"If private practices don't thrive and don't survive, then everyone has to become an employee at some point, and the leverage we have and negotiating power of radiologists goes away."
Radiology educator, neuroradiologist, and private practice advocate Ben White, MD's, warning comes at a time of tension over the role and influence of nonphysician financial interests in private medical practices, payment instability, and volume growth outpacing the rate of physician growth.
It can begin like this: After years of serving a community health system, a local, independent private practice radiology group has no choice but to terminate that relationship, as it has lost more than half of its radiologists. Whether a result of retirements, wanting all remote work following the COVID pandemic, or both, rebuilding the practice has proven too difficult.
"If private practices don't thrive and don't survive, then everyone has to become an employee at some point, and the leverage we have and negotiating power of radiologists goes away."
Radiology educator, neuroradiologist, and private practice advocate Ben White, MD's, warning comes at a time of tension over the role and influence of nonphysician financial interests in private medical practices, payment instability, and volume growth outpacing the rate of physician growth.
It can begin like this: After years of serving a community health system, a local, independent private practice radiology group has no choice but to terminate that relationship, as it has lost more than half of its radiologists. Whether a result of retirements, wanting all remote work following the COVID pandemic, or both, rebuilding the practice has proven too difficult.
"We are seeing a rising crisis in terms of the volatility of our radiologist workforce," noted Geoffrey Rubin, MD, chair and professor of medical imaging at the University of Arizona College of Medicine Tucson, at the 2024 meeting of the Society for Computed Tomography in Boston. "Sixty-six percent of radiologists are working full-time before retirement which means that fully a third are on part-time schedules."
With the volume of procedures outpacing the rate of physician growth, the burnout rates are estimated to be 46% amongst private practitioners, 37% amongst academicians, very high and something to be focused on, according to Rubin. Additionally, "COVID accelerated the transition to teleradiology, to remote reading, and this has fundamentally altered the labor market for radiologists," Rubin said.
A fork in the road
Senior partners of private radiology practices face a fork in the road: Consolidate under radiologist-owned and operated conditions or monetize their operation by selling to a larger corporation backed by private equity. When this happens, junior radiologists are left to pay the price from multimillion dollar lump-sum payouts and ensuing investor expectations on their financial returns, according to a study led by Harvey L. Neiman Health Policy Institute (HPI)'s Director of Economic and Health Services Research Eric Christensen, PhD.
Christensen probed radiologist migration for new affiliations after their practices ceased. Using data gathered from the Medicare Provider Data Catalog for the years 2014-2023, Christensen saw an emerging trend of radiologists moving to large multispecialty practices. This research, which we'll share later in this article, shows one aspect of how radiologists are either sticking with smaller practices or seeking greener pastures in large operations.
Generally, private practice is distinguished from academic practice. Others may want to further distinguish between private practices owned by radiologists and those owned by private equity, in which the radiologist is an employee. Likewise, private practice radiologists may also be employees of a larger health system.
Ben White, MD is a radiology educator, neuroradiologist, and private practice advocate.Ben White
“A true private practice is owned by radiologist shareholders, where radiologists have control over both the work they do and how they do it,” White said. “With the consolidation in that market now, there are many jobs that do not fit that bill."
And “with the changes in the radiology market after a lot of conglomeration and consolidation, a lot of people have lost faith in private practice because people have joined groups, and those groups then sold to private equity,” White told AuntMinnie.com.
By creating a small job board focused solely on independent radiology practices, White hopes to connect aspiring radiologists interested in the "extra stuff" of practice building with like-minded practices.
Fast stats about radiology
- Radiology is recognized by the U.S. Bureau of Labor Statistics (BLS), as of August 29, 2024, as the eighth highest-paid medical specialty in the U.S. (anesthesiologists No. 1, orthodontists No. 2., oral and maxillofacial surgeons No. 3).
- There are 36,024 radiologists enrolled in Medicare (Harvey L. Neiman Health Policy Institute, 2024)
- Median radiologist wage: $115+ per hour (2023 BLS) compared with an annual base salary of $473,000 (AuntMinnie.com's 2024 SalaryScan Survey).
- Among the largest outpatient radiology center networks in the U.S. are RadNet, Akumin, RAYUS Radiology, and SimonMed Imaging.
- In 2024, the number of radiologists in radiology-only practices had decreased by 12.8% (Harvey L. Neiman Health Policy Institute, 2024).
For AuntMinnie.com, Greg Nicola, MD, chair of the American College of Radiology (ACR) Commission on Medical Economics talked about two types of meaningful change that could address systemic problems and help sustain private radiology practices.
Payment stability
Is radiology more complicated than other medical specialties when it comes to economic challenges?
No, Nicola said. However, "payers are coming up with innovative solutions that are geared toward primary care so primary care may have a more diverse set of problems, but also a more diverse set of solutions," he said.
Nicola added, "The one issue that may separate radiology from other specialties is the growing desire to work from home, which is now ubiquitous."
This is creating challenges for hiring.
Greg Nicola, MD, is chair of the American College of Radiology's Commission on Medical Economics.Greg Nicola
“Practices and departments need a subset of radiologists to be on-premise to perform minimally invasive procedures, fluoroscopy, and provide in-person consultation for clinicians," Nicola explained. “The current market demand for teleradiology is so high, it leaves little workforce for the necessary task which must be performed in person and are also required services needed by the contracting facilities or offices staffed by radiology groups. I suspect this will also eventually be an issue in other specialties with the expansion of telecommunications technologies."
In his role as an appointed ACR board member, Nicola deals with economic issues facing radiologists. He interacts with policymakers, regulators, and commercial payers to advocate for radiologists. Nicola also serves on the American Medical Association's RVU Update Committee (RUC) and supervises several ACR committees. In his day-to-day life, he is a board member of a clinically integrated hospital network and an executive at Hackensack Radiology Group in New Jersey.
Payment instability creates the most stress in the radiology practice environment, Nicola told AuntMinnie.com.
"We've now had multiple years of declining reimbursement in radiology because Medicare has redistributed dollars out of specialty care toward primary care,” Nicola explained. "And the cuts are not over as we will continue to struggle with a stable radiology reimbursement with the constraints of statutory requirements that total physician compensation from Medicare is subject to budget neutrality as well as looming pervasive threats of radiology code bundling.”
Nicola noted, for example, a coming change in the code set for CT angiography (CTA). CTA head and CTA neck, billed together, have reached the threshold that triggers an automatic bundle, he said. However, the CPT bundle has not reached the RUC for valuation but could impact providers in 2026.
"To complicate that, volume growth is so robust that not only do you have an unstable outlook on your payments, you have an unstable idea of how many radiologists you need to stabilize your practice," Nicola said.
Unrealistic expectations
Another major stress is turnaround time pressure and unrealistic expectations, Nicola said.
"In the backdrop of workforce shortages and massively increasing volumes, there is an expectation of how quickly radiologists will have a report, or interpretation, that is clearly unrealistic at this point given those challenges," Nicola said. "We need all stakeholders to buy into the fact that we have unrealistic demands on radiologists."
Greener pastures?
Many radiology practices have ceased operations, but where the radiologists are going varies. Christensen's study from June found that after practices ceased, about half of those radiologists moved on to affiliate with radiology-only practices, meaning all physicians in the practice were radiologists.
The other half became affiliated with multispecialty practices where radiologists either comprised the majority of physicians, another specialty comprised the majority, or no one specialty comprised the majority of physicians, according to the researchers.
Through his study, Christensen also inferred that in the case of a radiologist previously in a ceased radiology-only practice and then in a no-majority-specialty practice, the radiology-only practice was absorbed by the no-majority-specialty practice.
Bigger better?
Notable in this research is the magnitude of all medical practice changes since 2014. That is, the number of radiologists in radiology-only practices of 100 or more increased 625% from 2014 to 2023, but similar trends can be observed in other practice types as Christensen's data showed (see below).
"For future research, we are considering studies looking at the impact of private equity ownership and ownership by very large health systems on imaging utilization," Christensen told AuntMinnie. "We are also considering studies looking at practice consolidation and what that means for the specialization of radiologists."
| Practices by type, number of affiliated radiologists, year | |||
|---|---|---|---|
| Practice type and year | No. of practices w/ 1-2 radiologists | No. of practices10-24 radiologists | No. of practices ≥ 100 radiologists |
| 2014 (radiologist only) | 1,371 | 587 | 4 |
| 2020 (radiologist only) | 1,009 | 417 | 29 |
| 2023 (radiologist only) | 915 | 360 | 29 |
| Change expressed as % | -33.3 | -38.7 | 625 |
| 2014 (multispecialty) | 862 | 323 | 29 |
| 2020 (multispecialty) | 891 | 278 | 73 |
| 2023 (multispecialty) | 900 | 321 | 119 |
| Change expressed as % | 4.4% | -0.6 | 310.3 |
| 2014 (all practice types) | 2,233 | 910 | 33 |
| 2020 (all practice types) | 1,900 | 695 | 102 |
| 2023 (all practice types) | 1,815 | 681 | 148 |
| Change expressed as % | -18.7 | -25.2 | 348.5 |
| Source: Christensen, American Journal of Roentgenology | |||
Many would agree that private medical practice consolidation in the U.S. is driven by various federal legislative actions. They include the following:
- The Affordable Care Act (ACA) enacted by former President Barack Obama in 2010
- Medicare Access and CHIP Reauthorization Act (MACRA) payment reform signed into law in 2015, which is seen by some as a disruptor for its risk-bearing, coordinated care directives
- The No Surprises Act and recent changes that pushed some radiology groups out of network, causing harmful reimbursement consequences
“Responding to the incentives created by these laws is facilitated with a larger practice,” added co-author of the HPI study, Jay Parikh, MD, a professor at the University of Texas MD Anderson Cancer Center in Houston, who with Frank Lexa, MD, from the University of Pittsburgh, spoke to AuntMinnie's Amerigo Allegretto in January about radiologist retention, radiologist value, and a better system for compensating radiologists.
AuntMinnie.com exclusive: Earlier this year, Frank Lexa, MD, from the University of Pittsburgh, and Jay Parikh, MD, University of Texas MD Anderson Cancer Center discussed radiologist retention, radiologist value, and a better system for compensating radiologists.
In Part 2 of our series on the state of radiology, we'll take an in-depth look at radiology business models and the challenges of the current reimbursement environment.