Rhode Island Medical Imaging (RIMI) has pulled off a rare juggling act in the world of private practice radiology that has benefited its hospital system, the patients it serves, the radiology residents it trains, and the 90+ individual radiologists who work for RIMI.

"We're unique in our practice model in that we are a wholly owned physician operated practice owned by the physician group—the shareholders of RIMI—yet we are the academic department at Brown University Medical School as well as the Department of Radiology at Brown University Health Hospital System, the main academic center for Brown University," explains John Pezzullo, MD, president of RIMI since 2014. 

"The model for academic groups typically is not our model," he continues. "It's the employed physician model through the academic foundation," he continued. "We've resisted that mainly because we want to remain an independent physician-owned practice. We are one of only two practices left at Brown Health that is not working through the foundation model."

As told by Dr. Pezzullo, who joined RIMI straight out of fellowship and never left, RIMI's history foreshadows the group's unicorn status today, from its earliest days as the inaugural radiology department at Rhode Island Hospital, to the small group of department radiologists who opened an outpatient x-ray office around 1943 but didn't incorporate as Ray Medical Imaging until the 1960s, and later reinvented itself as Rhode Island Medical Imaging in the 1980s, when the group decided to grow its outpatient presence.

The Academic Glow

The practice prizes its role as radiology faculty for the Warren Alpert Medical School of Brown University for several reasons, beginning with personal and cultural implications. "It allows our physicians to enjoy the intellectual stimulation of being part of an academic medical center," Dr. Pezzullo notes. "We're educating the next generation of radiologists; we're performing some groundbreaking collaborative types of research; we're improving patient care by being an integral part of the multi-specialty academic Foundation community. Because of that, we're able to attract the best radiologists who want to be part of an academic institution."

On the other hand, Dr. Pezzullo understands that some radiologists don't want to be part of an academic life that includes teaching, writing papers, grant writing, and giving presentations at national conferences. "If you don't want to do academics and you don't want to teach, no problem, you can be a community radiologist and work with one of the community affiliates or the outpatient practice and have a wonderful career," he adds. RIMI provides diagnostic and interventional radiology services to 11 hospitals representing six health systems throughout the region.

"We have the best of both worlds in my mind because we're able to offer a lot of the advantages of a private practice yet still be part of the academic system," he continues. "We're able to offer better salary and benefits than most academic centers and more time, perhaps, that the group subsidizes for doing academic research. Our model allows any individual to come and define what they want to do in their careers."

Another not insignificant advantage of having a residency program these days is the recruiting edge: many residents and fellows decide to stay with RIMI. "We know what we're getting as a radiologist when they come out," Dr. Pezzullo notes. "They know the system, and they know the culture of the group. We're always looking for the team player and the best radiologists, so we've been very, very fortunate in that we have a very good residency program that's allowed us to frankly develop a farm team for our own company."

A Community Player

Unlike other academic practices, RIMI operates a significant network of wholly owned outpatient imaging centers, 15 in all. "Certainly, we're not just building the professional component, we're building the global component," he acknowledges, "and that's one of the main reasons for our outpatient strategy. It's important to have a diverse portfolio of business interests in this time of declining reimbursements for imaging services. Developing the outpatient practice has allowed RIMI to remain independent financially from the hospitals, and that has been a huge benefit to us."

Patients also have benefited, Dr. Pezzullo asserts, especially older patients, who may find the hospital campuses confusing and intimidating.  "We provide a warm and safe environment within the outpatient practice, and patients feel cared for and comfortable," he reports. "If you think about it, every patient who is having an imaging study thinks that they could have a serious illness, and they're petrified. We try to provide an environment for them that may alleviate some of that fear, and this is very important in radiology."

RIMI's network of 15 imaging centers also provide Providence patients a lower-cost alternative to hospital imaging. "It's much more expensive for the patient to have imaging in the hospital, so overall, I think that we're helping the financial profile of health care in Rhode Island by providing outpatient imaging services," he says.

Real Challenges

Dr. Pezzullo cites continual decreases in reimbursement rates as a significant challenge all radiology groups grapple with, compounded by payment rates that are lower than in much of the rest of the country. "We have that added burden," he notes.

The radiologist workforce has been negatively impacted by baby boom retirements, but he also thinks that radiology is suffering from hyperbolic predictions that radiologists soon will be replaced by AI. "That scared a whole generation of radiologists away from the specialty," Dr. Pezzullo believes. "Our business continues to grow and add new service lines and new technologies that make us indispensable to the health care paradigm—I have yet to see an AI product that I would put in my office."

Technologists also are in short supply, a challenge to all providers of medical imaging. "For whatever reason, the younger individuals don't want to become X-ray technologists, MR technologists, or mammographers, so trying to get people to work for us has been a challenge of late," he notes. "I do believe some of that will be alleviated by technology, since a lot of the major vendors are developing these virtual control rooms—you'll have one tech sitting at one site controlling four different scanners."

Corporatization of medicine is another concern of Dr. Pezzullo's, particularly the purchase of physician practices by large corporations and VC- and PE-backed entities. "They're just draining any of the marginal profits that are remaining within these practices," he says. "It will depersonalize medicine in a lot of ways, with employed physicians punching a clock.

"In our model, physician-owned and operated, you are invested: You want to be part of the fabric of the hospital, you want to go out and greet that patient in the waiting room, you want to put your best foot forward and let that patient know who they're dealing with, because it helps them, and it helps you."

Large Opportunities

Within the current workforce crisis, Dr. Pezzullo sees tremendous opportunity. "Every hospital is looking for a radiology practice because the large national radiology groups—the equity-backed groups—are fraying at the edges, mainly because of the radiology labor markets," he observes. "Radiologists who opted for employment or cashed out on the sale of their practice are now looking at it and saying, 'They're ratcheting down my pay, the profits are going to the mothership, and I'm basically an office drone.' There's a tremendous opportunity for groups like ours to enter new markets, gain a foothold elsewhere, and continue to expand, mainly because of our model."

From Dr. Pezzullo's perspective, RIMI's membership in Strategic Radiology could develop into one of the practice's most important milestones. "We don't just want to take advantage of being a member of Strategic Radiology," he notes. "We want to contribute to the overall health and growth of the organization."

Dr. Pezzullo suggests that standards and best practices developed within SR that improve efficiency, expertise, and quality could be embraced not just by coalition members, but by all of private practice radiology.

"The big picture," he continues, "is that we can have an impact on overall health care as it relates not only to diagnostic imaging, but all of health care. That to me is the tremendous value of Strategic Radiology. And maybe, taking the 10,000-foot-view, it's not Strategic Radiology 10 years from now, maybe it's Strategic Medicine. That will bring all of medicine back to where it should be-physician owned and operated."