Changes in the Radiology Practice Landscape and Indicators of Practice Consolidation From 2014 to 2023.

Background: A range of economic and health policy incentives are leading to ongoing consolidation among payers, hospitals, and physician practices. Objective: To evaluate consolidation among radiologists' affiliated practices through 2023, analyze the impact of consolidation on such practices' specialty mix and size, and assess radiologists' new affiliations after prior practices cease. Methods: CMS data from 2014 to 2023 were used to identify all radiologists nationally along with their affiliated practices. Practices were categorized based on the specialty mix of all affiliated physicians as radiology-only or multispecialty; multispecialty practices were further categorized as radiology-majority, other-specialty-majority,or no-majority-specialty. Practices that ceased (i.e., became absent within CMS data) were identified. Temporal shifts were assessed, to infer consolidation patterns. Results: From 2014 to 2023, the number of Medicare-enrolled radiologists increased 17.3% from 30,723 to 36,024, while their number of affiliated practices decreased 14.7% from 5059 to 4313. The number of radiology-only, radiology-majority, other-specialty-majority, and no-majority practices changed by -31.8% (3104 to 2118), 10.8% (402 to 446), -5.7% (615 to 580), and 24.6% (938 to 1169), respectively. The number of practices with 1-2, 3-9, 10-24, 25-49, 50-99, and ≥100 radiologists changed by -18.7% (2233 to 1815), -34.4% (1406 to 923), -25.2% (910 to 681), 33.2% (352 to 469), 121.6% (125 to 277), and 348.5% (33 to 148). A total of 3494 practices ceased, including 2281 radiology-only practices. Among 3854 radiologists for whom their only affiliation was a ceased radiology-only practice, their subsequent-year affiliation was a radiology-only practice in 54.3% and a multispecialty practice type in the remaining instances. Conclusions: An overall decrease in the number of radiology practices and concurrent growth in the number of radiologists was mirrored by shifts from small toward large practices and from radiology-only toward multispecialty practices, consistent with ongoing practice consolidation. While determining causes of consolidation were beyond this study's scope, the shifts may relate to economic incentives and legislative changes favoring large multispecialty practices. Clinical Impact: Radiologists' continued consolidation into large multispecialty practices may facilitate subspecialization and greater negotiating power in payor contracting. Yet radiologists may prefer smaller and/or radiology-only practices for autonomy and influence on practice structure.

Formal wellness training of academic radiology leaders improves work-life conflict.

OBJECTIVE: To investigate the effect of formal leadership training of academic radiology leaders within an academic center on their own burnout and professional fulfillment. METHODS: The study cohort was academic radiology leaders within one of the largest academic organizations of academic radiologists within the United States. All academic radiology leaders within the organization were electronically mailed a weblink to a confidential IRB-approved survey in April 2021. The survey included validated questions from the Stanford Professional Fulfillment Index (PFI), values alignment, teamwork, overload, and work-family conflict. Academic leaders were invited in May 2021 to participate in instructor-led formal training on leading wellness focusing on 5 core leadership skills - emotional intelligence, self-care, resilience support, demonstrating care, and managing burnout. An identical follow-up survey was electronically mailed 6 months after initial training in November 2021. RESULTS: The overall response rate of academic radiology leaders was 59% (19/32). For both measures, there was acceptable internal consistency (Cronbach's α = 0.63 for work exhaustion and α = 0.90 for fulfillment). There was a statistically significant improvement in work-family conflict (3.32 vs 2.86; p = 0.04). No statistically significant differences were identified for fulfillment, work exhaustion, alignment, work overload, and teamwork scores after training. CONCLUSION: Formal instruction in leading wellness improved work-life conflict for academic radiology leaders. There was no significant change in burnout, fulfillment nor organizational alignment of the leaders. CLINICAL RELEVANCE STATEMENT: Formal instruction in leading wellness raised awareness and improved work-life conflict in academic radiology leaders.

Factors Contributing to Disproportionate Burnout in Women Breast Imaging Radiologists: A Review.

Physician burnout continues to increase in prevalence and disproportionately affects women physicians. Breast imaging is a woman-dominated subspeciality, and therefore, worsening burnout among women physicians may have significant repercussions on the future of the breast imaging profession. Systemic and organizational factors have been shown to be the greatest contributors to burnout beyond individual factors. Based on the Mayo Model, we review the evidence regarding the 7 major organizational contributors to physician burnout and their potential disproportionate impacts on women breast radiologists. The major organizational factors discussed are work-life integration, control and flexibility, workload and job demands, efficiency and resources, finding meaning in work, social support and community at work, and organizational culture and values. We also propose potential strategies for institutions and practices to mitigate burnout in women breast imaging radiologists. Many of these strategies could also benefit men breast imaging radiologists, who are at risk for burnout as well.

Breast Radiologists' Perceptions on the Detection and Management of Invasive Lobular Carcinoma: Most Agree Imaging Beyond Mammography Is Warranted.

OBJECTIVE: To determine breast radiologists' confidence in detecting invasive lobular carcinoma (ILC) on mammography and the perceived need for additional imaging in screening and preoperative settings. METHODS: A 16-item anonymized survey was developed, and IRB exemption obtained, by the Society of Breast Imaging (SBI) Patient Care and Delivery Committee and the Lobular Breast Cancer Alliance. The survey was emailed to 2946 radiologist SBI members on February 15, 2023. The survey recorded demographics, perceived modality-specific sensitivity for ILC to the nearest decile, and opinions on diagnosing ILC in screening and staging imaging. Five-point Likert scales were used (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). RESULTS: Response rate was 12.4% (366/2946). Perceived median (interquartile range) modality-specific sensitivities for ILC were MRI 90% (80-90), contrast-enhanced mammography 80% (70-90), molecular breast imaging 80% (60-90), digital breast tomosynthesis 70% (60-80), US 60% (50-80), and 2D mammography 50% (30-60). Only 25% (85/340) respondents were confident in detecting ILC on screening mammography in dense breasts, while 67% (229/343) were confident if breasts were nondense. Most agreed that supplemental screening is needed to detect ILC in women with dense breasts (272/344, 79%) or a personal history of ILC (248/341, 73%), with 34% (118/334) indicating that supplemental screening would also benefit women with nondense breasts. Most agreed that additional imaging is needed to evaluate extent of disease in women with newly diagnosed ILC, regardless of breast density (dense 320/329, 97%; nondense 263/329, 80%). CONCLUSION: Most breast radiologists felt that additional imaging beyond mammography is needed to more confidently screen for and stage ILC.

Radiologists' Out-of-Network Billing Trends, 2007 to 2021.

PURPOSE: Given the financial hardships of surprise billing for patients, the aim of this study was to assess the degree to which radiologists effectively participate in commercial insurance networks by examining the trend in the share of radiologists' imaging claims that are out of network (OON). METHODS: A retrospective study over a 15-year period (2007-2021) was conducted using claims from Optum's deidentified Clinformatics Data Mart Database to assess the share of radiologists' imaging claims that are OON. Radiologists' annual OON rate was assessed overall as well as for claims associated with inpatient stays and emergency department (ED) visits. Rates were assessed for all imaging studies as well as by modality. Linear regression was conducted to assess OON rate time trends. RESULTS: From 2007 to 2021, 5,039,142 of radiologists' imaging claims (6.3%) were OON. This rate declined from 12.6% in 2007 to 1.1% in 2021. Over the study period, the OON rate was 5.0% during an inpatient stay and 2.1% on the same day as an ED visit that did not lead to an inpatient admission. The linear trend in the overall OON rate declined 0.74 percentage points annually (95% confidence interval [CI], -0.90 to -0.58 percentage points) over the study period. Likewise, the annual declines were 0.54 percentage points (95% CI, -0.71 to -0.36) and 0.26 percentage points (95% CI, -0.33 to -0.20 percentage points) for imaging claims associated with inpatient stays and ED visits, respectively. CONCLUSIONS: Radiologists' imaging claims that are OON has significantly declined from 2007 to a minimal level in 2021. This may indicate effective negotiations between radiologists and commercial payers and new state-level surprise billing laws.

Financial Viability of the No Surprises Act Independent Dispute Resolution Process: Radiology and Other Hospital-Based Specialties.

BACKGROUND. The federal No Surprises Act (NSA), designed to eliminate surprise medical billing for out-of-network (OON) care for circumstances beyond patients' control, established the independent dispute resolution (IDR) process to settle clinician-payer payment disputes for OON care. OBJECTIVE. The purpose of our study was to assess the fraction of OON claims for which radiologists and other hospital-based specialists can expect to at least break even when challenging payer-determined payments through the NSA IDR process, as a measure of the process's financial viability. METHODS. This retrospective study extracted claims from a national commercial database (Optum's deidentified Clinformatics Data Mart) for hospital-based specialties occurring on the same day as in-network emergency department (ED) visits or inpatient stays from January 2017 to December 2021. OON claims were identified. OON claims batching was simulated using IDR rules. Maximum potential recovered payments from the IDR process were estimated as the difference between the charges and the allowed amount. The percentages of claims for which the maximum potential payment and one-quarter of this amount (a more realistic payment recovery estimate) would exceed IDR fees were determined, using US$150 and US$450 fee thresholds to approximate the range of final 2024 IDR fees. These values represented the percentage of OON claims that would be financially viable candidates for IDR submission. RESULTS. Among 76,221,264 claims for hospital-based specialties associated with in-network ED visits or inpatient stays, 1,482,973 (1.9%) were OON. The maximum potential payment exceeded fee thresholds of US$150 and US$450 for 55.0% and 32.1%, respectively, of batched OON claims for radiologists and 76.8% and 61.3% of batched OON claims for all other hospital-based specialties combined. At payment of one-quarter of that amount, these values were 26.9% and 10.6%, respectively, for radiologists and 56.6% and 38.4% for all other hospital-based specialties combined. CONCLUSION. The IDR process would be financially unviable for a substantial fraction of OON claims for hospital-based specialists (more so for radiology than for other such specialties). CLINICAL IMPACT. Although the NSA enacted important patient protections, IDR fees limit clinicians' opportunities to dispute payer-determined payments and potentially undermine their bargaining power in contract negotiations. Therefore, IDR rulemaking may negatively impact patient access to in-network care.

Should I Stay, or Should I Go? Early Phase Instrument Development of Workforce Movement-A Pilot Study with Breast Radiologists.

OBJECTIVE: The goal of this study was to develop a psychometrically valid survey on workplace satisfaction and examine predictors of workforce movement among breast radiologists. METHODS: Actively practicing members of the Society of Breast Imaging were invited to complete a survey on workplace satisfaction. Radiologists also indicated whether they had recently left their practice or were thinking of leaving their practice. RESULTS: In total, 228 breast radiologists provided valid responses (8.7% response rate); 45% were thinking of leaving or had left their practice. Factor analysis yielded five factors, and discriminant function analysis found six main aspects associated with workforce movement in breast radiologists: (1) not enough work-life balance; (2) salary too low; (3) not feeling valued; (4) wanting a different challenge and/or more growth opportunity; (5) safety concerns; and (6) not feeling respected by physician leadership. CONCLUSIONS: Pending further validation in larger and different cohorts, the survey created here can be administered by radiology practices to predict when breast radiologists are vulnerable to quitting. Atlhough this measure was designed for breast radiologists specifically, it could be adapted for other subspecialties.

The 2021 ACR/RBMA Workforce Survey: Practice Types, Employment Trends, and Hiring Needs.

PURPOSE: The aim of this study was to analyze current radiology practice types, specific subspecialty needs, employment trends, and retirement trends. METHODS: ACR members, nonmembers, and Radiology Business Management Association members were surveyed using predominantly structured closed-ended questions about a variety of current and recent radiology practice characteristics. Responses were group practice deduplicated and weighted. RESULTS: Of 1,702 survey respondents, 64% were men, with a median age of 51 years. In 2021, 62% of responding practices hired radiologists, with the average practice hiring 2 radiologists and academic practices on average hiring the most (3.5). Most radiologists (87%) were hired for full-time positions, with independent practices hiring the largest proportion of part-time positions. Body and breast imagers represented the largest numbers of hired radiologists (17% each). Practices anticipated similar hiring patterns in 2022, prioritizing breast (37%) and body (35%) imaging. Of all practice types, academic groups were least likely to prioritize general radiologist hiring. A large majority (82%) of radiology practices permit remote work (teleradiology), more common at academic than other practices. Of currently employed radiologists, 16% plan to seek new employment in the next year; early-career radiologists indicated the highest likelihood (92%) and academic radiologists the lowest (66%) of remaining in the same practice for at least 5 years. A large majority of practices (80%) reported no radiologist retirements in 2021. Of those retiring, the average age was 75 years, and 66% worked full-time until retirement. CONCLUSIONS: Radiologist recruiting remains robust. Current information on practice characteristics may help inform radiology practice leaders seeking to right-size their groups.

Practical Strategies to Retain Radiologists.

Since the great resignation associated with the coronavirus disease 2019 pandemic, radiology practices are now challenged with maintaining adequate radiology staffing requirements to cope with increasing clinical workload requirements. The authors describe practical strategies for radiology practice leaders to retain radiologists in the current challenging job market, while mitigating their burnout.

How breast radiologists can deal with the disruptive technologist.

Physician burnout continues to be a challenge in addressing radiologist wellness. The stressors contributing to breast radiologist burnout are distinctive due to the unique work environments of a breast center. The intimate nature of a subspecialized team of radiologist(s) and technologists at an imaging center may result in interpersonal challenges such as a disruptive technologist. It is important to address the stressors to mitigate the increasing burnout affecting breast radiologists. This article raises awareness among radiologists and administrators and provides strategies to breast centers and breast radiologists for guidance on dealing with a disruptive technologist.

A pre-post study of stressors and burnout affecting breast radiologists before and during the COVID-19 pandemic.

Rationale and objective: To compare burnout and stressors of breast radiologists prior to and during the COVID-19 pandemic. Materials and methods: Members of the Society of Breast Imaging were emailed an IRB-approved survey in January 2021 during the COVID-19 pandemic. Survey included questions from the Maslach Burnout Inventory and specific stressors including work pace, work-life balance, care of dependents, and financial strain. Data were compared to previous surveys prior to the pandemic. Results: The response rate was 25% (261/1061) for those who opened the email. Of the respondents, 74% (194/261) were female, 82% (214/261) were white, 73% (191/261) were full time, 71% (185/261) were fellowship trained, 41% (106/261) had more than 20 years of experience, and 30% (79/261) were in academic practice.Respondents in 2021 reported frequent levels of depersonalization (2.2) and emotional exhaustion (3.4) while reporting frequent levels of personal accomplishment (5.3), a protective factor. These values were nearly identical before the pandemic in 2020: (2.2, 3.5, 5.3, respectively, p = .9). Respondents rated practicing faster than they would like as the highest stressor; however, 5 of the 6 stressors improved after the pandemic onset (p < .05). Conversely, participants perceived these stresses had gotten slightly worse since the pandemic (p < .01). Almost 50% of respondents reported they were considering leaving their practice; the most common reason was work/life balance. Conclusion: Burnout in breast radiologists remains frequent but unchanged during the COVID-19 pandemic. While participants perceived that some stressors were worse during the pandemic, there was slight improvement in most stressors between the pre-pandemic and pandemic cohorts.

The 2021 ACR/Radiology Business Management Association Workforce Survey: Diversity in Radiology.

The landscape of the radiology workforce is changing, especially in the diversity of the demographics of practicing radiologists across subspecialties, practice types, and leadership positions in both academic and nonacademic settings. The 2021 ACR/Radiology Business Management Association Workforce Survey examines these facets in detail and contributes to our understanding of the current state of diversity in the radiology workforce and potential barriers to change. The results suggest opportunities and future directions for improving diversity, equity, and inclusion.