ACR board chair discusses radiology's 'culture clash' between 'suits and white coats'
The American College of Radiology is closely examining the seismic shift underway in how radiology practices are structured, as more than half of radiologists in the U.S. are now employed by hospitals, health systems, or private equity-owned entities
"Radiology just crossed over 50% now, where radiologists are employed rather than in independent private practice. That trend is a paradigm shift," explained ACR board leader Alan Matsumoto, MD, professor and chair of radiology at the University of Virginia, who spoke to Radiology Business at the 2025 American Medical Association House of Delegates meeting.
When he first started his career, the field was mostly independent private or academic practices, but that is no longer the case. He said the shift reflects a broader consolidation trend across the U.S. healthcare system, driven by growing administrative burdens, resource challenges, and the lure of scale and financial backing from large institutions or private investors. Medicare physician payment reductions, down 33% since 2000 when adjusting for inflation, have been a major driver of this change, since many physicians are finding they can no longer afford the cost of running a private practice. Hospitals on the other hand are paid by Medicare at a higher rate and they get inflationary increases, which physicians do not. While specialties such as cardiology reached nearly 90% employment in recent years, radiology is now catching up, he said.
Matsumoto said radiology has traditionally been a stronghold for independent private practice, but that is no longer the case. Younger radiologists entering the field today often do not see independent practice as viable.
Pros and cons of radiology practice consolidation
Matsumoto noted that this transformation offers both opportunity and risk. On one hand, consolidation can bring economies of scale, shared resources and improved access to cutting-edge technology. On the other, physicians may face reduced autonomy, increased burnout, and misalignment between clinical priorities and business goals. He said private equity is often grouped into the negative category, but there is no one size fits all. Some practices have felt saved by private equity and found it has helped them. But not all.
"I think there are private equity practices that have really enhanced the practices of some groups. They were frankly failing because they didn't have a deep enough infrastructure or resources. They actually feel rescued to some extent by private equity," he explained.
But on the other side, there are other practices that feel they made the wrong decision because the focus moved from patient care to corporate financial goals. “The feedback we’re hearing is mixed,” he said. “Some say consolidation has given them scale and stability. Others feel like they’re on a hamster wheel, losing the independence and purpose that drew them to medicine in the first place.”
"There's consolidation occurring with academic health systems taking over community practices, too, for scope. And so now you're getting this sort of blend that was black and white before, private practice academics, and now there's an interface between them," Matsumoto said.
ACR is planning to create a task force on practice consolidation to begin gathering input from a variety of practice types to better understand the pros and cons.
The rise of the 1099 radiologist
Another emerging trend is the rise of so-called “1099” radiologists who operate as independent contractors, hence use of 1099 tax forms, and are often covering multiple practices across states. This is a new business model that did not exist a decade ago.
"They're basically filling out a 1099 tax form and marking themselves as an independent practice helping to cover a group in Delaware and one in Pennsylvania and one in Virginia, for instance. This model offers flexibility and autonomy, but lacks the infrastructure and benefits of more traditional employment settings, raising questions about long-term sustainability," Matsumoto said.
Private equity is a divisive force in radiology
Private equity ownership in medicine remains controversial. While some radiology groups view PE partnerships as a lifeline—providing capital and back-office support—others worry about profit-driven decisions undermining clinical priorities.
“There are private equity firms that have truly helped practices survive and thrive,” Matsumoto said. “But others feel misled or regret selling. Not all private equity is the same, and that’s what makes this so complicated.”
He also acknowledged concerns about rural access to care, as PE firms might prioritize profitability over geography, potentially closing less lucrative clinics. Some states are considering legislation to review or restrict private equity acquisitions in healthcare.
Clash of culture between suits vs. white coats
Matsumoto warned of a deeper cultural rift emerging in healthcare where there is a growing disconnect between physicians—focused on mission—and nonclinician administrators focused on margins.
"Medicine occupies about 18% of the gross domestic product. The business of medicine is clearly a business of medicine, and wherever there's money, there's business people involved. Physicians are wired very differently than traditional business people. They're wired to try to make a difference in patients' lives, but they want to be appreciated and be valued for the services they provide. We're running into a little problem of what I like to say is the 'nonclinical MBAs, the suits, versus the physicians, the white coats,'" Matsumoto said.
This is a big cause of physician burnout. He said it results in moral injury, because physicians will work 20 hours a day for two weeks straight if they know they are making a difference and they are appreciated, and it is by their choice. But many will dread working eight hours a day if it is not by their choice or they're being asked to do what they do not want to do.
"That's one of the challenges we're trying to grasp is how we translate this into a business model and integrate it to our culture of really caring about patients. And that's where I think there is really a conundrum. I think that's what we're seeing is this culture clash between the suits and the white coats," Matsumoto concluded.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]