Massachusetts is known as the medical epicenter of our nation, but mimicking national trends, health care jobs have remained stagnant there too.

Why? According to an article in the Boston Business Journal, the push to lower medical costs and increase quality is eliminating a lot of health care sector jobs — including radiologists and radiology technicians.

Massachusetts is right in the middle of the health care payment transition. Most commercial payers around the country still reimburse based on fee-for-service, but in Massachusetts, they have already begun reimbursing for keeping people healthy and out of the hospital, something called pay-for-performance. (Massachusetts also reformed its health insurance system back in 2006. And the Affordable Care Act, which mandates insurance coverage, is modeled in large part on this system.)

Hospitals have found that it's cheaper to outsource services such as radiology and other diagnostics. An X-ray technician cited in the article, Chris Murphy from Quincy Medical Center in Massachusetts, says he's seeing fewer patients as more work moves away from hospital radiology departments to lower-cost outpatient centers.

Under pay-for-performance, hospitals will be paid for keeping patients healthy and out of the hospital. Since October 2012, hospitals with excess re-admissions have been penalized with reduced Medicare reimbursements under a provision in the Affordable Care Act.

Noting the trend, the article cites Partners HealthCare, a prominent health system in Massachusetts, which recently announced that it would acquire two hospitals and eliminate inpatient beds at one of them.

Radiology departments, once considered cash cows for hospitals, are now seen as burdens under pay-for-performance.

A well-known patient advocate and cancer survivor who goes by the name e-Patient Dave and blogs frequently about engaging patients in their health care, wrote recently about shopping for a chest CT scan. Instead of paying $1,736 at the hospital, he found Salem Radiology, an imaging center a half hour away from his home in Massachusetts. It charges $520 for a chest CT, including lab work and the radiologist's report.

Clearly, scans can be done cheaper at standalone centers.

Murphy says what's most concerning about moving radiology to the outpatient setting is reimbursement. "Diagnostic studies help subsidize Medicare and Medicaid, which is underpaid by the government. Without it, it's very hurtful to hospitals that are already struggling."

The article points out that the health care labor shake-up is being driven by three major trends: the shift from inpatient to outpatient care, health system consolidation, and increasing complexity. Besides radiology, it's affecting jobs on medical and surgical floors, food service and housekeeping, and bedside nurses. With fewer patients to tend to, jobs like these are the first to go.

Middle managers are also being eliminated, according to the article. Take for instance nurse managers, who are under direct supervision of nursing directors. Hospital clients are now giving reports directly to the nursing directors.

While these jobs may be on the out, others are being created under health care reform. These include new positions with titles like "director of care coordination," and "director of quality and safety". But other areas that are growing in health care — where jobs will be plentiful — include physician group practices, ambulatory settings and in home care.

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