Under Pressure: Spotting Private Practice Trouble Zones
Many radiology private practice groups today are under increasing financial pressure and facing more obstacles and competition to stay viable.
No, I’m not saying it’s doomsday for these groups, but there are very real issues that are and will continue to impact private practice. As they say, forewarned is forearmed.
In this post, I’ll take a more detailed look at some of the most pervasive challenges for private practice groups. I’ll also provide advice on spotting potential trouble zones and how you can help avoid them.
Keep an eye on these potential problem areas:
Hospital relationships
Most private practice groups have been quite dependent on hospital service agreements to survive. Freestanding imaging centers and creative revenue streams notwithstanding, most successful groups rely on symbiotic relationships with their local hospitals.
Radiology groups may have a number of agreements with hospitals, outpatient diagnostic imaging centers, urgent care clinics and physician clinics to provide their professional services. These different agreements provide diversification to the radiology group, generating revenue from multiple sources and precluding reliance upon one source. There is greater stability in a radiology group with long-term (generally one to five years) agreements in place with multiple sources.
Hospitals that contract with private practice groups have begun to incorporate rigorous service standards into contracts, including report turnaround time, time between the request and the completion of examinations, measures of patient and staff satisfaction, and resource use and efficiency.
Groups having trouble with their hospital relationships often work under a constant threat of being replaced (and teleradiology has made replacement easier to accomplish).
Practice viability, and other factors contributing to a financial squeeze
Compensation has traditionally been highest in the private practice setting, and still is to a large extent, but the trade-offs for a generous salary and autonomy are greater financial risk and administrative responsibility. Radiologists are dependent on effective management of the practice, adequate imaging volume, and high productivity to maintain salaries.
As such, the stability of private practice groups is increasingly being threatened by loss of hospital contracts and replacement by hospital-based radiologists. Private practice groups are also facing greater competition with teleradiology and other subspecialty services.
Further challenges abound because private radiology practice is not particularly well-equipped for the transition to a more capitated form of healthcare reimbursement with bundled payments and decreased reimbursement.
How do you know if a group is in trouble?
To assess the value and viability of a private practice group, it is important to assess the governance structure (i.e., does it enable rapid, appropriate decision making) and business infrastructure [1]. Having a capable business manager and controlling coding and billing are extremely important to a practice’s financial success and survival.
Other factors to consider are 1) Is the practice growing or shrinking?, 2) Is the caseload increasing or decreasing?, 3) Are there multiple practice sites, or does the group derive all income from one source?, and 4) Does the practice use appropriate marketing and engage in other practice-building activities? [2].
Partnership pitfalls
Partnership tracks are becoming less common, and even when present, may not always be meaningful, particularly in smaller groups that don’t have long-term locked-in contracts or don’t own imaging centers (and thus have no assets to bargain with except limited intellectual manpower).
Partnership track positions usually pay a lower amount at the beginning than an employed position until one becomes a partner. The radiologist on the partnership track puts in “sweat equity” by working harder and accepting fewer benefits (e.g., less vacation time, less choice on when vacation is taken, less desirable work rotations, etc.) in order to pay for the privilege of becoming a partner.
Practices also expect partnership track employees to be involved in practice building. This involves participation on hospital committees, giving grand rounds, attending tumor boards, being present at events outside normal business hours, and other important “non-clinical” functions. These activities are part of the essential training required to learn the business role of the partner.
Some new private practice hires may work very hard at a lower salary level while on the “partnership track” only to be let go prior to making partner (so-called “churn and burn”).
This may happen when established partners are used to earning a high salary and want to maintain that level of compensation during periods of falling reimbursement. When an employee becomes a partner, it dilutes the equity of the preexisting partners and each partner will get a smaller share of the profits.
| Some new private practice hires may work very hard at a lower salary level while on the “partnership track” only to be let go prior to making partner (so-called “churn and burn”). |
In exchange for higher compensation compared with a non-partner employee, the partners assume the risk of the practice and also manage practice issues. If reimbursement decreases, partners are affected first. If there is loss of an employee, the partners need to cover that position. If there is a lawsuit against the practice, the burden falls on the partners.
In addition, when hospitals convert private practice jobs to employed positions due to mergers and acquisitions, the radiologist on the partnership track will suddenly find out there is no partnership position. They will not make a partner salary and may lose their job, being lower on the totem pole than a partner.
A newly graduated radiologist should consider whether it makes sense to put “sweat equity” into what she doesn’t consider her long term dream job—and to be paid less for a partnership position that will likely not last for more than a few years.
In this situation, if there isn’t a more suitable job available, it might make more sense to work as a non-partnership track employee. The decision to become a partner in a practice versus a permanent employee may not be simple due to the personality of the applicant, job-related factors, and monetary considerations. A partnership, like a marriage, is a long-term commitment.
Bottom line: tread carefully and watch for these potential problem zones.
Remaining competitive on a personal level
To remain viable all radiologists must engage in lifelong learning. This can be a particular challenge for private practice radiologists who spend a substantial amount of time as a generalist. In academics, radiologists generally only need to keep up in their field of expertise, and have easy access to educational opportunities within a university setting.
Your time is a precious resource, but so is your noggin. It may not be possible to always predict the challenges ahead or avoid all the obstacles that may arise. Stay curious, stay sharp, and stay true to yourself; your prognosis is optimistic.
References
- Muroff LR. Taking your practice to the next level. J Am Coll Radiol 2008; 5:986-592
- Muroff L. How to evaluate a private practice radiology job offer. J Am Coll Radiol 2014; 11(10):934-935