he organization and logistics of medical imaging are changing rapidly in some countries. Independent small private practices disappear — Germany and Switzerland being good examples. The legal introduction of medical care centers (MVZs) in Germany some fifteen years ago has redefined the framework of radiological care. To many patients the radiologists’ offices might look the same, a thriving medical business, but what was formerly owned by one, perhaps two radiologists who had set themselves up, today is part of one of the specialist chains with branch offices in the region or all over the country.
We are watching the end of the epoch of the single, independent “universal” medical imaging specialist.
The German radiology market consists of over 1,000 imaging centers and 800 radiology hospital departments with more than 6,800 radiologists. That’s approximately 83 radiologists per one million inhabitants — compared to 68 in Great Britain [1].
Outside the hospitals, one sees a trend towards centralization: buying, advertising on their home pages and, e.g., Google adverts, bringing everything and everybody in one line, and adjusting manpower to the radiological overkill. This overkill is due to a dramatic increase of examinations for diagnostic questions that were not considered necessary some years ago. This also means a rise in specialized and sub-specialized radiologists required for the new spectrum of indications. General radiologists have problems to survive on their own.
During the past 15 years, for example, more and more imaging centers have been expanded, the number of salaried physicians working for the owner or owners of them has risen sharply, and many practices are organized in networks or purchasing associations.
Similar endeavors of independent radiology communities were launched in other European countries, for instance in France with VIDI, a network of private radiology. By creating an independent association, the founders intended to protect the quality of medical imaging for all patients and facilitate access throughout France to excellent diagnostics and care.
They stated: "We accompany our patients throughout their medical imaging journey, from screening to interventional procedures, from diagnosis to care. The strength of our network is also to give our patients access to a group of radiologists who are highly specialized in all areas of expertise. The radiologists in the Vidi network share values of responsibility, commitment, accessibility and human relations [2]."
The network was created in January 2017, comprising 14 imaging centers with 207 radiologists; in December 2020 the VIDI cooperative network consisted of 50 medical imaging centers in France and included nearly 900 radiologists working alongside nearly 3600 employees to examine more than 5 million patients per year.
In a completely different approach, radiologists turned businessmen and started acquiring imaging practices or entire centers from colleagues and helped creating wholesale companies for pharmaceuticals, mostly contrast agents, to generate additional revenue. Thus several physician-led radiology networks or chains with several hundred employees formed during the last decades. One of these company conglomerates and its affiliates in Germany sees more than three quarters of a million patients a year pass through their facilities in more than twenty cities. In some of these chains equipment manufacturers have an interest and access to data that might be helpful in developing new applications.
Medical and increasingly non-medical investors and private equity enterprises have moved into the formerly protected health care market and started taking over doctors’ offices in a number of disciplines: radiology, orthopedics, neurology, rheumatology, dialysis and even physiotherapy.
Private equity enterprises pursue a buy-build-resell strategy. Commonly they invest in consumer, health, and industrial companies and in business services. They acquire existing firms, for instance radiological chains, keep them going, and after period of five to six years search for suitable buyers. They generate the greater part of their returns not from current income during the time they own a company, but from the higher price they score when the company is sold. Often the investors’ funds are located in offshore financial centers, primarily the Cayman Islands and the Channel Islands of Guernsey and Jersey.
There is also a health-political aspect to the new landscape: the permanent call for more efficiency in medicine; pathetic statements of politicians, insurance managers and equipment manufacturers, consultants — and investors. They have no medical, practical or health ethics background, but are part of an excessive bureaucracy that has to prove that they are all-important and indispensable. It’s the old game of gaining a little personal power and making money.
Privately, chain-employed radiologists complain that they realize a gradual loss of quality and efficiency — just the contrary of what is being preached. There is also a latent fear of a lack of transparency of the intentions of some owners who as lay people do not understand the possible flaws of replacing some of the radiological evaluations by AI software programs. The employed radiologists are afraid that they might be forced to use AI to save money and to take the sole responsibility for the risks involved.
The radiologist generation 50-plus looks forward to — early — retirement if it is financially acceptable; on the other hand younger radiologists appreciate the offer of a better “life balance” between working and private life. Regular working hours, free weekends, long holidays, less responsibility, little management and administrative tasks are major attractions.
The salary of an employed certified radiologist in Germany is around € 140,000 per year. After taxes and health insurance that’s sufficient for a decent middle-class life. However, as one elderly radiologist told me:
“In the long run it’s not enough any more to build or buy a house for the family. For the younger generation it will be tight. They don’t want to work as hard as we did, but even if they do they will feel the difference.”
He retired some time ago and added:
“I have worked and paid into the physicians’ pension fund for 35 years. I get that pension and a second, smaller one. After taxes and health insurance payments less than € 1,400 are left per month. That’s not enough to survive. You have to have additional means. Some school mates of mine were high school teachers. Their state pensions and fringe benefits are far better. And the young minister of health just bought a villa for 4 million euros. He is lucky, he hasn’t studied medicine.”
1. Ward P. U.K. radiology's looming crisis deepens in COVID-19 pandemic. AME (Aunt Minnie Europe) 28 April 2021.
2. VIDI: Manifeste. www.groupe-vidi.fr/pionnier-radiologie-liberale-vidi
Citation: Rinck PA. New realities in medical imaging. Rinckside 2021; 32,2: 5-6.
An edited digest version of this column was published as:
Europe’s era of independent practitioners draws to a close.
Aunt Minnie Europe. Maverinck. 18 May 2021.
Rinckside • ISSN 2364-3889
is published both in an electronic and in a printed version. It is listed by the German National Library.
Rinck is my last name, and a rink is an area of combat or contest.
Rinkside means by the rink. In a double meaning “Rinckside” means the page by Rinck. Sometimes I could also imagine “Rincksighs”, “Rincksights” or “Rincksites” …
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© 2021 by Peter A. Rinck and TRTF.
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