Since I started writing about private equity in radiology back in 2022 and more recently since featuring private practice jobs on the site followed by launching Independent Radiology, I often get questions that read something like this:

If private practice is so great, why are so many groups struggling?

Because it’s hard.

I believe that private practice is important. It provides an anchor for how doctors are paid and establishes standards for how a specialty chooses to practice. When employed positions are good, that is largely a direct result of the need to compete with private practice in a tight labor market.

However, it does not necessarily follow that all or even most practices are run well. It was relatively easy (I imagine) to run a business during the golden age of radiology; it isn’t easy now. And we should admit, without hesitation, that of course there are also poorly-run unsavvy groups just like we’ve all experienced poorly run hospitals and other businesses.

It’s also much easier to run an effective business when it’s a small democratic group where everyone has skin in the game and the desire to make it work. Increasing imaging volumes and increasing consolidation combined with increasing regulatory burdens and have resulted in overall fewer and overall larger groups. That increases the stakes and increases the complexity. The growing pains are real.

Instability is Everywhere

I do think the current shortage, shifting lifestyle demands, and the (probably temporary) sweetheart deals for mammo ultimately have destabilized radiology practice in general, not limited to but certainly including small democratic practices where radiologists wanted to be treated the same historically. (As in, a young breast imager’s desire for shorter workweeks of 100% breast without any evenings or call doesn’t easily jive with how many practices have historically practiced, and the need to play ball to recruit sometimes requires substantial chances to practice structure with negative downstream consequences). I think the shortage has absolutely shredded some democratic groups, especially those that are small with a lot of physical presence, call, or struggling to staff women’s imaging.

Everything is Local

The reality is that the success of any given model is in part predicated on regional dynamics. If the hospitals don’t have to play ball in tough group negotiations, it’s hard for groups to get what they need for retention and recruitment in the current climate. Stipends are increasingly table stakes to cover off-hours and on-site work in an era where direct reimbursement is falling and labor supply is insufficient. We aren’t a free market in medicine because we don’t control how much we charge. In a normal labor market, a labor shortage will drive up compensation. That needs to happen here too, but that money has to come from somewhere when it can’t happen organically from CMS or the commercial payors in our fee-for-service model.

Hospitals have the ability to supplement compensation with a fraction of technical fees and stipends, which means that–if they want to–they can (potentially temporarily) offer more money and potentially even a “better” job than a group relying on professional fees alone. They could give that support to a private practice so that the group is healthy, or if they are more daring, they can be aggressive and use that as leverage to bring the group in-house. In the short term, I imagine the downsides of employment for radiologists are probably pretty small right now. The market is so tight they can’t play too many games or risk the whole thing blowing up. Longer term, I am more skeptical.

The Tele Problem

One thing that gets lost in the generally increasing hospital stipend support trend and more remote work: some hospitals in less affluent areas will struggle to pay higher rates and may be hard-pressed to provide stipends needed to account for competitive compensation in the current market or high levels of bad debt from unfunded patients. Some areas are geographically undesirable, adding another wrinkle to any efforts at recruitment. If you can’t recruit to the area because no one wants to live there, then you need to pay for remote rads. But the market for remote rads is increasingly national, not local. Which means you need to be able to compete nationally.

The more people who want to do teleradiology, the more groups struggle to sustainably get the work done locally. So we can just say it: people’s individual desires are destabilizing the field. It may be reasonable for the individual and their family but no doubt it’s a growing problem for local high-touch practices. It also makes it easier for rads to quit their jobs for any reason and find work without having to make geographic changes. Lower friction means mobility, which means more volatility and churn.

But it’s essentially a tragedy of the commons situation. If everyone wants to work from home sometimes, no big deal. But if too many people want to work remotely too quickly, it’s hard for the industry to quickly accommodate and it destabilizes everyone’s work.

Note that instability here isn’t necessarily bad long term, it could even lead to long-lasting improvements in some domains. But, increased volatility and drama are inarguably close bedfellows with the current tele trend.

Could most radiologists give up contrast coverage, basically refuse to do the vast majority of fluoro of any kind, and be 100% remote? In some practice settings, probably. But the downstream long-term consequences of too much of the field going that way is to throw open the doors to replacement. The faster we consider practicing radiology only to mean interpreting imaging, the less real clout we have.

Consolidation is Real

One factor that does matter is size. Larger groups servicing a larger part of a large client are harder to replace, tend to be able to provide more remote work options, have dedicated nightfolks/less call, etc. A fragmented market with many small groups in the current era of big consolidated health networks, payer shenanigans, CMS cuts, and stupid MIPS compliance measures is less predictable than one with a few big groups that are busy enough that they really aren’t competing with each other so much as holding a line against the hospitals. These jobs aren’t always better. The groups may be culturally diluted and overall indistinguishable structurally from any other medium to large company. But, they may be more stable when faced with headwinds.

Ultimately, radiology is still a human enterprise. Relationships matter. Hospital leadership, radiologist leadership, other clinicians, the patients–they matter. So I do think it’s critical that no one should take an overall trend facing our field with a prediction for any specific group. There are thriving small groups that are killing it.

Macro trends are easy to opine about as a random person on the internet. But real life is lived in the details.

Risks & Opportunities

A staffing shortage climate nationwide is only an opportunity because it’s also a risk. The increasing complexity of regulation coupled with needing to work with increasingly consolidated revenue- and growth-focused mega health systems and fight large payors increases the stakes and bureaucracy of running a practice. And that can be especially hard when recruitment and retention are intrinsically unstable as everyone starts working harder than they want to.

There is a zero-sum recruiting component to the whole radiology enterprise where some companies with better contracts are able to at least temporarily offer better jobs on paper with more flexibility in order to handle their overflow or fuel their growth in remote coverage. Look no further than the recent United and Aetna lawsuits against Radiology Partners to see how one really great contract can provide the temptation to double down on arbitrage as the core business model (even in cases where it might be…illegal).

Dominoes are falling–and that means opportunity for others–but all that opportunity only exists because some practices are failing or falling behind or dropping contracts–and hospitals are desperate. For every group that comes in and sweeps up by landing some great contract, it means that someone else has downsized, failed, and/or some hospital was recalcitrant in how they approached an important negotiation. Even when everything works out well, it means there’s a lot of stress and conflict in the process.

In summary, I think a large part of the instability really has less to do with the practice model itself and much more to do with staffing shortages more broadly.

The reality:

I don’t think this is a simple time to be a radiologist or to run a practice, but I think the real existential difference between private practice and other models is that the hospital can get locums or pay extra for a different group if they are forced to, but an independent practice fails when it fails. There is no alternative: it either works or it doesn’t.

Your value as a person is never just your job performance, but even your value as a resident isn’t just what you bring to your early efforts: after years of steady skill and knowledge acquisition during school and internship, the R1 step backward into novicehood can be emotionally challenging.

For better or worse, it’s in many ways a fresh start.

And, in the beginning, you are going to be wrong so much.

Day to day, some attendings are harsher than others, and some cases are simply more challenging than others. A lot of cases are negative/normal, but there will inevitably be countless situations where you swing and miss. Recency bias is a hassle we never truly escape (so we all suffer from it forever), but it often happens to comic effect at the beginning of training. There’s a reason why a classic radiology rite of passage is to miss an important finding and then overcall it on subsequent cases.

So it’s important to not confuse your value with that those inevitable growing pains and sometimes frustrating feedback during the early learning process. Everyone involved in medical education should acknowledge that a trainee’s need to learn while working means a down payment on future “value” even when not really “helping” today. That’s why you’re there, and that’s why your attendings are there too. Everyone is on the same team with the same goal of you one day becoming an outstanding clinical radiologist.

So don’t take the forced transcribing or the need to edit your drafts too much to heart. You’re likely to run into at least one attending who basically deletes everything you do or seems overly pedantic (note: they might be). Instead of being frustrated, try to bring a healthier growth attitude to those exchanges. Some of that negative feedback probably has some truth, even if it doesn’t feel good. Have a sense of humor (please, please, I promise it’s more fun this way).

Yes, your work right now might not be up to snuff yet.

It might even be “bad“–but you are not bad. You are learning.

Never confuse someone’s negative feedback as a mark or a reflection of your value. You aren’t just your job even at the height of your career, let alone on your first day.

People often ask me what I think will/does happen when private equity groups fail. The answer I’ve always said is it probably depends.

The work needs to get done, so there are three big options:

1. Direct hospital/system employment probably with locums in the short term
2. New private practice
3. Outsourced to teleradiology firm (potentially with IR/DR split and locus/direct employment for on-site procedural work)

There was a story this past summer in Radiology Business that I don’t think I shared here: to my knowledge, Mid Atlantic Radiology Consultants is the first completely new group to form to take back work from a reportedly unsatisfying Radiology Partner’s owned practice:

[President and CEO of Trinity Health Mid-Atlantic] “Woodward declined to identify the “large scale” imaging group to the publication, citing contract confidentiality requirements. But he shared a personal belief that such PE-backed provider groups “serve their shareholders’ interest, not the patients’ and doctors’ and hospitals’ interests.

Radiologists he spoke with conveyed a dissatisfaction with investor-backed groups that “come in and forget about the patients.”

This is an example of a hospital that chose to help create an independent group instead of trying to bring everyone in-house. Now, it’s worth noting this is probably not charity. They may have realized they’d have a harder time recruiting in the market with direct employment. They may not have had enough outpatient work to fully justify the numbers of rads they’d need to cover the on-site call pool. They may have preferred an external entity that they could blame when things go wrong or pressure, which wouldn’t be possible the same way for employed rads. The accountability calculus is simply different.

Regardless of the reason, it happened. I know some other hospitals, like some in Chicago, have shifted rads in-house. Still others, like one in Tulsa, have resorted to teleradiology.

Here are several things to consider about learning radiology in addition to my articles on Approaching the R1 Year, How to be a First Year Radiology Resident, and Radiology Call Tips.

Develop Robust Search Patterns

Real search patterns are not just the order in which you analyze a fresh scan, they are a series of if-then statements:

If I see this finding, then I will look carefully at this other structure for an associated abnormality.

For example, if I see a lobar hemorrhage, I will look extra carefully at the dural venous sinuses and regional cortical veins on this non-contrast CT to ensure there is no hyperdensity to suggest thrombosis. If I see a spine fracture, I will look extra carefully at the soft tissues to ensure no obvious epidural hemorrhage or interspinous widening to suggest a ligamentous injury. If I see scalp swelling, I will look at the immediate underlying bone and underlying & countercoup intracranial contents to ensure no subtle fracture or hemorrhage escaped my notice on the first pass.

Interrogate Your Knowledge & Test Yourself

In today’s educational environment, asking pointed questions–especially those designed to stretch and assess your knowledge (pimping)–has fallen out a favor. This may be a combination of generational changes as well as the desire to create a safe space for learning, but regardless it is not as common as it used to be.

That being said, it is important for you to interrogate and assess your knowledge. This includes testing in the form of multiple choice questions and spaced repetition flashcards and things of that nature, but should also include self-pimping: you need to learn the skill of asking yourself the same questions that a harsh attending would ask of you.

As a deliberate learning exercise, ask yourself what it would take for your differential considerations to be plausible. Sure, this low-ish density collection is probably a chronic subdural hematoma or hygroma. But what would it take for you to consider a subdural empyema? Did you look at the mastoid air cells and paranasal sinuses?

Be Proactive

Don’t wait until somebody tells you to read about something to learn something, you already probably know the things that would’ve helped because you know the things that would’ve meant a better performance today: which pathological terms you didn’t understand, which body parts you had no clue about, which differentials were totally beyond your fund of knowledge.

Yes, it’s good to get through some kind of comprehensive entry-level text on your first rotation and to do whatever else people ask you to do, but it’s also worth learning about the things that are relevant to you now before you make the same mistake twice. Every diagnostic consideration raises its own series of differentials and potential complications.

Acknowledge the gaps and work to fill them every day. Adding the fruits of that labor to an Anki deck is probably an easy right move. Doing it continuously will remove a lot of the friction and build-up that makes us otherwise never quite get around to it.

Excuses Are Generally a Waste of Time

There’s a blurry line between explaining yourself to improve your approach and making excuses for your unavoidable lack of experience or inevitable mistakes.

Unless you want to explain your reasoning in order to have somebody correct your faulty reasoning, it usually doesn’t matter why you’re wrong. Not seeing things is just part of the learning process. Making the finding but reaching the wrong conclusion is often a teachable moment, but many mistakes are just a matter of reps. We all know that satisfaction of search and anchoring are big biases, so your attending doesn’t need you to explain why you didn’t notice something. The miss speaks for itself.

If you want to know why you’re wrong, then keep talking. Otherwise, let’s move on.

Reasonable Thoughts

Common sense and Bayesian updating are perhaps the most critical skills for medical critical thinking.

Base rates matter. They matter so much.

Common things are common. Weird presentations of common things are usually still more common than rare things. And rare things often only become reasonably plausible when their pretest ability becomes higher in context.

For example, intramedullary lymphoma is quite rare. But it would make more sense as a consideration for spinal cord pathology in a patient with new weakness if the patient has a known widespread lymphoma than if they just, say, had a flu shot.

Common sense and context awareness would prevent many diagnostic blunders.

Separate Content from Source

You can learn from every attending, even the bad ones.

Avoid their mistakes.

Finally, It’s OK That It’s Hard.

Difficulty and challenge aren’t bad, they are a critical part of human flourishing.

If you’ll excuse the crotchety-old-man moment, I think many of us have gotten into a mindset where we feel that the things people ask of us are an impediment to us living our best life, that hard work is intrinsically unfair, that anything even the slightest bit tedious is scut.

Not only is all this wrong–and trust me it’s not just because I’m getting older–but it’s also unhelpful.

There are certain parts of the world that we can change and certain parts that we can’t. The reality is that even the best careers have boring, tedious, and even unfair parts. We can’t have the good parts of a meaningful career if we are too quick to reject every part that doesn’t spark joy.

The first pile-on lawsuit against Radiology Partners has arrived: UnitedHealth’s original 2023 lawsuit against RP for an alleged “pass-through billing scheme” wrapped up this fall, and Aetna just filed their own Christmas present on December 23.

For those curious about how that United lawsuit played out, here are my three posts covering that story:

1. United against Radiology Partners
2. United is Still Fighting Radiology Partners
3. Counting Chickens: RP loses its windfall award from United

They provide a helpful backdrop of what’s happening now.

In the first part of its suit, Aetna alleges the same pass-through billing scheme:

In phase one of the scheme, Radiology Partners identified [its RP-owned practice] MBB as having the most lucrative in-network contracts with commercial payors in Florida, including Aetna, and began using MBB’s name and Tax Identification Number (“TIN”) to bill for services performed by all its “affiliated” Florida radiology groups. Radiology Partners’ use of MBB’s TIN to bill for services performed by other radiology groups misrepresented that MBB—as opposed to another radiology group with its own separate in-network contract—performed the services billed.

Lots of businesses merge or sell to do this legally (barring antitrust concerns).

The issue here is that RP wants to have it both ways. Each RP-owned practice retains its initial identity despite being functionally owned by RP. Part of this is to get around laws barring the corporate of medicine in some states. These groups maintain their original Tax ID and payor contracts while RP has operational control and its specified share of the profits. You don’t get to say each group is an individual “physician-owned” private practice on the one hand and then funnel all the billing through your best contracts as if every RP-owned practice was in fact one company. They’re either separate companies or they’re not.

By 2022, MBB was submitting significantly more claims to Aetna than it had historically because of Radiology Partners’ scheme. But when asked about this increase in claims volume, MBB deflected Aetna’s inquiries. Ultimately, Aetna terminated MBB’s in-network contract, causing MBB to go “out-of-network” with Aetna. The other radiology groups implicated by Radiology Partners’ scheme remained “in-network” with Aetna, however.

The cancellation of this contract seems like an important distinction with the United lawsuit. In that case, United unilaterally started paying RP under a different contract, which violated the terms of their original agreement dating back to 1998. So when the arbitration panel told both parties to just go away, they stated both parties got nothing because of their “breaches of the 1998 Agreement” and “other acts and omissions.” We’ll have to see what RP’s rebuttal will be, but it’s not clear here that Aetna made the same mistake as United of violating their contract. In the United case, the panel didn’t go into details but didn’t seem to like RP’s behavior (e.g. those breaches, acts, and omissions resulted in the panel vacating an almost $100 million interim award). If Aetna didn’t make a mistake, then presumably RP’s similar behavior here standing alone is less likely to result in just another mulligan.

But that canceled contract led to the second part of the claim, which is an equally egregious-sounding scheme of abusing the independent dispute resolution (“IDR”) process used to adjudicate out-of-network claims:

As an out-of-network radiology provider, MBB’s claims were now subject to the No Surprises Act (“NSA”), 42 U.S.C. §§ 300gg-111, which is intended to protect patients from surprise medical bills when, for example, they unwittingly receive services from out-of-network providers (such as MBB) at in-network hospitals. The NSA does not apply to in-network providers.

Rather than properly bill the services provided by Radiology Partners’ other radiology practices through those groups’ existing contracts with Aetna, the Defendants continued to bill all services through MBB, using MBB’s TIN. This, too, was a material misrepresentation that caused Aetna to pay MBB funds to which it was not entitled.

Defendants wanted to take even more from Aetna and its plan sponsors. To do so, Defendants initiated tens of thousands of arbitrations under the No Surprises Act’s independent dispute resolution (“IDR”) process for services that were provided by the Radiology Partners-controlled medical groups that had—and still have—in-network contracts with Aetna. These arbitrations were all initiated based on Defendants’ misrepresentations that they were for medical services provided by MBB. In truth, they were for medical services provided by other medical groups who had contracts with Aetna, rendering those services ineligible for arbitration under the NSA.

Now, MBB itself should have been using the IDR. That’s how it’s supposed to work, and if they still made great money via that process, so be it. The Brookings paper below suggests that the outcome of IDR being higher than typical market rates has been pretty common so far. What’s hard to imagine is what plausible argument RP has for submitting claims for work performed by its other Florida radiologists through the IDR process when those other groups had contracts in force.

If you’re employed by group X and working for group X and group X has a contract with Aetna, I don’t see how you pretend you’re out of network and bill through group Y, which does not employ you. If someone with billing expertise wants to weigh in, I’m very curious. The answer will probably help inform how many more of these lawsuits we should expect to see.

As Aetna (and others) point out:

As scholars studying NSA IDR data recently noticed, Radiology Partners and three other private-equity-backed provider groups have accounted for “a large and disproportionate share of IDR cases.” In fact, Radiology Partners is responsible for over 90% of all IDR cases involving claims for professional radiology services.

The referenced work is “A first look at outcomes under the No Surprises Act arbitration process” from Brookings, which noted that four companies (TeamHealth, SCP Health, Envision, and Radiology Partners) generated 74% of the studied IDR claims. RP is apparently responsible for over 90% of radiology claims despite a market share of probably no more than 10%.

For those who aren’t very familiar with this part of the No Surprises Act, the paper breaks down the process well. To be clear, the NSA is a great example of well-intentioned but totally broken legislation, and the IDR process is a mess.

When you see a news story that a handful of private equity companies are responsible for the vast majority of IDR claims, it makes you wonder: Is it just because they bought the groups with the best contracts and therefore those most likely to be dropped by insurers in the aftermath of the NSA? Is it because their practice-consolidation approach results in higher costs that the payors are unwilling to pay leading to these subsequent reimbursement fights? Are they just better at playing the game and going after the unscrupulous payors? Or–as the case may be here–are we looking at a combination of likely all of these things plus potentially/allegedly a bunch of fraud, bypassing in-force contracts to funnel unrelated work through the arbitration process in bulk in order to hide what should be lower-paying work? What a mess.

Ultimately, this is another emotionally unfulfilling conflict. Aetna is not a “good guy” here. There are no good guys. The No Surprises Act means that an insurance company has the option to drop a high-paying legacy contract and force a group to go out of network as a negotiating tactic to renegotiate rates and push reimbursement down. The Brookings’ analysis suggesting that recent IDR awards have so far trended toward the higher pre-NSA out-of-network surprise bills and not the lower dubiously-defined qualifying payment amount (QPA) doesn’t change the fact that the payors have been using it as a bullying tool in their arsenal to pay less. That RP may have deserved it here is only part of a much larger depressing story.

One imagines Aetna has learned from recent events and likes its chances.

One also wonders how many more payors in how many more states might be polishing up additional suits for 2025.

From “The U.S. Radiologist Workforce: AJR Expert Panel Narrative Review,” just published in AJR:

Between 2014 and 2023, the number of radiology practices decreased by over 17%, while the number of practices with 25-49, 50-99, and 100 or more radiologists grew by 33%, 126%, and 349%, respectively.

Consolidation in action. An arduous regulatory climate, challenging payor relationships, tumor-like health network/hospital/system growth, and the increasing volume and intensity of after-hours work all favor a smaller number of larger groups. Scale to combat scale.

Imaging provider Akumin’s new post-bankruptcy CEO, in an interview with Radiology Business, describes their new owner, Stonepeak, which took control of the company after swapping ~$470 million in debt for equity and dropping an extra $130 million as part of a Chapter 11 bankruptcy:

Stonepeak has a longer-term investment horizon compared to traditional private equity, which typically holds assets for three to five years. For Stonepeak, eight to 12 years has been their typical investment horizon. Our relationship has gone really well with them because, once they own an asset in this space, they stay with it for a long time.

In this industry, a decade is considered a “long time.” I guess that’s true: It took me a decade after college to become a radiologist.