Is the Small Practice Dead?

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With the rapid changes in health care, radiology (like other specialties) has had to adapt to survive. Smaller practices have been acquired or consolidated with larger practices. This allows greater emphasis on efficiency, shared risk, and economies of scale. There is also a perceived sense of security that comes with the size of the organization. Larger organizations, in addition, have greater negotiating power with both providers and insurers. These practices have the ability to attract top-level management and administrative talent as well. Lost are the participatory governance and sense of ownership inherent in belonging to a smaller practice. There is great fear, in smaller practices, regarding their viability in a changing health-care environment. Consolidation is not always desirable or practical for small radiology practices. The reasons can include geographic limitations, cultural differences, and individual preferences, as well as regulatory, legal, and contractual obligations. Small radiology practices are not necessarily doomed, however, and these practices can thrive in the current environment if the group can navigate change effectively. Is the 10-person radiology group dead? To the contrary: It is alive and well, in our experience. Our practice of 10 radiologists provided staffing to a community hospital, in addition to three outpatient imaging centers, which we owned and managed. The sudden departure of four partners to a large, national multispecialty provider network was a wake-up call to our practice to restructure and attempt to survive in a rapidly changing environment, where job security and competitive income were rapidly evaporating for the remaining partners. The outpatient centers were suffering from high overhead costs and were servicing a sea of debt. The group was ineffective in responding to the changing dynamics because of internal turmoil. The result was a group that was being perceived as dysfunctional, unable to meet the needs of its primary hospital contract, and burdened by poor financial management—because noncompetitive outpatient ventures were draining both time and money from the practice. There was a strong desire, among the remaining partners, to retain and restructure the practice for future success. To make our practice thrive, we needed a national partner to acquire our technical assets, freeing the group from the debt burden and the great deal of time needed to manage the outpatient enterprise (and enabling us to refocus on the professional component of our practice). This refocusing required strong leaders and a competent management team, working with willing and flexible participatory partners. The partners were presented with a business plan clearly outlining the steps needed to ensure future success. The 10-point plan was devised to address the main concerns facing the group. These included enhanced income generation and the strengthening of hospital relations to align our practice with the strategic objectives of the hospital. Strong nonphysician management was necessary for accomplishing this task; we sought a radiology-specific management company able to support us with strong billing, contracting, and governance support. Democracy at Work Effective change requires involvement of all members of the group in decision making and committees (including finance/compensation, staffing, scheduling, quality assurance, outreach, and more). This allows greater acceptance and ownership of decision making—unique to smaller practices and harder to achieve in larger ones. This ability to make decisions rapidly, facilitated by a participatory governance model, allowed us quickly to adopt and implement the proposed plan that has transformed our group. This change included an incentive plan with financial rewards for productivity, enhanced customer service, and decreased report-turnaround time. Adopting a 24/7, 365-day coverage model (allowing us to provide in-house night-coverage service with final interpretations) resulted in significant cost savings to the practice and enhanced revenues. As a result, our daytime staffing needs decreased. These changes, along with the hiring of a neurointerventionalist and an interventional physician assistant, were perceived positively by the hospital administration, thus stregthening our relationship. In addition, it became imperative for the subspecialists to develop a comfort level in providing interpretations outside their specialties. Also adopted was a strong disciplinary policy for conflict resolution (necessary in small practices, where daily familiarity might limit the ability to resolve workplace issues effectively and honestly). A major component of this plan is fairly addressing the issue of both interventional and general radiology call and weekend-coverage needs. With greater cross-coverage among the different subspecialists, the group also needed to adopt a strong peer-review and quality-assurance program to ensure continued high quality. Even though the group’s size decreased by three radiologists, we are able to provide enhanced service, to generate greater revenues, and to have better relationships with our contractual clients, all the while obtaining a satisfied and cohesive group. After some soul searching and evolution, this 10-person radiology group is not dead: It is alive and well.

Anil Narang, DO, is president of Clinical Radiologists Medical Imaging and Diagnostic Medical Imaging (Silver Spring, Maryland).