When she purchased, installed, and staffed the single-photon emission computed tomography (SPECT) camera at a cost of more than $500,000, Andrea Berson thought it was one of the most difficult things she had done as chief operating officer at Sinai Hospital. Looking back, however, it could pale in comparison with the problem looming on the horizon. The SPECT camera's three-dimensional visualization of the heart makes it an exquisite diagnostic tool. Cardiologists commonly perform biplanar (two-dimensional) nuclear cardiology studies in their offices, but SPECT's high cost virtually precludes its use in physicians' offices.

 

Sinai has an exclusive contract with a radiology group to perform all inpatient radiology services. Four members of the group are board certified in nuclear medicine and credentialed for SPECT. Several cardiologists who refer patients to Sinai have expressed grave concerns about the quality of the readings of SPECT scans done by two of these four radiologists. When SPECT scans are done on their patients, these cardiologists want privileges to read the scans at Sinai. They threaten to refer patients for SPECT scans and other diagnostic radiology workups to a competing hospital if their request is denied.

The radiologists learned of the cardiologists' request and sent Berson a letter stating they expect her to meet the terms of their exclusive contract. The letter stated that the radiologists board certified in nuclear medicine do high-quality work and have the training, experience, and proven ability to read SPECT scans. The letter emphasized that the change contemplated would adversely affect the quality of patient care because the technologies involved in two- and three-dimensional scans are very different and reading SPECT scans requires unique skills. In addition, granting these privileges to cardiologists would violate established relationships and cause other, unspecified disruptions. Berson suspected there might be an economic reason too.

The problem in radiology reminded Berson of the turf war between interventional radiologists and surgeons about using lasers and the turf war over which specialties should perform laparoscopic surgery. As she reread the letter, Berson mused about the course of modern medicine. Many conditions can now be diagnosed and treated without a scalpel. She thought briefly about Dr. McCoy, the Star Trek physician who had only to pass a small, handheld device over someone to make a diagnosis. Is that where we're headed? She wondered.

"But, enough of science fiction," she said to herself. "How do I solve yet another turf battle without too many casualties, not the least of whom could be me?"

Questions Identify the quality-of-care issues. 

How are they similar to, and how are they different from, the economic issues? 

What information should Berson possess to understand the facts and issues? 

To whom should Berson turn for advice? 

Develop three options that Berson could use. Identify and justify your choice of the best. Identify three other quality/economic controversies that occur among institutional or personal health services providers.