Are employed, teleradiology practice models eroding private practice dominance?

Ten years ago, the overwhelming majority of radiologists were engaged in private practice; today just 41% to 54% of respondents to ACR-sponsored workplace surveys say that they are in private practice, according to a report in the current issue of the Journal of the American College of Radiology.

The report from the ACR Commission on Human Resources takes a look at practice environment options in radiology, and offers thoughts on the pros and cons of each practice model in the current healthcare environment. Based on responses to the commission’s 2012 and 2013 workforce surveys, 19% to 21% of radiologists were in academic or university practice, 10% were hospital employees, and <10% were employed by corporations or the federal government in U.S. Department of Veteran Affairs or military medicine.

Private practice still represents the most popular practice model, but several factors may be causing interest to ebb.  While the private practice provides the greatest amount of autonomy, the move to super-sized practices has resulted in a diminished role in decision-making for partners, the authors suggest. In addition, the lack of income predictability and job security may have reduced radiologist appetite for independence.

“Private practice radiology flourished in the era of fee-for-service medicine but it is less well poised for the transition to a more capitated form of health care reimbursement with bundled payments and decreased reimbursement,” the authors write.

Just 10% of respondents reported being employed by hospitals, but the authors say the trend is gathering momentum.  Indeed, the first author, Sharon C. Dutton, MD, MPH, was a member of a large private practice in Sacramento whose partners are now largely employed by a sizeable health system in Northern California.

The example cited in the report is the Kaiser Permanente model, in which salary, benefits and hiring and firing are largely centralized. While lacking individual autonomy, the model is well positioned for the move to bundled payments, although specialty physician payment may suffer because primary-care physicians outnumber specialists.

Ivory-tower Radiology

Academic practices also typically offer less autonomy to the radiologist, but greater job security. The authors attribute the deficit of academic radiologists to a dramatic increase in imaging since 2000 and insufficient funding for research. Opportunities do exist, however, to assume leadership roles within the hospital or healthcare system, and promotions typically are not based on productivity.

The newest practice model, which the authors call corporate radiology, arose in response to the need for 24/7/365 radiology service via teleradiology in even remote settings. Teleradiologists are salaried employees and the corporation generally sets the standard for performance and efficiency. Many corporate radiology groups assume contracts previously held by private practices, and sometimes offer employment to the former partners. While there is a lack of autonomy and radiologists have little or no say over the imaging equipment in use, this model may enable subspecialists to spend more time reading within their chosen subspecialty.

Finally, government radiology practice provides a variety of employment relationships, including active military service and civilian employment. Radiologists are typically salaried and work in a wide variety of environments, ranging from teaching hospitals to outpatient clinics, with opportunities for research at VA hospitals. Private practices may offer more autonomy, the authors say, but government radiology provides more opportunity for advancement earlier in a career.

Prior to the 1960s and 1970s, radiologists were primarily hospital based, the authors initially point out. Legislation that allowed licensed professionals to incorporate and the decision by the Health Care Financing Administration to allow the separation of the professional and technical components facilitated the migration of radiologists into private practice.

No one can reliably predict whether radiology will make a 365-degree return to its early days as a hospital-based specialty, but the annual workforce survey, initiated in 2012, will provide an interesting new tool for observers of the specialty. For the 2013 survey, the commission distributed 2,067 surveys to the leaders of practices in the ACR’s Practice of Radiology Environment Database, which represents 65% of all practicing radiologists in the United States. Responses were received from 462 of the practices, roughly 22%, or 7,206 of the country’s 31,000 practicing radiologists.