Dr Karl Merckx
Hikstraat 43, 2200 Herentals
Along with its neighbours France and Germany, Belgium has a long tradition of organising radiology facilities outside of hospital radiology departments. Until about 1970, the number of ‘private’ practices remained fairly limited, but since that date, has risen to about 110. Out of a total of around 1,400 Belgian radiologists, approximately 130 operate in the extramural sector.
Infrastructure and Equipment
Most private practices are owned and manned by a single radiologist, usually with the assistance of one or more technicians and secretaries.
The premises used for these practices vary greatly. They often consist of ground floor rooms of an apartment building, or, alternatively, the practice may be housed in an extension to the radiologist’s private house. In terms of equipment, the following inventory is usual; a remote-controlled X-ray table with scopy facilities, a smaller X-ray unit for examinations without scopy, a mammography unit, a DEXA bone densitometer, an orthopantomograph for panoramic mouth scans, and a high-performance echography unit with Doppler. The following apparatus is used for film processing: a wet daylight system and/or a digital CR system. In terms of digitisation of the imaging, extramural radiologists generally opt for CR (Phosphorus) systems in view of their low cost and their flexibility. A digital link to the referring physician is also usually provided for transferring records and, in future, X-ray and echography scans. Five practices in Flanders have a CT scanner.
Organisation and Operation
of Private Practices
There is, however, a difference in the working practices of radiologists operating in the Dutch-speaking part of the country (Flanders) and those working in the French-speaking part of Belgium (Brussels-Wallonia). In Flanders, extramural RX practices operate autonomously and are always independent of a hospital. The private radiologist (or sometimes two radiologists) works full-time for his or her practice.
In the French-speaking part of Belgium, there are private practices with multiple radiologists, who must spend part of their time working in a hospital. This phenomenon is less common in Flanders.
Patients are usually referred by general practitioners who also operate outside of hospitals, or, in a small number of cases, specialists linked to a hospital and resisting pressure to refer patients to that hospital.
A separate phenomenon consists of radiology departments in outpatient clinics set up by a cooperative of practitioners offering a comprehensive range of treatments. Under these circumstances, the radiologist then
does not own the practice, but is paid for each item of service rendered. Radiologists of this kind are not usually regarded as true ‘private operators’.
Changes in Work and Technology
Until the early 1970s, the job description of private radiologists was virtually identical to that of their hospital colleagues, with the exception of arteriography; the latter was a new technique at that time, and it was difficult to perform on an outpatient basis.
When CT scanning was introduced in 1974 the Belgian government decided to pay only for CT scans performed in a hospital. Since then, private practices have had to perform CT and MR scans without reimbursement.
Nevertheless, there are currently 5 CT units operating in Flemish extramural radiology practices. The fee for the scan performed is paid in full by the patient without any possibility of reimbursement by the health insurance funds. This, of course represents a major constraint on the operation of extramural CT units.
Attempts by extramural radiologists to gain re-imbursement for modern imaging technologies such as CT and MR have, to date, yielded few results. Many private practitioners see this as a failure of political will coupled to a negative attitude on the part of some hospital radiologists.
In 2001, this latter situation prompted the creation of a separate professional association for extramural radiologists: VERB-AREB (Association for Extramural Radiologists in Belgium, known in Dutch as the Vereniging voor Extramurale Radiologen van België and in French as the Association des Radiologues Extramuraux de Belgique).
Nevertheless, private radiologists have not become isolated and are represented on practically all official boards and committees. They send representatives to the Flemish recognition committee, the Consilium Radiologicum, the accreditation committees and the doctors’ syndicate. The current chairman of the national professional association NUR-UNR (the National Union of Radiologists, known in Dutch as the Nationale Unie van Radiologen and in French as the Union Nationale des Radiologues) is a radiologist who operates exclusively in the private sector.
Over the last three decades, the activities of private practices have gradually changed from conventional radiology procedures to include significant elements of both echography and mammography.
In the case of radiology examinations, echography, Doppler scans and, particularly, mammography, many patients opt for private practice on account of a perception of greater privacy, punctual follow-up of appointments and the rapid availability of records. Of course, the fact that there is easy access to private practitioner in the patient’s own neighbourhood also plays a part.
The Other Side of the Coin
One handicap for the private radiologist in single-handed practice is the need for him or her to find a locum radiologist whenever he wants to take a holiday or attend a conference. To compound this problem, many recently qualified radiologists who would be willing to stand in for a colleague working alone may no longer be familiar with performing X-rays personally; a routine task for the extramural radiologist.
Partnerships of several radiologists, working cooperatively in a single private practice, have until now, been fairly rare.
If, however, CT and MR scans carried out by private radiology practices were to be reimbursed by the medical insurance funds, an increase in economic scale would become and more associations would doubtless form. For several years the presence of a minimum of two private radiologists operating full-time and working cooperatively was offered as a concession by their own professional group in order to obtain CT re-imbursement.
Aside from non-re-imbursable CT and MR services, the fees paid by the medical insurance funds are identical for all outpatient services, both those performed by the hospitals and those performed extramurally in private practice.
Whilst many private practices are remunerated direct by the patient himself who reclaims the cost from his or her own insurer, most practices now use the ‘third payer’ system. This means that the invoice is sent direct to the medical insurance fund and the patient pays only the ‘brake money’. This is the element of the fee that is not reimbursed by the medical insurance fund.
Principally due to an exponential increase in the number of CT and MR examinations taking place, radiology departments in hospitals are expanding rapidly. This increase in scale is not matched by private practitioners. The latter can, however, hold their own through the provision of echography and mammography examinations tailored to the needs of individual patients. Nevertheless budget constraints which have denied private practitioners re-imbursement for CT and NMR scans represent a serious constraint on the continued existence of extramural radiology in Belgium.