not talk about it.
West Central Tribune photo by Ron Adams
– Factors and Incentives Driving Investment in Medical Facilities, a 2007 report by the Minnesota Department of Health
– The Medical Arms Race Syndome, by the National Institute of Health Policy
This article is from Medical News Today on the relationship between quality and competition in health care. This article, also from Medical News Today, explores the cost and overuse of medical imaging tests. Finally, here’s a thoughtful look at regulation, the free market and inefficiency.