If you haven’t yet read an explainer on “AI”, I consider Jeremiah Lowin’s “An Intuitive Guide to How LLMs Work” to be a good one.
The radiologist shortage is definitely here. There are different ways to approach the market, but balancing short-term vs long-term plays is nontrivial. Leverage is great, but using too much can amplify negative downstream second-order consequences too.
What’s happening now varies and what will happen is anyone’s guess, but this anonymous op-ed “Radiologists need to be realistic about the job market” is absolutely worth reading.
…Hospitals quite literally cannot operate beyond a few hours without diagnostic radiology. We are the bottleneck for all inpatient care. All service lines run through us. Any radiologist can easily take one of the hundreds or thousands of teleradiology jobs, which offer less commute, less non-interpretive work, and often higher pay per hour. Hospital systems simply have no leverage against their radiologists except fear of the unknown.
We work in interesting times:
A group of radiologists is severely understaffed, reading far beyond what they normally would. Radiologists are overextended, and high-volume readers are threatening to quit unless something is done. The group is unable to afford hiring radiologists in the current market. Many other unsolvable issues, such as retirements, interpersonal issues, poor work ethic, interventional radiology (IR) vs. diagnostic radiology (DR) squabbles, and [plug in your practice’s problems here] plague the group. Negotiations with the hospital have yielded minimal results. What is a group to do? Take the money, or continue the negotiations?
Again, imagine all of the unsolvable problems this group may face: recruitment, billing issues, MIPS, exploding volumes during nights and weekends, older partners wanting to cut down or retire, cantankerous partners who are indispensable, ad infinitum. More money can’t solve all of these problems, because in this labor market, an exclusive contract is a massive liability. The group decides to turn these liabilities into leverage: They walk away from the contract and tell the hospital they can hire them as employees for base + productivity, or see you later.
The tables have immediately been turned. Suddenly, all of the issues that were unsolvable now become points of leverage. Can’t recruit? More leverage for us. Can’t staff weekends? More leverage for us. A couple of people retired? More leverage for those who stayed. Volume too high? I’m on productivity, or I’ll read slowly and take my base salary. Billing sucks? Not my problem. Overnight services increased their rates? Not my problem. Want to find another group? Good luck, there’s nobody else. We have three months of trailing AR to keep us fed until we get credentialed literally anywhere else.
Guess who wins?
An important pre-tax vs Roth argument that is often missed, from “Why Pre-Tax Retirement Contributions Are Better Than Roth In Peak Earning Years (Even If Tax Rates Increase)“:
The most powerful argument for a pre-tax account as a retirement savings vehicle is that it comes with the option to convert the pre-tax dollars in the account to Roth at any time. That is to say, the account owner can choose when they want to be taxed on the funds in the account (which is what happens when pre-tax funds are converted to Roth), and make those dollars tax-free from that point on. Which makes it very useful to have pre-tax funds available to convert to Roth in years with lower-than-normal income, such as the years between retiring and beginning Social Security and/or RMDs. During this time, the funds can be converted to Roth and taxed at a lower rate than they would have been during high-income working years, or in later years when Social Security and RMDs push the owner into a higher tax bracket.
Notably, Roth accounts do not have this option: There’s no way to move funds from a Roth to a traditional account and take a tax deduction in a higher-than-normal income year (i.e., the opposite of what someone would do with a Roth conversion). The ability to choose when income is recognized only goes in one direction, from traditional to Roth. So from a tax timing perspective, it’s more valuable to have pre-tax funds, with the possibility of converting them to Roth during lower-income years, than to have Roth funds that stay Roth no matter what.
Which is ultimately why, even if tax rates are expected to go up at some point in the future, it can still make sense to contribute to a pre-tax traditional retirement account. Whether or not tax rates increase, the tax timing opportunities to recognize income from pre-tax accounts will still exist. For higher earners, if there’s a reasonable chance of having several low- or zero-income years after retirement, it can make sense to defer the recognition of some of their income from a higher-tax year into a lower-tax year by making pre-tax retirement contributions.
As in, the Roth conversion option gives high-earners the benefits of a Roth contribution without committing to high taxes upfront. Play your cards right and you could even take out some of that pre-tax money tax-free in retirement too. The article’s discussion of historical taxes is worth the read.
The important counterargument is that, in real life, the effective investment between a maxed-out pre-tax and Roth account is already not apples to apples. As in, $10k in a Roth has already been taxed and is therefore reflects a greater than $10k investment. Many people (including presumably most doctors) investing in pretax accounts do not take the extra money they would need to max out a Roth and invest that in a taxable account alongside their pretax contribution. It’s all a set-and-forget it payroll deduction. So, optimized tax considerations aside, many retirees will end up with more money to spend with the Roth contribution just because they saved more money upfront. The option for a Roth conversion is powerful, but it adds complexity and requires timing, two things investors often struggle with.
Both types of accounts have strengths, and all outcomes are a combination of math and behavior in a largely unpredictable tax context.
Another paper suggesting that clinicians prefer some structure (but not too much structure) in radiology reports. There are always edge cases where structured reporting becomes cumbersome–and overly parsed reports are also inefficient/unreadable–but there’s no denying it’s so much easier for me to scan a prior report when it’s not narrative free text.
A reader asked if anyone had successfully started a new radiology private practice recently, particularly one that involved financing, opening up new imaging centers, and fresh payor contracts. There is a vacuum in some areas, especially with the PE-exacerbated instability, and therefore a clear opportunity to those who can muster the manpower (no easy feat).
As a follow-up, I thought I’d ask (on their behalf): is anyone who has willing to mentor other upstarts?
In The Happiness Hypothesis, Jonathan Haidt describes work by William Damon at Stanford that sought “to see why some professions seemed healthy while others were growing sick”:
Picking the fields of genetics and journalism as case studies, they conducted dozens of interviews with people in each field. Their conclusion is as profound as it is simple: It’s a matter of alignment. When doing good (doing high-quality work that produces something of use to others) matches up with doing well (achieving wealth and professional advancement), a field is healthy.
In their study, modern journalists were suffering in the era of market consolidation and the growing attention economy:
Many journalists who worked for these empires confessed to having a sense of being forced to sell out and violate their own moral standards. Their world was unaligned, and they could not become vitally engaged in the larger but ignoble mission of gaining market share at any cost.
Contrast that with genetics, where doing good and doing well are usually the same thing.
Decide if you think being a healthcare worker in the now-typical corporatized environment reflects a coherent or incoherent profession. This is essentially the premise behind the “moral injury” reframing of physician burnout.
Unfortunately, recognition doesn’t really help because reclaiming coherence is hard:
A coherent profession, such as genetics, can get on with the business of genetics, while an incoherent profession, like journalism, spends a lot of time on self-analysis and self-criticism. Most people know there’s a problem, but they can’t agree on what to do about it.
The battle between Radiology Partners and UnitedHealthcare has ended with United as the victor.
The summary:
- RP claimed United owed them lots of money for underpayment because United was using a 2020 contract to determine some of its payments instead of a more lucrative 1998 contract originally held by one of its purchased groups, Singleton.
- United then sued Radiology Partners alleging an illegal pass-through billing scheme. It’s a good read.
- The arbitration panel awarded RP an interim award of $153 million. This was very much interim, not just because the independent panel had awkward bias conflicts, but also because the panel decided to separate the question of whether Singleton’s lucrative contract was in effect (it was) and if RP was abusing it (which it was) into separate steps.
The $153 million award would really have only been an extra $94 million since United had already paid for the work at a lower rate. (Author’s note: That’s quite the contract.)
Phase III—that awkward fraud question—just finished. The ultimate findings of the panel (free login required):
In the Phase I Decision entered on April 2, 2023, the Panel made the following finding: “The Panel finds the 1998 contract to be the operative agreement between the parties.” The Panel confirms this finding.
In Phase II the Panel entered the Interim Award On Singleton’s Arbitration Demand on September 26, 2023. The Panel now vacates that Interim Award.
The difference between the amount United paid on claims pursuant to the rates specified in the 2020 Agreement and the amount it would have paid pursuant to the rates specified in the 1998 Agreement is $94,275,324.00. United’s underpayment of Singleton’s claims at the rate specified in the 2020 Agreement was a breach of the 1998 Agreement.
Because of its breaches of the 1998 Agreement and its other acts and omissions, Singleton is not entitled to recover this difference and underpayment or any other relief against United. Because of its breaches of the 1998 Agreement and its other acts and omissions, United is not entitled to any other relief against Singleton. The Panel determines that the evidence fully supports these decisions at law and in equity.
Translation: you are both jerks, you are both wrong in your typical unique and despicable ways, please go away forever:
United was wrong to unilaterally use the incorrect contract to determine payments. RP was wrong to hide its ownership and then essentially pretend that every group in the region it owns was Singleton when they clearly weren’t.
(For more description/backstory, see the previous two posts: United against Radiology Partners & United is Still Fighting Radiology Partners.)
For those keeping score at home, United’s lawyer was correct when they said, “We do not agree that Singleton will recover an award from UnitedHealthcare.”
In other news, whether or not they were right, United is still a terrible company.
Or, “Why Independent Radiology is different from most job boards (but also still boring)”
So recently I created a simple, small website called Independent Radiology. It’s a boring job board, but it’s also different from most job boards.
Jason Fried from 37signals (makers of Basecamp, HEY, and other stuff) argued years ago that software should be opinionated. A random WordPress website isn’t software per se, but I feel as a random dude on the internet with a full-time job, family, writing avocation, etc that anything extra worth doing in this sphere is only worth doing if it’s going to help someone and is unabashedly done the way I would do it. It’s a project that reflects my biases, preferences, and mission. It’s idiosyncratic. It’s opinionated.
The Context
When I first thought seriously about the issues with the ACR job board earlier this year that inspired this project (now significantly improved, you’re welcome), I was partly irritated by disingenuous job listings from Radiology Partners that were masquerading as independent private practices. But I was also struck by several things:
Read More →
The month of August has been almost exclusively related to the usual activities of daily living and the new/growing job board I’ve started dedicated to true independent physician-owned radiology private practices, which now has 45 groups. I know a service like Independent Radiology probably has more impact than my usual sporadic writing, but I’m personally looking forward to getting back to my usual idiosyncrasies in September.
Something happened to the field of Radiology.
Actually, a lot of things have happened and are happening to Radiology all the time, but one of those things has been that the proliferation of corporate and private equity-backed radiology practices over the past decade has been followed by a historic radiologist shortage, a subsequent piping-hot radiology job market, and a challenging zero-sum game to hire on-site and even remote radiologists.
There are thousands of rad jobs available in the country and more work than the field can handle, but only a fraction of those positions are at independent radiologist-owned and controlled private practices. A lot are not.
That’s why I’ve temporarily been posting a radiology job ad on this otherwise very personal site, and that’s why I’ve just launched Independent Radiology.
From the “Why?” page:
The thriving independent private practice of radiology is critical to the future of the field. True private practice–where doctors control the organization, are responsible to their peers and patients, and earn the full fruits of their labor–is the benchmark that sets the market and provides the anchor against exploitation from unscrupulous employers.
This site exists to help those radiologists looking for the real deal.
You don’t have to agree with me, and you also don’t have to care. Not everyone needs or wants to work in private practice, and of course that’s fine. I also believe in the academic mission, and there’s nothing inherently wrong with being an employee. I also don’t want to just glamorize a practice model. Models aren’t destiny, and a private practice isn’t necessarily a good practice.
But, I do believe every radiologist should hope for the success of independent radiologist-owned private practices. The ability to join a thriving independent practice where doctors get paid for the full amount of their professional work and have the autonomy to choose how to do it is what forces employers to compete. It’s the anchor. It’s the BATNA that every hospital and corporate suit knows you have. It’s what keeps them honest.
By another analogy, the employment model is the renting to a partnership’s buying. There’s nothing wrong with renting. Renting can be great! Sometimes, based on your finances, the available options, and the local factors, renting is simply a better, safer option than buying. It’s undeniable. Not every house is a good purchase. And, when you have a good landlord, who charges you a fair market rate and is quick to fix the things that break down, renting can be an easy low-friction experience.
But we are stronger as a field when ownership is a real possibility. And, like homeownership, when you buy a good property, in the long run, you generally end up ahead. You have to deal with some upfront costs and the upkeep—oh, the upkeep!—but you also have more say about the property and you’re not reliant on someone else’s goodwill or business savvy. You have a good place to live: a home, not just a house. For the renter, the landlord can always change. They can always call your bluff and see how far they can push you before you decide to move. That’s why viable options are important for the whole market.
So, I wanted to make some space online to help those who want to join and help build a practice to find what they’re looking for. And, I wanted to build a place to showcase true independent radiologist-owned private practices in order to help them find radiologists in this challenging market.
I hope it’s helpful.