Mease Hospitals in Pinellas County is in the awkward position of trying to fire one of its most renowned physicians, all in the name of improving patient care.
Dr. Gerry Niedzwiecki, an interventional radiologist who is also president of Mease's medical staff, is fighting Mease's attempt to terminate his privileges at its facilities in Countryside and Dunedin. He has sued to stop the action.
The termination has nothing to do with Niedzwiecki's medical skills, which are highly praised by patients, referring physicians and hospital executives alike. Instead, the conflict revolves around issues of . . .
Cash, culture, control
The dispute will give outsiders a glimpse into the business of health care, where maximizing revenue and minimizing cost take precedence, even at nonprofit institutions such as Mease.
Niedzwiecki (knee-edge-viet-ski) was told he would no longer have privileges at Mease in mid August, after the hospitals awarded an exclusive contract for all radiology work to a group in Clearwater.
The doctor, who has been doing procedures at Mease for eight years, was supposed to be out by Oct. 1. In late September, a Pinellas County circuit judge granted a temporary injunction postponing his termination pending resolution of the lawsuit.
The hospitals' top executive said the decision to funnel Mease's radiology business to one group of doctors has nothing to do with Niedzwiecki and everything to do with administrative efficiency.
"He's known we wanted one group for almost four years," said Jim Pfeiffer, Mease's president and chief executive. "He didn't win the contract, and now he's suing because he didn't win."
Niedzwiecki, a solo practitioner who did 90 percent of all interventional procedures at Mease last year, said the hospitals just want total control over a very lucrative piece of business.
"The more they can control the market, the more they can throw their weight around," said Niedzwiecki, whose patients are referred to him by physicians throughout the Tampa Bay area. "If another group of doctors wants to compete with me, more power to them. But they're trying to push me out so they can have everything."
Although Mease executives insist the incoming radiology group is well-prepared to handle the same procedures Niedzwiecki has performed, medical personnel familiar with his talents think that if the hospital prevails, patients will lose.
"I'm still astounded by his skill, integrity, concern for patients and concern about what goes on with his staff," said Jeannette Hill, a registered nurse at Mease with 40 years' experience who has worked closely with Niedzwiecki. "If I were a patient, this is what I'd want for quality care."
The controversy stems from the friction between a traditional hospital business model and the rapidly evolving specialty of radiology. For decades, radiology has been a largely unseen but integral part of every hospital's services. It also is a major revenue generator. So far in 2004, imaging services for both inpatient and outpatient procedures have accounted for about 27 percent of Mease's gross revenues.
The vast majority of the radiology services at Mease and other hospitals are diagnostic. Accident victims who come into the emergency room get X-rays for broken bones and CT scans for concussions. Obstetric patients get ultrasounds. Patients with suspected spine injuries get MRIs. Radiologists on staff read the images and make the initial diagnoses. While their skill is critical, their interaction with the patient is generally limited to a bill in the mail.
But over the past two decades, radiology has moved beyond simply reading films and making recommendations. Using real-time imaging and guide wires about the thickness of angel hair pasta, specially trained interventional radiologists are performing a growing number of minimally invasive procedures.
Subspecialists like Niedzwiecki use image-guided needles to deposit bone cement into patients' vertebrae to relieve painful compression fractures. They use radio frequency energy to cook and kill cancerous liver, kidney and lung tumors. They snake catheters through the carotid artery to the brain to re-establish blood flow and try to limit the damage after a stroke. As technology advances, new interventional procedures are replacing traditional open surgery, resulting in less pain and shorter hospital stays for patients.
With such progress comes the kinds of problems encountered by Niedzwiecki, who has been the first in the area to perform a number of groundbreaking interventional procedures. He was one of the first 10 interventional radiologists in the nation trained to do radio frequency closure of varicose veins. He is one of only 30 in the country and three in Florida releasing radioactive beads into the liver to attack tumors. And a few weeks ago, he was the first in the area to insert a newly approved stent in a patient's carotid artery as an alternative to open carotid surgery.
"I've been keeping us on the cutting edge of radiology," said Niedzwiecki, 41, who graduated in the top 10 percent of his class at the University of Rochester Medical School and did his residency and interventional training in Pittsburgh before coming to Clearwater.
As someone who's continually pushing the envelope in his field, Niedzwiecki finds himself clashing with the way radiologists have always operated.
"If I join a hospital group, I walk in in the morning, do a procedure that some doctor has ordered and walk out," he said. "Business magically appears. There's a sense of entitlement in radiology that I don't buy."
Both the doctor and the hospitals, who are reimbursed separately by insurers, say interventional procedures are not necessarily any better-paying than routine diagnostic work.
"I might get paid $300 to $400 to do a procedure and $100 for reading an MRI," Niedzwiecki said. "But it takes an hour and a half to do the procedure, while it takes less than 10 minutes to read the MRI. So on a per-hour basis, it's much more profitable to read films."
But that doesn't mean interventional procedures aren't highly lucrative. Gross revenue to the hospital from the interventional lab at Mease Countryside last year was more than $14-million; net was $5.6-million.
Though Niedzwiecki was once a member of a radiology group at Mease, three years ago he went on his own. Unlike his colleagues, who work strictly out of the hospital, Niedzwiecki opened an off-site office with 10 employees, where he sees patients for preprocedure consults and follow-up care. Physicians who refer patients to Niedzwiecki say his willingness to see patients in his office is crucial.
"The continuity of care is distinctive," said Dr. Gary Goldstein, an internist and pediatrician in Palm Harbor.
Dr. Steve Scranton, an internist with a practice in the Countryside area, sent patients to the Mayo Clinic or Cleveland Clinic before Niedzwiecki came to town.
"He has talent, as well as communication skills with patients," he said.
While Niedzwiecki's clinical practice is highly unusual for a radiologist - and thought to be unique in the area - experts say it's likely to be the norm in the future. Dr. Anne Roberts, former president of the 5,000-member Society of Interventional Radiology and head of the interventional radiology department at University of California at San Diego's Medical Center, praised Niedzwiecki's work.
"There's been an enormous shift in how interventional radiology is practiced and Gerry is in the vanguard of people doing that," said Roberts, who watched Niedzwiecki do procedures at Mease two years ago. "He was doing stuff then that we've only just started doing here at the university. He's technically very skilled and willing to evaluate new procedures and make them available to patients."
But as many managers know, dealing with folks who don't fit a mold can be difficult. Pfeiffer, Mease's head, said most of the nation's hospitals and 80 percent of Florida's hospitals have exclusive contracts with a single radiology group. Such arrangements minimize the administrative headaches involved in assuring availability of a wide range of radiology services around the clock, every day of the year.
By giving one group exclusive right to all of Mease's radiology business, Pfeiffer said, it ensures someone will be there to read the routine mammogram for the uninsured mother as well as the better-paying CT scan for a Medicare patient. Exclusivity also helps groups recruit new members in a field that is experiencing shortages of trained specialists.
"This is not about Dr. Gerry," said Pfeiffer, who claims the existing system of having competing radiologists has led to a hostile work environment. "We have people bickering over who gets what case. This cannot go on."
Mease put out a request for proposals to handle its radiology services in late spring. Niedzwiecki responded with an offer to handle the interventional procedures, though he said he was willing to share those cases with other doctors.
Radiology Associates of Clearwater, which also covers Morton Plant and North Bay hospitals, bid on the whole package. The Clearwater group, which will have 30 doctors covering four hospitals, won the bid.
An exclusive contract will not change the way any of the parties are paid. The hospitals will be reimbursed at the same rate as before by insurers, as will the doctors. But Pfeiffer said locking in a radiology group will bring other money-saving efficiencies.
For one, it will allow him to stop using temporary radiologists who have been filling in coverage gaps.
"That costs me $8,000 to $10,000 per week," he said. With just one group of radiologists, Pfeiffer also thinks he has a better chance of standardizing procedures and equipment.
Dr. Daniel Krop, president of the group that won the Mease contract and began work there Oct. 11, insists that exclusivity is essential if a radiology practice is to be profitable.
"If the contract is not exclusive, people start to pick out the things they like to do and things like mammograms, which are at the low end of the reimbursement scale, might become orphaned," he said. "Hospitals might not be able to meet the need because there is greed, not accountability."
Nevertheless, Krop insists that the battle raging within Mease's radiology department is not about turf or dollars.
"It's really about the unity of the department," he said. "It's the kiss of death to have an open radiology practice."
Niedzwiecki and his supporters, including executives of the American Medical Association and the Society of Interventional Radiology, respond that it's not only possible but beneficial for patients to have access to competing radiologists, just as they do to competing surgeons and cardiologists.
Lin Rhea, whose husband has been treated by Niedzwiecki since 1997, describes the impasse with Mease as "incredibly sad."
"I was born at Mease and have volunteered there and it would just about kill me to go somewhere else," she said. "But I will. Wherever he goes, we will follow him."
