After completing his radiology residency and neuroradiology fellowship at Emory University, Ivan DeQuesada, MD, left Atlanta in 2016 and headed southwest to join one of the nation’s largest private radiology practices, Radiology Associates of North Texas, in Fort Worth, Texas.

It was not a choice he made lightly. Prior to joining RADNTX, he had observed life in academic practice first-hand and also consulted mentors on the private practice and employed models. Ultimately, he determined that practice ownership offered him the flexibility to achieve the highest level of job satisfaction. His decision boiled down to the model’s ability to enable three essential freedoms: personal, professional, and financial.

Personal Freedom

After 10 years in rigorous academic pursuit of a medical degree, personal freedom was not a trivial factor in his decision to join a private practice. “Most private practices offer more vacation,” DeQuesada observes, “and that is part of the freedom and flexibility. Most have a little bit more ability to cover nights, weekends, and call by trading your shifts, and I didn’t get the sense that there was that flexibility in academia.”

He also confesses to harboring a notion that, one day, he may live abroad and do teleradiology, unencumbered by location. “That almost certainly does not exist in academia,” he notes

As business owners, private practice radiologists have the opportunity to both pursue their personal interests and contribute their personal strengths to the enterprise, DeQuesada notes. During residency and fellowship, he attended national meetings and participated in organized radiology through the ACR, developing an interest in medical specialty economics. Two years after joining RADNTX, he is looking forward to engaging at the grass-roots level in how the arcane mechanics of radiology reimbursement affect him personally as a partner.

“Some people don’t care about billing, reimbursement, or the structure of a physician practice, and that’s OK, because we have a lot of administrative folks who take care of this,” notes DeQuesada. “But they may be passionate about something else, like customer service or quality. As independent owners, there is the opportunity to contribute their individual strengths to the strength of the practice. As a practice owner, I enjoy the freedom to practice in a way that gives me the most satisfaction.”

Professional freedom

DeQuesada perceives the acquisition of private radiology practices by private equity and public companies as a growing threat to the professional autonomy—and freedom—of radiologists. “At some point in the future, there will be a not insignificant minority of radiologists who are employed,” he observes

He suggests that competing interests in the medical economy—insurers, device manufacturers, pharmaceutical companies, and investors—pose potential conflicts of interest. “If physicians don’t own their practices, they don’t have that freedom to determine the right thing to do—and they also don’t have the freedom to advocate for the right thing to do,” he notes. “If you off-load your autonomy and your ability to practice freely, then one day you can’t get that back—that day may already be here for some.”

Practices that are able to remain independent and physician-owned will hold onto the ability to do those things that are important to maintain satisfaction of practice. “I think it would be easy to develop a poor culture in a corporate practice, to not pay attention to the health of employees, in this case the radiologists. Also, if there ever is any downward pressure from an economic standpoint, they will be the first to suffer.”

As a member of Strategic Radiology, RADNTX sends DeQuesada to twice-annual Quality Forums where he enjoys collaborating with members of other private practices across the country. A current SR quality initiative is the implementation of new guidelines from ACR on gadolinium contrast for MRI, which recommend against routine renal function testing prior to administration of gadolinium.

“This was not widely publicized,” notes DeQuesada. “If I didn’t own a private practice, I don’t know that I would be paying attention to this because as an employee, I would rely on hospital personnel or other people whose domain this is in the academic practice.  I take responsibility for those things as the owner of the practice, and the people I work with know that I am invested in their success.”

Being able to pursue his interests on behalf of his practice is part of both the personal and professional freedoms that DeQuesada prizes. “In private practice, if you want to do something to make an improvement and you are going to do a good job, people are more than happy to pass that to you and let you achieve in that way,” he observes.

Financial Freedom

As practice owners, radiologists have the financial freedom to invest in what is important to them and reap the rewards of their efforts. This can drive innovation, high levels of service, and patient-centered care, says DeQuesada. “If you own your business, there is intrinsic motivation to be successful because you enjoy the rewards of your success,” he says. “You are motivated to work to expand the business, to do what it takes to get new business, to advocate for the specialty, protect reimbursement that is fairly earned, and develop new service lines.”

In general, he adds, salaries and dividends in private practice add up to more than academic or employed salaries.

Consolidation is an evolutionary step in mature industries, DeQuesada observes: “It has happened in almost every industry in America. It is happening in media, manufacturing, retail, and it’s happening in health care, too.”

The loss of that financial freedom in medicine concerns DeQuesada because corporate ownership has the potential to restrict the freedom to advocate for personally held values due to conflicts of interest. “In some business sectors, there are protections in place—unions, consumer advocacy, government regulations—that provide a counterbalance to the corporate motivations of those consolidated businesses and their profit motives,” he observes.

In medicine, physician-owned practices provide that counterbalance, he says. With consolidation, patients are likely to see further decreases in benefits and coverage and more increases in out-of-pocket costs. Likewise, physician salaries—and the salaries of others—will decline over time. “Physician wellness and satisfaction also will decline because there will be less autonomy and less control over the working conditions,” he predicts.

He is hopeful that physicians will continue to resist the pull of short-term profits and maintain their autonomy. “Right now, the overwhelming majority of people— even other physicians—have no idea who their physician actually works for,” he concludes. “That is troubling.”