Jonathan
H. Sunshine,
PhD
Swati
#{149}
Operational, Characteristics in the United
a similar
percentage
R aspect
on this
cally have tional and work
tribute
and
This
principal
findings
the
ACR
regarding
fessional, of U.S.
business group
every
The
1989
designed
Group
by
the
provide.
The
to all 2,591
were
From
the Department of Research, American of Radiology, 1891 Preston White Dr, Reston, VA 22091. Received September 23, 1991; revision requested October 29; revision received December 10; accepted December 30. Address reprint requests to J.H.S. Further data, including more detailed tables, are available from the authors. ‘ RSNA, 1992
was
consisting
on the
one
master
list had
in the
middle
of 1988
radiologist by
each
and
tween
one
follow-up
June
963 responses 37% of the
and
group
mailing
October
were sample.
would
be
occurred
1989.
groups
of
Standard tables
in a category
of the
actual
errors have been and are a measure
of a statistic
re-
given remix
of
included in of the uncer-
as a result
of sampling.
that
diagnostic-only
bewas 48
were “out-of-sample,” that is, they were not multiple-member radiology groups. (Most out-of-sample responses were from solo practices that had had two
practices
radiologists per full-time per
year
averaged equivalent
compared
with
12,088 (FTE)
with
10,171
procedures per FTE radiologist per year in practices with 11 or more radiologists. The question is whether this difference of approximately 1,900 procedures per FTE ra-
as
per
1,058
year
is real.
first figure
and
that
statistical
The
standard
is shown
for
Thus, the formula of 1.96 x (1,0582 out
to
Altogether,
received, which Of the responses,
number
their responses were to make the weighted
ror for the
ade-
responses were An original mailing of the 2,591 groups
estimated
and weight
diologist
been asking
all ACR members what group they belonged to and who all the members of the group were. The ACR indicated that one from
of re-
of the
radiologist
practices;
of only
The
the
11 or
number
sponded, a larger
two to four procedures
was
practices
to 10, and
the
centage
shows
department
form
each
The difference between two figures is regarded as statistically significant at 5% if the difference equals at least 1.96 x (a2 + b2) 2 where a is the standard error of the first figure and b is the standard error of the second figure. For example, Table 2
range of ACR and departinformation it
survey
eight
groups,
the
Survey
within
of in
actual groups, and the weights used in each of the four census regions and the four size categories. A relatively large weight means that a below-average per-
the Group the ACR con-
research
of what
U.S. radiol-
The basis of groups
and,
I shows
sponses representative U.S. groups.
Practice
group
quate, and duplicate counted only once. the group president I
pro-
tables tabu-
of groups in each of (two to four radiolo-
to seven,
Table
list
estimate
regions
characteristics practices.
list of U.S. radiology
excluded.
response
College
pre-
METHODS
with input from a broad committees, commissions, ments interested in the
practices
a and
of the
AND
an
be if every
responded. the number
census
five
tainty
ACR
had was
sponding
3 years.
MATERIALS
gists,
Col-
article
Data come chiefly from Practice Survey, which ducts
four
more).
the operational,
and radiology
mailed
183:535-540
the
American
activities.
sents
would
region, the number four size categories
lege of Radiology (ACR) undertakes number of information-gathering research
represent
the
organizational the
and
findings
con-
to radiologists
master
lations
ogy group weighting
to
the
shown in the text and are based on weighted
the
that
when
Numbers of this article
of
patient cane To augment
of practice,
compiled 1992;
They
available
aspects
facets
objectives
range from prompt financial soundness. on operational
typi-
of operaaspects of
are important.
ACR master so-
they
these
to important
information
or three members was compiled.)
they
patient-related
profession,
However,
their
to provide Because
less knowledge organizational
practice.
and
trained
services.
of their
could
Radiology
are
ADIOLOGISTS
concentrate
pro-
radiologists departmental and radiologists,
and Business Groups
nadiologic
vides only radiation therapy for oncologic patients, and the remainder provides both types of services. Fortyone percent of groups practice only in hospitals, 11% practice only in an office, and 48% practice in both settings. Diagnostic-only practices average 10,000-12,000 procedures per fulltime equivalent radiologist per year. Groups typically require new members to be part of the group for almost 3 years before they become full partners. Formal call schedules are nearly universal among radiology groups. Groups are becoming increasingly involved with health maintenance organizations and other “alternative delivery systems,” but fee-for-service remains by far the dominant source of groups’ revenue. Most studied characteristics of groups are changing relatively slowly, and trends are generally toward increasing formalization of arrangements. Index terms: Radiology Radiology and radiologists, management #{149} Radiology cioeconomic issues
MS
Professional, ofRadiology States’
To learn the main operational, professional, and business characteristics of U.S. radiology group practices, researchers at the American College of Radiology surveyed these groups. Major findings included the following: Approximately 30% of groups provide only diagnostic radiologic services,
Bansal,
the
in Table
second
er2
is 1,309.
states that a difference + 1,3092)l 2 is required
significance.
to approximately
This
formula
3,300;
thus,
for
works the
dif-
ference of 1,900 is not statistically significant. The standard deviation is another figure often useful in describing and interpreting data. However, its easy use is largely con-
(5%)
Abbreviations: Radiology,
ACR FTE
=
=
full-time
American College equivalent.
of
535
fined
to normally
distributed
data,
that
is,
data with a bell-shaped curve. Many of the statistics in this article are skewed and have a long right-handed “tail,” that is, a few cases have very high values. (This situation
is common
medical care.) less informative
for
statistics
regarding
The standard deviation in this situation and
therefore is not reported here. ever, easily be calculated from dard error by multiplying the error by the square root of the cases
that
underlie
plc, in the entire responses
and
answer
the
for any
was provided
of the respondents.
statistic.
survey,
is
It can, howthe stanstandard number of For exam-
we had 915 valid given
question,
by about Thus,
an
80%-90%
for statistics
in-
volving all group sizes combined, the standard deviation would generally be approximately (0.85 x 915)1/2 or 28 times the standard error. RESULTS Operational
Characteristics
In 1989, almost half of U.S. radiology groups had two to four radiologists, almost one-fourth had five to seven radiologists, 12% had eight to 10 radiologists, and 14% had 11 or more radiologists (Table 1). This was approximately the same size distnbution of groups as that seen in 1986. Large groups were more likely than small groups to provide both diagnostic radiologic services and radiation therapy for oncologic patients. Among groups with two to seven radiologists, approximately one-third provided only diagnostic services, one-third provided only radiation therapy for oncologic patients, and one-third provided both services (Table 2). In contrast, among groups with eight on more radiologists, threefourths of those responding to the survey reported providing both diagnostic radiologic services and radiation therapy for oncologic patients. The average (mean) number of patients seen per year increased with group size. It was approximately 14,000 for groups with two to four 536
Radiology
#{149}
radiologists
but
almost
100,000
for
groups with 11 or more radiologists. For diagnostic-only practices, there was a similar pattern of increase in the number of services, ranging from an average of 36,000 procedures per year in groups with two to four radiologists to an average of 165,000 procedures per year in groups with 11 or more radiologists. However, the numben of procedures per year per radiologist was relatively constant. In diagnostic-only practices, there were 10,000-12,000
procedures
per
year
pen
FTE radiologist, regardless of group size. These per-physician productivity statistics have not changed much from what they were in 1986. Only 30% of groups with two to four radiologists practiced in both a hospital and an office, 55% were solely hospital based, and 16% were solely office based. In contrast, over 70%
of groups
diologists settings; fice-only one-fourth
with
eight
or more
ra-
practiced in both types of approximately 5% were ofpractices, and approximately were
hospital-only
prac-
tices. Statistics from the 1986 survey were similar. Larger groups operated at more sites than smaller ones, but the differences were less than those that might be expected. The average number of hospital locations for groups that had any hospital practice increased from 1.5 for groups with two to four radiologists
to 2.0 for
groups
with
11 or
more members. For groups with any office practice, there was a similar increase from 1.5 office sites for the groups with two to four radiologists to 3.1 office sites for the groups with 11 or more radiologists. Again, figures from 1986 were similar. The settings in which radiology groups most frequently practiced were private nonprofit hospitals (56% of groups practiced in this setting), private
nonprofit
offices
(36%
hospitals
of groups),
(25%),
public
freestand-
ing imaging plc-specialty groups
were
centers groups
(19%), (16%).
more
likely
and multiLarge
to practice
in
university teaching hospitals, government hospitals, and freestanding imaging centers than were small groups. Full-time female radiologists were somewhat concentrated in the groups with 1 1 or more radiologists. Women constituted 11% of the full-time staff in these groups compared with 7% or less
in smaller
Professional
groups.
Arrangements
In 1989, radiology groups typically required new members to be pant of the group for almost 3 years before they became full partners (Table 3). The time was slightly less (about 2 years)
in small
groups
and
slightly
more in large groups. A similar pattern was found in 1986. Physician involvement in practice management in 1989 was primarily through individual activity (71%) rather than committee work (24%). Individual activity was somewhat more important in smaller groups, whereas committee activity was cited as the mode of involvement 38% of the time in the largest groups (those with I 1 or more members). The percentage of groups with noncompetition clauses in their employment contract increased slightly with group size. (A noncompetition clause is an agreement that when the radiologist leaves the group, he or she will not practice in a location that competes with the group for a defined period, generally 2 years or less.)
In 1989,
the
percentage
of
groups with noncompetition clauses ranged from 52% for groups with two to four radiologists to 58% for groups with 11 on more radiologists. In each size category, the percentage of groups
with
noncompetition
was about five percentage higher in 1989 than it was
clauses
points in 1986. May
1992
Table 2 Operational
Characteristics
of Radiology
.
Groups
No. of Members
Item All
.
Operational Percentage
of groups
Diagnostic
therapy
No. of patients Mean
2-4
for oncologic
patients
37(3.1) only
Median No. of diagnostic Mean Median No. of diagnostic Mean
18(1.9)
10(0.4) 3(0.3) 87 (3.3)
30(2.8) 28(1.3) 42(2.9)
96,851 (6,210) %,000
32,098 (1,077) 28,000
Groups
Rate (%)
31(1.7)
30(1.8) 35(1.9)
33 (1.1)
35 (1.7)
21(1.0) 61 (4.7)
13,818
39,097
65,652
(569) 12,000
(1,311) 39,500
(3,504)
35,968 (4,219) 32,000
64,550 (2,833) 60,582
98,995 (7,704) 99,980
12,088 (1,058)
11,162
11,577 (465) 11,153
11,664 (879) 11,716
11,647
11,201
11,252
60
procedures
per FTE radiologist
procedures
per radiologist
62,000
63 164,887 (14,535)
147,439
54,716 (2,667) 55,000
per year
per
52 10,171 (1,309) 9,536
11,861 (493) 11,000
year
51
Median
9,111
(1,057)
(466)
(888)
10,667
10,714
11,222
(477) 9,258
11,445 (493) 10,510
55 (1.8) 16 (2.5) 30 (2.3)
35 (1.0)
22 (3.0)
27 (1.6)
41 (2.5)
9 (3.0)
4 (1.2)
5 (1.1)
11 (1.7)
56 (2.5)
74 (3.0)
68 (2.9)
48(1.4)
1.5 (0.1) 1.0
1.6 (0.1) 1.0
1.9 (0.1) 2.0
2.0 (0.2) 2.0
1.7(0.1) 1.0
1.5(0.1)
2.1(0.2)
2.9(0.1)
3.1(0.3)
1.8(0.1)
1.0
2.0
2.0
2.0
2.0
50 (2.3) 12 (1.5) 3(0.6) 26 (1.2) 3 (1.0) 27(3.1)
63 (7.4) 10 (2.7) 5(1.1) 29 (2.9) 6 (1.1) 36(0.3) 21 (0.7)
53 (3.0) 12 (0.9) 27(3.2) 20 (0.3) 12 (0.4) 50(2.1) 22 (1.7)
56 (3.1) 11 (0.9) 7(0.8) 2(2.9) 5(0.9) 36(3.9)
13 (1.4)
10 (0.9) 5(1.5)
19 (0.2) 5(0.5)
72 (5.6) 13 (0.8) 5(1.5) 18 (0.2) 4 (0.5) 58(9.1) 12 (0.4) 31 (0.7)
40 (2.5) 8(1.9)
19(1.3)
of practice
59
Percentage
in hospital
Percentage Percentage
in office only in hospital and
only office
No. of hospital locations for groups with hospital activity Mean Median No. of office locations for groups with office activity Mean Median Percentage of groups that practice Private nonprofit hospital Proprietary hospital University teaching hospital
Public
nonprofit
Government
Private
88
57
in a:
98*
hospital hospital
office
Multiple-specialty
Freestanding
group
imaging
center
Other No. of radiologists Full-time
of radiologists
84.8
error of groups
A mandatory
is given in parentheses. indicating location of at least
retirement
age
is
more common in large groups than in smaller ones, with 40% of groups with 11 or more members having a mandatory retirement age in 1989 compared with 10% of groups with two to four members. Figures were similar in In 1989,
about
54%
of the
groups with a mandatory retirement age set that age at 65 years, and 37% set it at 70 years. In 1986, age 65 years had been a more common mandatory 183
5.1 (0.1)
87.6
7.8 (0.1)
87.9
15.7(0.7)
83.0
5.6(0.2)
85.2
(men)
Mean Percentage of radiologists Full-time (women) Mean Percentage of radiologists Part-time (women) Mean Percentage of radiologists Note-Standard * Percentage
6(0.7)
89 2.5 (0.1)
Percentage Part-time
9(1.5)
16(0.3)
(men)
Mean
Volume
11
per year
Procedures in exclusively diagnostic practices No. of diagnostic procedures per year Mean
1986.
8-10
53
services only
Median
Location
5-7
performing:
radiologic
Radiation Both
Characteristic
Response
Number
#{149}
2
one
practice
0.2(0.1)
0.2(0.1)
0.4 (0.1)
0.7 (0.1)
0.3(0.1)
6.3
4.2
4.3
3.6
4.4
0.2 (0.1)
0.4 (0.1)
05 (0.1)
2.2 (0.3)
0.6(0.1)
7.1
6.2
5.4
0.1 (0.1) 1.8
0.1 (0.1) 2.0
0.2 (0.1) 2.4
11.4
0.4 (0.1) 2.0
8.4
0.2(0.1) 2.1
site.
age; about 70% of groups with a mandatory retirement age had used age 65 years, and only about 20% had used age 70 years. In 1989, formal call schedules were nearly universal in radiology groups. Eighty-seven percent of small groups
cialty) basis, except in the largest groups (11 or more members). In the largest groups, subspecialty and gencral organization are about equally common. Some groups use multiple bases of organization. Similar patterns of call organization were found in
(two
1986.
retirement
to four
members)
and
96%-98%
of larger groups had a formal call schedule. Groups with a formal call schedule predominantly organize it on a general (rather than subspc-
In 1989, approximately 36% of groups had a mandatory age at which radiologists stopped participating in the call schedule. This age was typiRadiology
#{149} 537
Table
3
Professional
Arrangements
Groups
of Radiology
ProfessionalArrangements
No. of years
2-4
No. of Members
Item
8-10
Response Rate (%)
5-7
All
11
for full partnership
84
Mean
2.4
Median
(0.1)
2.0
Involvement
2.7 (0.1)
3.0 (0.1)
3.2 (0.1)
2.7(0.1)
2.0
3.0
3.0
2.0
in management
Percentage
of individual
Percentage
of committee
95
Percentage of other Percentage with noncompetition contract Percentage
of groups
with
75 (3.5) 21 (2.3) 4 (0.3)
68 (3.2) 27 (1.9) 5 (0.1)
54 (3.9) 38 (4.5) 8 (0.3)
71 (3.9)
52 (1.0)
55 (2.0) 21 (2.1)
56 (1.2) 27 (3.3)
58 (1.0) 40 (4.1)
54 (2.3)
82
10 (2.1)
19 (2.1)
99
47 (1.2) 39 (2.1)
65 (6.5) 26 (3.1)
77 (1.0) 19 (3.0)
39 (1.2) 54 (2.1)
54(4.1)
87 (2.8)
97 (3.8)
96 (3.2)
98 (2.9)
92(4.2)
84 (1.3)
86 (4.2) 13 (0.7)
78 (2.8) 26 (0.6)
58 (1.6)
26 (0.9) 45 (1.2)
4 (0.1) 40 (4.5)
59 (2.1) 5 (2.2) 44 (3.8)
76 (3.8) 17 (1.0) 7(0.8) 36 (2.3)
64 (0.8) 65
62 (0.6) 64
62 (3.7) 65
63 (1.7) 60
63(0.6)
81 (7.8) 76 (4.8)
57 (3.6) 76 (8.9)
57 (4.5) 72 (5.6)
57 (6.7) 52 (3.6)
69 (2.9) 72 (8.3)
1.2 (0.1) 1.0
1.3 (0.1)
1.5 (0.3)
2.4 (1.9)
1.5(0.1)
1.0
1.0
2.0
1.0
is no longer of radiologists.
on call schedule.
24(2.1)
5(0.9)
in employment
clauses
mandatory
82 (4.6) 16 (0.3) 2 (0.5)
retirement
age
Mandatory
retirement age, if any Percentage set at 65 y Percentage set at 70 y Call schedule characteristics Percentage Organization Percentage
Percentage
92* 37 (3.9) 98
with formal call schedule of call schedule, if formal of general basis of subspecialty basis
Percentage of other Percentage of groups with mandatory
4 (2.1) 10 (4.1) 31 (0.5)
age for not
56
being on call schedule If yes, age (y) Mean
49t
Median Percentage
of those Percentage
that reduce compensation not on call schedule of groups with adequate no. of radiologists
If inadequate,
how many
needed?
Mean Median
Note.-Standard * Response t Response t Response
65
of groups
error rate among rate among rate among
is given in parentheses. practices with mandatory practices in which there practices reporting that
retirement age. is a mandatory age at which they do not have an adequate
the physician number
42t 99 83
cally about 65 years. About 69% of the groups reduced the radiologist’s cornpensation when participation in the call schedule stopped. Seventy-two percent of groups reported that they had an adequate number of radiologists; 28% said that they did not. A perceived shortage was more common among the largest groups. Specifically, 48% of groups with 11 or more members indicated that they did not have an adequate number of radiologists, whereas only
of the groups with two to four members reported an involvement with preferred provider organizations, and the figure was two-thirds for groups with eight or more members (Table 4). These figures were about 10 percentage points above corresponding statistics for 1986. Forty-one percent of groups had an involvement with individual practice associations in 1989. Again, involvement was somewhat more common for larger practices than for smaller
Overall, in 1989, groups reported that 32% of radiologic procedures were for medicare patients; 76% of groups reported accepting medicare assignment. (The survey did not ascertain the frequency with which they accepted assignments.) Medicare program data show more “participation” (ie, agreement in advance always to accept assignment during the coming year) in 1989 than in earher years (1). Medicare reports 50% of radiology groups were participating
24%-28%
ones
in 1989.
of groups
with
fewer
rnem-
bers reported this situation. Groups reporting an inadequate number of radiologists typically reported a need for one more radiologist. However, groups with 11 on more members typically reported needing two more radiologists.
.
Business
Arrangements
Radiologists are becoming increasingly involved with health maintenance organizations and other alternative delivery systems. Involvement with preferred provider organizations is most common. In 1989, almost half 538
Radiology
#{149}
and
was
generally
about
10 per-
centage points higher in 1989 than it was in 1986. In contrast, involvement with health maintenance organizations was more common among small groups (42% for groups with two to four members) than it was for larger groups (18% for groups with 11 or more members). Despite radiologists’ growing involvement with alternative delivery .
As would be expected, large groups more commonly have a full-time business manager than do small groups. Fifty-one percent of groups with two to four members had a business managen in 1989, whereas 75% of groups with eight on more members had one. There has been some growth since 1986 in the percentage of groups with a business manager, particularly
.
systems, fee for service remains the dominant source of their income, with 92% of the groups’ income derived from this form of payment in 1989. Most groups reported that 100% of their income is derived from fee for service.
among groups with two to four members, for which the figure increased by eight percentage points. Billing methods for office services have also changed since 1986. Inhouse computers have become more common, in-house manual systems May
1992
Table 4 Business
Arrangements
of Radiology
Groups Item Response Rate (%)
No. of Members Business
Arrangements
2-4
Percentage involved with: HMOs PPOs 1PM Percentage of revenue from*: Fee for service Mean Median
5-7
11
8-40
All
92 42 (2.1)
25 (1.6)
15 (0.9)
18 (1.1)
35(2.4)
46 (1.5) 34 (5.8)
52 (2.2) 42 (3.1)
68 (5.1) 59 (6.7)
65 (2.0) 48 (3.2)
53(6.3) 41 (5.2) 72t
97 (0.8)
92 (1.6)
100
100
2 (0.7) 0.0
0.0
% (1.6)
88 (2.3)
92(0.8)
100
100
100
3 (1.5) 0.0
8 (2.1) 0.0
5(0.7) 0.0
Salary
Mean Median Other Mean
1 (0.4)
Median Percentage of procedures Mean Median Percentage
of groups
Percentage of Billing methods Percentage Percentage Percentage Billing methods Percentage Percentage Percentage Percentage
performed
that
accept
for medicare
medicare
Percentage
of claims
assignment
of groups
0.0
35 (1.0) 35
34 (1.2) 34
33 (1.3) 34
28 (0.9) 30
75 (4.2) 51 (2.2)
74 (3.8) 62 (3.1)
84 (1.8) 75 (1.0)
77(2.2) 76 (2.0)
32(0.5) 33 76 (1.1)
95
60 (2.1)
99
66 (4.0)
74 (3.2)
75 (0.8)
74 (3.4)
70 (3.2)
95 7 (2.0)
2 (0.9)
1 (0.4)
0 (0.0)
4(0.6)
27 (1.0)
24 (2.1)
24 (2.7)
26 (1.5)
26(4.1)
28 38 13 21
32 40 8 20
(1.9)
37 (2.8)
31 (1.7)
(2.0)
28 (2.6)
(1.1) (1.6)
13 (1.9) 23 (2.4)
37 31 10 23
5 (1.1)
37 (3.1)
40 (5.2)
46 (5.6)
95 (1.8)
63 (1.5)
60
54
92 (1.4) (4.8) (3.5) (1.3)
maintenance
organizations,
PPOs
=
preferred
provider
nate and number of FTE radiologists so that figures but only 72% responded with figures that added rate and number of FIt radiologists so that figures
were
using
more members verse pattern that did their
a
seven
organizations,
reflect
IPAs
percentage
up to approximately reflect
percentage
manually.
computers
were
groups 74%
with or
used
two
by
to four
of groups
75%
The
using indepenwas fairly simsizes. In-house 66%
of
members with
five
and or
=
(almost 30%). The rewas found for groups own billing. Thirty-
percent
of groups
with
eight
or
“claims
billed
36(2.0)
12(2.5) 21 (1.9)
made”
type
were
(2.9)
individual
36(1.1) 64(4.1)
(2.0)
practice
associations.
Standard
error
is
of all revenue of practices in size category. 100% for all sources of compensation. of all procedures of practices in size category.
these
of groups companies all group
(2.5) (2.5) (1.6) (2.3)
86
more members did their own billing for hospital services compared with 30% of groups with fewer than eight members. Professional liability policies of the
groups
3(0.4)
0.0
computer; 26%, an independent billing company; and 4%, an in-house manual system. Manual billing was found almost only among small groups (two to four members); 7% of percentage dent billing ilar among
5 (1.2)
0.0
type
are rapidly disappearing, and mdcpendent billing companies are being used somewhat less frequently. In 70%
1 (0.5)
0.0
56
made
Note.-HMOs = health given in parentheses. * Weighted by sampling t In total, 79% responded, Weighted by sampling
1 (0.3)
0.0 patients*
groups with full-time business manager in office using in-house computer using in-house manual billing using independent billing company in hospital using group billing using independent billing company using hospital billing using other methods
Pnofessionalliability policy Percentage of occurrence
1989,
7 (1.6)
more
corn-
about the time period before members of a group become or the number of procedures formed
by
a typical
new partners per-
radiologist
in a
year. A search of the journal literature disclosed no data on the topics in this article. We expect, therefore, that the data reported here have substantial value to radiologists. Limitations
of these
data,
however,
mon in 1989 than “occurrence” type policies. Sixty-four percent of groups had the former policies, whereas 36%
should be recognized. First, our data arc broad averages and thus do not reflect special situations that may cx-
had
ist in particular
the
policy one
latter.
types end
However,
varied
of the
the
by group
spectrum,
95%
mix
size.
of
At
of
ond, which
the
radiology
figures
is not
groups.
represent
Sec-
what
necessarily
the
is,
same
as
more members. Billing arrangements for services provided at hospitals were quite diffcrent. In 1989, 31% of groups billed directly for services rendered at hospitals, 36% used an independent bill-
groups with two to four members had claims-made policies, with only 5% having occurrence policies. In contrast, among groups with 11 or more members, claims-made policies predominated by only a small amount
what should be, what is logical, or what is efficient. Third, as with all data based on samples, our data are subject to sampling error and nesponse bias. In particular, the limited response rate achieved in the survey
ing
relative
raises
company,
12%
done for them 21 % had other with
fewer
had
their
billing
by the hospital, arrangements.
than
eight
and Groups
183
Number
#{149}
policies.
DISCUSSION
radiologists
used independent billing companies for hospital billing somewhat more often (39%) than groups with eight Volume
to occurrence
2
ment
or
The data reported are of major interest to radiologists. For example, ACR staff receive numerous inquiries
concerns
about
possible
re-
sponse bias, although this concern is somewhat allayed by the good agreebetween
data
from
the
survey
that are not included in this article and an independent survey of hospital radiology departments (2). Radiolov
#{149} 539
Finally, some responses did not make sense, and results have been presented consistently with the limitations of responses. For example, we deleted from the tabulations on sources of income (Table 4) the roughly 6% of questionnaires on which the various income sources did not add up to approximately 100%. Despite these limitations, we believe we have presented an extensive body of important data on radiology group practices. CONCLUSIONS One interesting broad uniformity emerges: Most organizational, professional, and business characteristics of radiology groups change rather slowly, with groups’ operational characteristics being particularly stable. This is the implication of the generally small differences found when the 1989 Group Practice Survey is cornpared with the 1986 survey. The stability
of groups’
characteristics,
partic-
ularly of operational characteristics, contrasts notably with the rapid changes in technology seen in radiology-for example, the recent advent of the wide-scale use of magnetic resonance imaging. Although cross-sectional imaging equipment is far more
540
Radiolosrv
#{149}
expensive than equipment for older technologies, its rapid spread apparently is not causing radiologists to join together into larger groups in which there would be more practitio-
In any case, ben of additional
ners
programs
available
to share
its costs.
The limited changes that we found were generally toward greater formalization and more “businesslike” anrangements. For example, we found more noncompetition clauses in cmployment contracts, expanded use of business managers, and the disappearance of manual billing. Future group practice surveys will continue to track the pace and direction of change. Also, they will be conducted with methods that should improve response rates. The implication of groups’ statements on the adequacy of their staffing is interesting. The fact that groups with 11 or more members were more likely to report having an inadequate number of radiologists than were smaller groups may only reflect that a staffing shortfall of a few percent looks different to large groups than it does to small groups. For large groups, such a shortage may amount to a substantial percentage of an FTE and be perceived as a staffing shortage, whereas in small groups, it amounts to only a small fraction of an FTE and the group probably does not perceive itself as needing another radiologist.
groups
say
proximately the output
nationwide, radiologists
they
would
1,100, of U.S. oncology
numthat
totals
ap-
which is less than radiology residency
(diagnostic
radiation
like
the
radiology
and
combined)
in I
year. Moreover, 1,100 is probably a substantial overestimate of actual employment opportunities for radiologists, since another study we have
under ally
way recruit
shows for
that
groups
considerably
actufewer
ra-
diologists than they say they would like to add. Clearly, in 1989, there was no large-scale shortage of radiologists.
U
Acknowledgments:
MD, and Millard ership of the ACR that oversaw the ela J. Kassing for survey; and Dana drafts and tables
We thankJ.
Owsley, leadcommittee and commission survey; Elise Bernal and Pamtheir extensive work on the Friedman for typing the in the manuscript.
C. Spencer,
Hal
MD, for their
References 1.
2.
Ways and Means Committee, U.S. House of Representatives. Medicare reimbursement to physicians: overview of entitlement programs. Washington, DC: Government Printing Office (Ways and Means Committee print 102-9), 1991; 425. Kirschner LB. AHRA survey: staff utilizalion. I. Radiol Manage 1989; 11:55-67.
May
1992
H. Sunshine,
PhD
Swati
#{149}
Operational, Characteristics in the United
a similar
percentage
R aspect
on this
cally have tional and work
tribute
and
This
principal
findings
the
ACR
regarding
fessional, of U.S.
business group
every
The
1989
designed
Group
by
the
provide.
The
to all 2,591
were
From
the Department of Research, American of Radiology, 1891 Preston White Dr, Reston, VA 22091. Received September 23, 1991; revision requested October 29; revision received December 10; accepted December 30. Address reprint requests to J.H.S. Further data, including more detailed tables, are available from the authors. ‘ RSNA, 1992
was
consisting
on the
one
master
list had
in the
middle
of 1988
radiologist by
each
and
tween
one
follow-up
June
963 responses 37% of the
and
group
mailing
October
were sample.
would
be
occurred
1989.
groups
of
Standard tables
in a category
of the
actual
errors have been and are a measure
of a statistic
re-
given remix
of
included in of the uncer-
as a result
of sampling.
that
diagnostic-only
bewas 48
were “out-of-sample,” that is, they were not multiple-member radiology groups. (Most out-of-sample responses were from solo practices that had had two
practices
radiologists per full-time per
year
averaged equivalent
compared
with
12,088 (FTE)
with
10,171
procedures per FTE radiologist per year in practices with 11 or more radiologists. The question is whether this difference of approximately 1,900 procedures per FTE ra-
as
per
1,058
year
is real.
first figure
and
that
statistical
The
standard
is shown
for
Thus, the formula of 1.96 x (1,0582 out
to
Altogether,
received, which Of the responses,
number
their responses were to make the weighted
ror for the
ade-
responses were An original mailing of the 2,591 groups
estimated
and weight
diologist
been asking
all ACR members what group they belonged to and who all the members of the group were. The ACR indicated that one from
of re-
of the
radiologist
practices;
of only
The
the
11 or
number
sponded, a larger
two to four procedures
was
practices
to 10, and
the
centage
shows
department
form
each
The difference between two figures is regarded as statistically significant at 5% if the difference equals at least 1.96 x (a2 + b2) 2 where a is the standard error of the first figure and b is the standard error of the second figure. For example, Table 2
range of ACR and departinformation it
survey
eight
groups,
the
Survey
within
of in
actual groups, and the weights used in each of the four census regions and the four size categories. A relatively large weight means that a below-average per-
the Group the ACR con-
research
of what
U.S. radiol-
The basis of groups
and,
I shows
sponses representative U.S. groups.
Practice
group
quate, and duplicate counted only once. the group president I
pro-
tables tabu-
of groups in each of (two to four radiolo-
to seven,
Table
list
estimate
regions
characteristics practices.
list of U.S. radiology
excluded.
response
College
pre-
METHODS
with input from a broad committees, commissions, ments interested in the
practices
a and
of the
AND
an
be if every
responded. the number
census
five
tainty
ACR
had was
sponding
3 years.
MATERIALS
gists,
Col-
article
Data come chiefly from Practice Survey, which ducts
four
more).
the operational,
and radiology
mailed
183:535-540
the
American
activities.
sents
would
region, the number four size categories
lege of Radiology (ACR) undertakes number of information-gathering research
represent
the
organizational the
and
findings
con-
to radiologists
master
lations
ogy group weighting
to
the
shown in the text and are based on weighted
the
that
when
Numbers of this article
of
patient cane To augment
of practice,
compiled 1992;
They
available
aspects
facets
objectives
range from prompt financial soundness. on operational
typi-
of operaaspects of
are important.
ACR master so-
they
these
to important
information
or three members was compiled.)
they
patient-related
profession,
However,
their
to provide Because
less knowledge organizational
practice.
and
trained
services.
of their
could
Radiology
are
ADIOLOGISTS
concentrate
pro-
radiologists departmental and radiologists,
and Business Groups
nadiologic
vides only radiation therapy for oncologic patients, and the remainder provides both types of services. Fortyone percent of groups practice only in hospitals, 11% practice only in an office, and 48% practice in both settings. Diagnostic-only practices average 10,000-12,000 procedures per fulltime equivalent radiologist per year. Groups typically require new members to be part of the group for almost 3 years before they become full partners. Formal call schedules are nearly universal among radiology groups. Groups are becoming increasingly involved with health maintenance organizations and other “alternative delivery systems,” but fee-for-service remains by far the dominant source of groups’ revenue. Most studied characteristics of groups are changing relatively slowly, and trends are generally toward increasing formalization of arrangements. Index terms: Radiology Radiology and radiologists, management #{149} Radiology cioeconomic issues
MS
Professional, ofRadiology States’
To learn the main operational, professional, and business characteristics of U.S. radiology group practices, researchers at the American College of Radiology surveyed these groups. Major findings included the following: Approximately 30% of groups provide only diagnostic radiologic services,
Bansal,
the
in Table
second
er2
is 1,309.
states that a difference + 1,3092)l 2 is required
significance.
to approximately
This
formula
3,300;
thus,
for
works the
dif-
ference of 1,900 is not statistically significant. The standard deviation is another figure often useful in describing and interpreting data. However, its easy use is largely con-
(5%)
Abbreviations: Radiology,
ACR FTE
=
=
full-time
American College equivalent.
of
535
fined
to normally
distributed
data,
that
is,
data with a bell-shaped curve. Many of the statistics in this article are skewed and have a long right-handed “tail,” that is, a few cases have very high values. (This situation
is common
medical care.) less informative
for
statistics
regarding
The standard deviation in this situation and
therefore is not reported here. ever, easily be calculated from dard error by multiplying the error by the square root of the cases
that
underlie
plc, in the entire responses
and
answer
the
for any
was provided
of the respondents.
statistic.
survey,
is
It can, howthe stanstandard number of For exam-
we had 915 valid given
question,
by about Thus,
an
80%-90%
for statistics
in-
volving all group sizes combined, the standard deviation would generally be approximately (0.85 x 915)1/2 or 28 times the standard error. RESULTS Operational
Characteristics
In 1989, almost half of U.S. radiology groups had two to four radiologists, almost one-fourth had five to seven radiologists, 12% had eight to 10 radiologists, and 14% had 11 or more radiologists (Table 1). This was approximately the same size distnbution of groups as that seen in 1986. Large groups were more likely than small groups to provide both diagnostic radiologic services and radiation therapy for oncologic patients. Among groups with two to seven radiologists, approximately one-third provided only diagnostic services, one-third provided only radiation therapy for oncologic patients, and one-third provided both services (Table 2). In contrast, among groups with eight on more radiologists, threefourths of those responding to the survey reported providing both diagnostic radiologic services and radiation therapy for oncologic patients. The average (mean) number of patients seen per year increased with group size. It was approximately 14,000 for groups with two to four 536
Radiology
#{149}
radiologists
but
almost
100,000
for
groups with 11 or more radiologists. For diagnostic-only practices, there was a similar pattern of increase in the number of services, ranging from an average of 36,000 procedures per year in groups with two to four radiologists to an average of 165,000 procedures per year in groups with 11 or more radiologists. However, the numben of procedures per year per radiologist was relatively constant. In diagnostic-only practices, there were 10,000-12,000
procedures
per
year
pen
FTE radiologist, regardless of group size. These per-physician productivity statistics have not changed much from what they were in 1986. Only 30% of groups with two to four radiologists practiced in both a hospital and an office, 55% were solely hospital based, and 16% were solely office based. In contrast, over 70%
of groups
diologists settings; fice-only one-fourth
with
eight
or more
ra-
practiced in both types of approximately 5% were ofpractices, and approximately were
hospital-only
prac-
tices. Statistics from the 1986 survey were similar. Larger groups operated at more sites than smaller ones, but the differences were less than those that might be expected. The average number of hospital locations for groups that had any hospital practice increased from 1.5 for groups with two to four radiologists
to 2.0 for
groups
with
11 or
more members. For groups with any office practice, there was a similar increase from 1.5 office sites for the groups with two to four radiologists to 3.1 office sites for the groups with 11 or more radiologists. Again, figures from 1986 were similar. The settings in which radiology groups most frequently practiced were private nonprofit hospitals (56% of groups practiced in this setting), private
nonprofit
offices
(36%
hospitals
of groups),
(25%),
public
freestand-
ing imaging plc-specialty groups
were
centers groups
(19%), (16%).
more
likely
and multiLarge
to practice
in
university teaching hospitals, government hospitals, and freestanding imaging centers than were small groups. Full-time female radiologists were somewhat concentrated in the groups with 1 1 or more radiologists. Women constituted 11% of the full-time staff in these groups compared with 7% or less
in smaller
Professional
groups.
Arrangements
In 1989, radiology groups typically required new members to be pant of the group for almost 3 years before they became full partners (Table 3). The time was slightly less (about 2 years)
in small
groups
and
slightly
more in large groups. A similar pattern was found in 1986. Physician involvement in practice management in 1989 was primarily through individual activity (71%) rather than committee work (24%). Individual activity was somewhat more important in smaller groups, whereas committee activity was cited as the mode of involvement 38% of the time in the largest groups (those with I 1 or more members). The percentage of groups with noncompetition clauses in their employment contract increased slightly with group size. (A noncompetition clause is an agreement that when the radiologist leaves the group, he or she will not practice in a location that competes with the group for a defined period, generally 2 years or less.)
In 1989,
the
percentage
of
groups with noncompetition clauses ranged from 52% for groups with two to four radiologists to 58% for groups with 11 on more radiologists. In each size category, the percentage of groups
with
noncompetition
was about five percentage higher in 1989 than it was
clauses
points in 1986. May
1992
Table 2 Operational
Characteristics
of Radiology
.
Groups
No. of Members
Item All
.
Operational Percentage
of groups
Diagnostic
therapy
No. of patients Mean
2-4
for oncologic
patients
37(3.1) only
Median No. of diagnostic Mean Median No. of diagnostic Mean
18(1.9)
10(0.4) 3(0.3) 87 (3.3)
30(2.8) 28(1.3) 42(2.9)
96,851 (6,210) %,000
32,098 (1,077) 28,000
Groups
Rate (%)
31(1.7)
30(1.8) 35(1.9)
33 (1.1)
35 (1.7)
21(1.0) 61 (4.7)
13,818
39,097
65,652
(569) 12,000
(1,311) 39,500
(3,504)
35,968 (4,219) 32,000
64,550 (2,833) 60,582
98,995 (7,704) 99,980
12,088 (1,058)
11,162
11,577 (465) 11,153
11,664 (879) 11,716
11,647
11,201
11,252
60
procedures
per FTE radiologist
procedures
per radiologist
62,000
63 164,887 (14,535)
147,439
54,716 (2,667) 55,000
per year
per
52 10,171 (1,309) 9,536
11,861 (493) 11,000
year
51
Median
9,111
(1,057)
(466)
(888)
10,667
10,714
11,222
(477) 9,258
11,445 (493) 10,510
55 (1.8) 16 (2.5) 30 (2.3)
35 (1.0)
22 (3.0)
27 (1.6)
41 (2.5)
9 (3.0)
4 (1.2)
5 (1.1)
11 (1.7)
56 (2.5)
74 (3.0)
68 (2.9)
48(1.4)
1.5 (0.1) 1.0
1.6 (0.1) 1.0
1.9 (0.1) 2.0
2.0 (0.2) 2.0
1.7(0.1) 1.0
1.5(0.1)
2.1(0.2)
2.9(0.1)
3.1(0.3)
1.8(0.1)
1.0
2.0
2.0
2.0
2.0
50 (2.3) 12 (1.5) 3(0.6) 26 (1.2) 3 (1.0) 27(3.1)
63 (7.4) 10 (2.7) 5(1.1) 29 (2.9) 6 (1.1) 36(0.3) 21 (0.7)
53 (3.0) 12 (0.9) 27(3.2) 20 (0.3) 12 (0.4) 50(2.1) 22 (1.7)
56 (3.1) 11 (0.9) 7(0.8) 2(2.9) 5(0.9) 36(3.9)
13 (1.4)
10 (0.9) 5(1.5)
19 (0.2) 5(0.5)
72 (5.6) 13 (0.8) 5(1.5) 18 (0.2) 4 (0.5) 58(9.1) 12 (0.4) 31 (0.7)
40 (2.5) 8(1.9)
19(1.3)
of practice
59
Percentage
in hospital
Percentage Percentage
in office only in hospital and
only office
No. of hospital locations for groups with hospital activity Mean Median No. of office locations for groups with office activity Mean Median Percentage of groups that practice Private nonprofit hospital Proprietary hospital University teaching hospital
Public
nonprofit
Government
Private
88
57
in a:
98*
hospital hospital
office
Multiple-specialty
Freestanding
group
imaging
center
Other No. of radiologists Full-time
of radiologists
84.8
error of groups
A mandatory
is given in parentheses. indicating location of at least
retirement
age
is
more common in large groups than in smaller ones, with 40% of groups with 11 or more members having a mandatory retirement age in 1989 compared with 10% of groups with two to four members. Figures were similar in In 1989,
about
54%
of the
groups with a mandatory retirement age set that age at 65 years, and 37% set it at 70 years. In 1986, age 65 years had been a more common mandatory 183
5.1 (0.1)
87.6
7.8 (0.1)
87.9
15.7(0.7)
83.0
5.6(0.2)
85.2
(men)
Mean Percentage of radiologists Full-time (women) Mean Percentage of radiologists Part-time (women) Mean Percentage of radiologists Note-Standard * Percentage
6(0.7)
89 2.5 (0.1)
Percentage Part-time
9(1.5)
16(0.3)
(men)
Mean
Volume
11
per year
Procedures in exclusively diagnostic practices No. of diagnostic procedures per year Mean
1986.
8-10
53
services only
Median
Location
5-7
performing:
radiologic
Radiation Both
Characteristic
Response
Number
#{149}
2
one
practice
0.2(0.1)
0.2(0.1)
0.4 (0.1)
0.7 (0.1)
0.3(0.1)
6.3
4.2
4.3
3.6
4.4
0.2 (0.1)
0.4 (0.1)
05 (0.1)
2.2 (0.3)
0.6(0.1)
7.1
6.2
5.4
0.1 (0.1) 1.8
0.1 (0.1) 2.0
0.2 (0.1) 2.4
11.4
0.4 (0.1) 2.0
8.4
0.2(0.1) 2.1
site.
age; about 70% of groups with a mandatory retirement age had used age 65 years, and only about 20% had used age 70 years. In 1989, formal call schedules were nearly universal in radiology groups. Eighty-seven percent of small groups
cialty) basis, except in the largest groups (11 or more members). In the largest groups, subspecialty and gencral organization are about equally common. Some groups use multiple bases of organization. Similar patterns of call organization were found in
(two
1986.
retirement
to four
members)
and
96%-98%
of larger groups had a formal call schedule. Groups with a formal call schedule predominantly organize it on a general (rather than subspc-
In 1989, approximately 36% of groups had a mandatory age at which radiologists stopped participating in the call schedule. This age was typiRadiology
#{149} 537
Table
3
Professional
Arrangements
Groups
of Radiology
ProfessionalArrangements
No. of years
2-4
No. of Members
Item
8-10
Response Rate (%)
5-7
All
11
for full partnership
84
Mean
2.4
Median
(0.1)
2.0
Involvement
2.7 (0.1)
3.0 (0.1)
3.2 (0.1)
2.7(0.1)
2.0
3.0
3.0
2.0
in management
Percentage
of individual
Percentage
of committee
95
Percentage of other Percentage with noncompetition contract Percentage
of groups
with
75 (3.5) 21 (2.3) 4 (0.3)
68 (3.2) 27 (1.9) 5 (0.1)
54 (3.9) 38 (4.5) 8 (0.3)
71 (3.9)
52 (1.0)
55 (2.0) 21 (2.1)
56 (1.2) 27 (3.3)
58 (1.0) 40 (4.1)
54 (2.3)
82
10 (2.1)
19 (2.1)
99
47 (1.2) 39 (2.1)
65 (6.5) 26 (3.1)
77 (1.0) 19 (3.0)
39 (1.2) 54 (2.1)
54(4.1)
87 (2.8)
97 (3.8)
96 (3.2)
98 (2.9)
92(4.2)
84 (1.3)
86 (4.2) 13 (0.7)
78 (2.8) 26 (0.6)
58 (1.6)
26 (0.9) 45 (1.2)
4 (0.1) 40 (4.5)
59 (2.1) 5 (2.2) 44 (3.8)
76 (3.8) 17 (1.0) 7(0.8) 36 (2.3)
64 (0.8) 65
62 (0.6) 64
62 (3.7) 65
63 (1.7) 60
63(0.6)
81 (7.8) 76 (4.8)
57 (3.6) 76 (8.9)
57 (4.5) 72 (5.6)
57 (6.7) 52 (3.6)
69 (2.9) 72 (8.3)
1.2 (0.1) 1.0
1.3 (0.1)
1.5 (0.3)
2.4 (1.9)
1.5(0.1)
1.0
1.0
2.0
1.0
is no longer of radiologists.
on call schedule.
24(2.1)
5(0.9)
in employment
clauses
mandatory
82 (4.6) 16 (0.3) 2 (0.5)
retirement
age
Mandatory
retirement age, if any Percentage set at 65 y Percentage set at 70 y Call schedule characteristics Percentage Organization Percentage
Percentage
92* 37 (3.9) 98
with formal call schedule of call schedule, if formal of general basis of subspecialty basis
Percentage of other Percentage of groups with mandatory
4 (2.1) 10 (4.1) 31 (0.5)
age for not
56
being on call schedule If yes, age (y) Mean
49t
Median Percentage
of those Percentage
that reduce compensation not on call schedule of groups with adequate no. of radiologists
If inadequate,
how many
needed?
Mean Median
Note.-Standard * Response t Response t Response
65
of groups
error rate among rate among rate among
is given in parentheses. practices with mandatory practices in which there practices reporting that
retirement age. is a mandatory age at which they do not have an adequate
the physician number
42t 99 83
cally about 65 years. About 69% of the groups reduced the radiologist’s cornpensation when participation in the call schedule stopped. Seventy-two percent of groups reported that they had an adequate number of radiologists; 28% said that they did not. A perceived shortage was more common among the largest groups. Specifically, 48% of groups with 11 or more members indicated that they did not have an adequate number of radiologists, whereas only
of the groups with two to four members reported an involvement with preferred provider organizations, and the figure was two-thirds for groups with eight or more members (Table 4). These figures were about 10 percentage points above corresponding statistics for 1986. Forty-one percent of groups had an involvement with individual practice associations in 1989. Again, involvement was somewhat more common for larger practices than for smaller
Overall, in 1989, groups reported that 32% of radiologic procedures were for medicare patients; 76% of groups reported accepting medicare assignment. (The survey did not ascertain the frequency with which they accepted assignments.) Medicare program data show more “participation” (ie, agreement in advance always to accept assignment during the coming year) in 1989 than in earher years (1). Medicare reports 50% of radiology groups were participating
24%-28%
ones
in 1989.
of groups
with
fewer
rnem-
bers reported this situation. Groups reporting an inadequate number of radiologists typically reported a need for one more radiologist. However, groups with 11 on more members typically reported needing two more radiologists.
.
Business
Arrangements
Radiologists are becoming increasingly involved with health maintenance organizations and other alternative delivery systems. Involvement with preferred provider organizations is most common. In 1989, almost half 538
Radiology
#{149}
and
was
generally
about
10 per-
centage points higher in 1989 than it was in 1986. In contrast, involvement with health maintenance organizations was more common among small groups (42% for groups with two to four members) than it was for larger groups (18% for groups with 11 or more members). Despite radiologists’ growing involvement with alternative delivery .
As would be expected, large groups more commonly have a full-time business manager than do small groups. Fifty-one percent of groups with two to four members had a business managen in 1989, whereas 75% of groups with eight on more members had one. There has been some growth since 1986 in the percentage of groups with a business manager, particularly
.
systems, fee for service remains the dominant source of their income, with 92% of the groups’ income derived from this form of payment in 1989. Most groups reported that 100% of their income is derived from fee for service.
among groups with two to four members, for which the figure increased by eight percentage points. Billing methods for office services have also changed since 1986. Inhouse computers have become more common, in-house manual systems May
1992
Table 4 Business
Arrangements
of Radiology
Groups Item Response Rate (%)
No. of Members Business
Arrangements
2-4
Percentage involved with: HMOs PPOs 1PM Percentage of revenue from*: Fee for service Mean Median
5-7
11
8-40
All
92 42 (2.1)
25 (1.6)
15 (0.9)
18 (1.1)
35(2.4)
46 (1.5) 34 (5.8)
52 (2.2) 42 (3.1)
68 (5.1) 59 (6.7)
65 (2.0) 48 (3.2)
53(6.3) 41 (5.2) 72t
97 (0.8)
92 (1.6)
100
100
2 (0.7) 0.0
0.0
% (1.6)
88 (2.3)
92(0.8)
100
100
100
3 (1.5) 0.0
8 (2.1) 0.0
5(0.7) 0.0
Salary
Mean Median Other Mean
1 (0.4)
Median Percentage of procedures Mean Median Percentage
of groups
Percentage of Billing methods Percentage Percentage Percentage Billing methods Percentage Percentage Percentage Percentage
performed
that
accept
for medicare
medicare
Percentage
of claims
assignment
of groups
0.0
35 (1.0) 35
34 (1.2) 34
33 (1.3) 34
28 (0.9) 30
75 (4.2) 51 (2.2)
74 (3.8) 62 (3.1)
84 (1.8) 75 (1.0)
77(2.2) 76 (2.0)
32(0.5) 33 76 (1.1)
95
60 (2.1)
99
66 (4.0)
74 (3.2)
75 (0.8)
74 (3.4)
70 (3.2)
95 7 (2.0)
2 (0.9)
1 (0.4)
0 (0.0)
4(0.6)
27 (1.0)
24 (2.1)
24 (2.7)
26 (1.5)
26(4.1)
28 38 13 21
32 40 8 20
(1.9)
37 (2.8)
31 (1.7)
(2.0)
28 (2.6)
(1.1) (1.6)
13 (1.9) 23 (2.4)
37 31 10 23
5 (1.1)
37 (3.1)
40 (5.2)
46 (5.6)
95 (1.8)
63 (1.5)
60
54
92 (1.4) (4.8) (3.5) (1.3)
maintenance
organizations,
PPOs
=
preferred
provider
nate and number of FTE radiologists so that figures but only 72% responded with figures that added rate and number of FIt radiologists so that figures
were
using
more members verse pattern that did their
a
seven
organizations,
reflect
IPAs
percentage
up to approximately reflect
percentage
manually.
computers
were
groups 74%
with or
used
two
by
to four
of groups
75%
The
using indepenwas fairly simsizes. In-house 66%
of
members with
five
and or
=
(almost 30%). The rewas found for groups own billing. Thirty-
percent
of groups
with
eight
or
“claims
billed
36(2.0)
12(2.5) 21 (1.9)
made”
type
were
(2.9)
individual
36(1.1) 64(4.1)
(2.0)
practice
associations.
Standard
error
is
of all revenue of practices in size category. 100% for all sources of compensation. of all procedures of practices in size category.
these
of groups companies all group
(2.5) (2.5) (1.6) (2.3)
86
more members did their own billing for hospital services compared with 30% of groups with fewer than eight members. Professional liability policies of the
groups
3(0.4)
0.0
computer; 26%, an independent billing company; and 4%, an in-house manual system. Manual billing was found almost only among small groups (two to four members); 7% of percentage dent billing ilar among
5 (1.2)
0.0
type
are rapidly disappearing, and mdcpendent billing companies are being used somewhat less frequently. In 70%
1 (0.5)
0.0
56
made
Note.-HMOs = health given in parentheses. * Weighted by sampling t In total, 79% responded, Weighted by sampling
1 (0.3)
0.0 patients*
groups with full-time business manager in office using in-house computer using in-house manual billing using independent billing company in hospital using group billing using independent billing company using hospital billing using other methods
Pnofessionalliability policy Percentage of occurrence
1989,
7 (1.6)
more
corn-
about the time period before members of a group become or the number of procedures formed
by
a typical
new partners per-
radiologist
in a
year. A search of the journal literature disclosed no data on the topics in this article. We expect, therefore, that the data reported here have substantial value to radiologists. Limitations
of these
data,
however,
mon in 1989 than “occurrence” type policies. Sixty-four percent of groups had the former policies, whereas 36%
should be recognized. First, our data arc broad averages and thus do not reflect special situations that may cx-
had
ist in particular
the
policy one
latter.
types end
However,
varied
of the
the
by group
spectrum,
95%
mix
size.
of
At
of
ond, which
the
radiology
figures
is not
groups.
represent
Sec-
what
necessarily
the
is,
same
as
more members. Billing arrangements for services provided at hospitals were quite diffcrent. In 1989, 31% of groups billed directly for services rendered at hospitals, 36% used an independent bill-
groups with two to four members had claims-made policies, with only 5% having occurrence policies. In contrast, among groups with 11 or more members, claims-made policies predominated by only a small amount
what should be, what is logical, or what is efficient. Third, as with all data based on samples, our data are subject to sampling error and nesponse bias. In particular, the limited response rate achieved in the survey
ing
relative
raises
company,
12%
done for them 21 % had other with
fewer
had
their
billing
by the hospital, arrangements.
than
eight
and Groups
183
Number
#{149}
policies.
DISCUSSION
radiologists
used independent billing companies for hospital billing somewhat more often (39%) than groups with eight Volume
to occurrence
2
ment
or
The data reported are of major interest to radiologists. For example, ACR staff receive numerous inquiries
concerns
about
possible
re-
sponse bias, although this concern is somewhat allayed by the good agreebetween
data
from
the
survey
that are not included in this article and an independent survey of hospital radiology departments (2). Radiolov
#{149} 539
Finally, some responses did not make sense, and results have been presented consistently with the limitations of responses. For example, we deleted from the tabulations on sources of income (Table 4) the roughly 6% of questionnaires on which the various income sources did not add up to approximately 100%. Despite these limitations, we believe we have presented an extensive body of important data on radiology group practices. CONCLUSIONS One interesting broad uniformity emerges: Most organizational, professional, and business characteristics of radiology groups change rather slowly, with groups’ operational characteristics being particularly stable. This is the implication of the generally small differences found when the 1989 Group Practice Survey is cornpared with the 1986 survey. The stability
of groups’
characteristics,
partic-
ularly of operational characteristics, contrasts notably with the rapid changes in technology seen in radiology-for example, the recent advent of the wide-scale use of magnetic resonance imaging. Although cross-sectional imaging equipment is far more
540
Radiolosrv
#{149}
expensive than equipment for older technologies, its rapid spread apparently is not causing radiologists to join together into larger groups in which there would be more practitio-
In any case, ben of additional
ners
programs
available
to share
its costs.
The limited changes that we found were generally toward greater formalization and more “businesslike” anrangements. For example, we found more noncompetition clauses in cmployment contracts, expanded use of business managers, and the disappearance of manual billing. Future group practice surveys will continue to track the pace and direction of change. Also, they will be conducted with methods that should improve response rates. The implication of groups’ statements on the adequacy of their staffing is interesting. The fact that groups with 11 or more members were more likely to report having an inadequate number of radiologists than were smaller groups may only reflect that a staffing shortfall of a few percent looks different to large groups than it does to small groups. For large groups, such a shortage may amount to a substantial percentage of an FTE and be perceived as a staffing shortage, whereas in small groups, it amounts to only a small fraction of an FTE and the group probably does not perceive itself as needing another radiologist.
groups
say
proximately the output
nationwide, radiologists
they
would
1,100, of U.S. oncology
numthat
totals
ap-
which is less than radiology residency
(diagnostic
radiation
like
the
radiology
and
combined)
in I
year. Moreover, 1,100 is probably a substantial overestimate of actual employment opportunities for radiologists, since another study we have
under ally
way recruit
shows for
that
groups
considerably
actufewer
ra-
diologists than they say they would like to add. Clearly, in 1989, there was no large-scale shortage of radiologists.
U
Acknowledgments:
MD, and Millard ership of the ACR that oversaw the ela J. Kassing for survey; and Dana drafts and tables
We thankJ.
Owsley, leadcommittee and commission survey; Elise Bernal and Pamtheir extensive work on the Friedman for typing the in the manuscript.
C. Spencer,
Hal
MD, for their
References 1.
2.
Ways and Means Committee, U.S. House of Representatives. Medicare reimbursement to physicians: overview of entitlement programs. Washington, DC: Government Printing Office (Ways and Means Committee print 102-9), 1991; 425. Kirschner LB. AHRA survey: staff utilizalion. I. Radiol Manage 1989; 11:55-67.
May
1992
