How a growing private practice is looking to become the ‘Amazon of radiology’

At a time when myriad market pressures are pushing many independent radiology practices into the arms of national groups and investor-backed companies, some private groups are just saying “No thanks.” But that’s not always easy. The temptations on offer—expanded strategic resources, Big Data management capacities, high-finance know-how and more—are considerable.

Many of the groups holding onto their autonomy in this consolidating business climate have something in common: They find a way to get bigger and stronger on their own.

Midstate Radiology Associates is a sterling case study in this strategy. As recently as 2015, the Meriden, Connecticut-based practice had 11 radiologists and two advanced practitioners (APs) serving a single hospital and two outpatient imaging centers. It was still about the same size as at its founding in 1955. By the end of 2019, Midstate had grown to more than 40 rads and seven APs serving four Hartford Healthcare hospitals while running 17 outpatient imaging centers and three vein centers.

How’d they grow so fast? To find out, Radiology Business Journal spoke with two members of the group’s leadership: President Gary Dee, MD, who also serves as chair of the Hartford Healthcare Radiology Council, and Director of Operations Tom Cappas, who additionally serves as a regional radiology director for the seven-hospital, two-state Hartford Healthcare system and co-chairs its imaging capital committee.

RBJ: What changed five or so years ago to make you realize you had to pursue growth in a very concerted way?

DEE: The entire healthcare landscape had changed. You’ve now got national practices with backing from investors. You need access to very expensive technology. And you need IT infrastructure to support Epic, Nuance, a VNA and other technologies. To be using these things, you have to be part of a bigger group. Small groups can’t afford the $1 million-plus it takes to maintain that every year.

We’re entrepreneurial, we’re businesspeople and we want to make our own decisions as much as we can. And we know that having those size-based capabilities is a big driver of business. If you can’t afford to keep up, you’re not going to grow. You’re not going to make it.

You grew your footprint by merging with other practices and bringing them under the Midstate Radiology Associates umbrella. How do you make sure new member physicians get a chance to have their voices heard on key decisions that affect the business?

DEE: As each group comes in, they automatically get two seats on the board. The board is led by me as president and a vice-president. The board has the power to make decisions for the organization, but there are some very significant restraints on certain issues.

Having said that, there are things that I can do as president without going to the board. This allows us to be nimble. But we have a backup for the things that are especially important—hiring and firing, setting salaries, allocating vacation time.  

If you ask member physicians what they want, they want job security. They want a good place to work. And they want some financial security. Our radiologists feel that, in the board, they have protection from their own respective groups. I think this structure works well. Groups that have 14 or 15 members voting—and I know a couple of groups that do that—can’t get anything done.

CAPPAS: I would just add that, as groups merge into Midstate Radiology Associates, along with getting two members on our board, they also get a chance to have members serve as section chiefs or medical directors for clinical sections. We really look at each imaging modality as an individual business unit. For example, we have a section chief of MRI. That person is paired with an operations manager to oversee all MRI operations, hospital as well as IDTF, for our practice.

And really the core component of this dyad is business development—looking at growing that individual imaging modality—plus day-to-day operations and clinical standardization and optimization. The leadership dyads have meetings on clinical operations. As groups merge into us, the board votes on who the section chiefs will be. They have full autonomy, with support from the board, to carry out their business how they feel the business should be carried out.

The term people keep coming back to when talking about survival in private practice is the need for alignment on mission and vision with your primary client hospital or health system.

DEE: In our case that’s Hartford Healthcare, which has more than 24,000 employees and operating revenues of $4.3 billion. One reason that kind of alignment is so important is that reading images is a commodity.

There’s always going to be a price that will be cheaper but no worse in quality. You do not want your radiology reading service to become a commodity chosen only on price. Aligning with your client health system gives you a huge amount of stickiness with your health system that you need today. It’s a safety net. That was another motivator for us to pursue growth. We wanted to increase our stickiness with our health system.

CAPPAS: We truly love our health system. Hartford Healthcare is a market leader and the only integrated health system in the state of Connecticut. Its unified culture of accountability and innovation continually inspires Midstate Radiology Associates to be the best. It’s a true partnership. But to answer your question, great management of the services you provide is key.

We run and manage joint-venture operations with outpatient imaging centers as well as managing hospital [radiology] operations. Most large groups will manage one or the other, but they won’t do both. Hospital operations are very challenging. But we look to create value for our health system by managing both service lines together. And we’ve done so to reduce costs, reduce variation, increase clinical standardization, provide best-in-class experience for our customers and create more value with alignment.

It was really a design that Dr. Dee envisioned 20-plus years ago with the creation of a joint venture with an outpatient imaging center and one hospital. All these years after he started working toward that, we now have one management team overseeing 21 hospital and IDTF locations. This new management team and structure was created three years ago—all designed to create value for Hartford Healthcare and our collective patients and physicians.

This arrangement helps the radiologists, it spurs growth, it helps with clinical standardization. It just helps with the overall success of the business. And it’s radiologists providing value, because they have a sense of ownership. Having a shared bottom line lets them be a part of the growth engine.

When you have disparate operations—separate management teams for IDTFs and hospitals—you have clear competition between the businesses.

What issues are you struggling with as healthcare economics continue to change?

DEE: Just like any other business, we don’t know the future. We don’t know what the next elections are going to bring. We’re also trying to drive quality and offer the best technologies while under financial pressures. So our pain points are really things over which we have no control.

We also don’t know what the next big disrupter is going to be. Look what Amazon has done to their market sectors. They’ve blown everyone else away. What’s going to be the Amazon of healthcare? We don’t know.

It just might be Amazon itself.

DEE: It might be. We believe in Amazon’s customer service model. We have an access center that Tom correctly identified and developed. It’s now a competitive advantage for us. We’ve invested considerably in access, opening our front door to our customers. It’s a 15-second target to answer the phone when a customer calls. Why do you buy from Amazon? Because if you have a problem, they take care of it. No questions. They’re reliable. Your product arrives when you want it.

We’re trying to be the Amazon of radiology. We want to deliver service that’s of the highest quality so that we can weather whatever changes come along. We want to deliver a high-quality patient experience. It’s service first.

CAPPAS: We will be the Amazon of radiology. Our motto is ‘Yes.’ We figure out how to make things better and easier for our customers—and all our stakeholders—to access. Our patient experience scores show that we’re succeeding. Press Ganey shows we’re consistently in the top 10% in the nation on patient experience. And we don’t rest on that. Fifteen seconds to answer a phone call is great, and it’s definitely the gold standard for the industry. But I don’t settle on that. I want us to pick up on the first ring. We’re obsessed about adding that level of value to our customers.

And this takes us back to that entrepreneurial mindset. Everything starts around improving access to care and building the best experience. That’s been the key differentiator for us—and we’ll never be satisfied with our successes. We owe it to our customers.