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.

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?