The workforce shortage in radiology is not news. 

ACR members experience the challenges of unsustainable workloads daily, and patients encounter delays in diagnostic information that is critical to their care. Although the simplest answer is to train more radiologists and technologists to meet the growing demand, this is neither a quick fix nor a long-term solution, nor does it address the prevalence of unnecessary imaging. Alternatively, some are looking at AI or non-physician practitioners (NPPs) to fill the gap, versus directly addressing unsustainable imaging growth. The resulting inflationary effect would erode the economics that support access to high-value, quality radiologic care. 

In this issue of Research Rounds, I’m covering the evidence unfolding from our work from the Harvey L. Neiman Health Policy Institute^® (HPI), where we are studying the shifting dynamics and underlying causes of the workforce shortage. 

I want to start with an example of steep growth in advanced imaging. A recent HPI paper co-authored by Joshua A. Hirsch, MD, FACR, senior affiliate research fellow and vice chair of procedural services at Massachusetts General Hospital (MGH), found a 67%increase in the use of CT angiography (CTA) for patients with headache or dizziness over five years in the ED of a large medical center. Over the same period, the rate of positive findings on those same exams decreased. Specifically, the number of abnormalities detected on the CTA studies went from 71 in 422 in 2017 to 69 in 662 in 2021. The study raises concerns about necessary and appropriate use of imaging. In the HPI press release, Hirsch said, “The observed trends in neurovascular imaging mirror broader trends of increasing intensity and technologically advanced care. The solution isn’t to restrict access to valuable advanced imaging such as CTA, but to provide referring physicians with a frictionless way to evaluate the appropriateness of imaging.” The ACR Appropriateness Criteria (AC), created to guide appropriate imaging, are incorporated into ACR Select®, clinical decision support (CDS) software that is designed just for this purpose.

ACR members experience the challenges of unsustainable workloads daily, and patients encounter delays in diagnostic information that is critical to their care.

One hypothesized driver of inappropriate imaging and growing utilization is the increasing scope of practice of NPPs. Another MGH study found that CTAs ordered by attending physicians were three times more likely to demonstrate a finding of high severity than those ordered by NPPs. This single-institution study is a local example of what the HPI found in a national study and published in JAMA Network Open. The HPI study found that imaging utilization was related to a state’s scope of practice for NPPs. The presence of NPPs in the ED was associated with 5.3% more imaging studies per ED visit. Eric Christensen, PhD, HPI director of economic and health services research, designed this study at a macro level to understand the influence of state scope-of-practice policy and to avoid confounding by the likely possibility that NPPs provide care to patients presenting with lower severity in the ED.  “To put this 5.3% imaging increase in context, it equates to more than one million imaging studies per year when applied to the roughly 20 million annual ED visits for the entire Medicare fee-for-service population,” stated Christensen in the press release. “The variation we found in practice patterns between physicians and non-physician practitioners highlights an opportunity to ensure the judicious use of imaging. These efforts need to address both when and what imaging is appropriate.” 

Although NPPs are helping expand the clinical workforce amid healthcare workforce shortages, this research indicates they may actually be contributing to that very shortage. The rapid increase in NPPs providing care that was previously only provided by physicians is creating a cyclical effect whereby the increased “supply” of medical care is also contributing to increased “demand.” And the current workforce in and out of radiology is not sized to meet the growing volume. In a press release, AMA President Jesse M. Ehrenfeld, MD, MPH, said, “the physician shortage that we have long feared — and warned was on the horizon — is already here. It’s an urgent crisis … hitting every corner of this country.” 

The extent of imaging growth among Medicare beneficiaries was assessed in another recent HPI study. The study found that imaging use increased by 13%, as measured by RVUs, on average for each Medicare patient. Time and time again, Medicare responds to growing volume by decreasing reimbursement. With its statutory budget neutrality requirement, if costs or utilization growth occur in one area or overall, Medicare cuts its per-unit payment (conversion factor) to maintain overall spending. The nominal conversion factor dropped 8% over the 2005 to 2021 period of our study but, when considering inflation, radiologist reimbursement per patient dropped 29.1% over the same period, despite delivering 13% more services. It is well established in healthcare economics that access to care differs based on reimbursement. Commercially insured patients have better care access than Medicare patients, and adding a higher workload on top of the lower reimbursement will only compound the problem. And, unfortunately, decreased access is more likely to affect already underserved groups.

Having discussed causes and consequences of unchecked imaging growth, let’s talk about a solution. In 1993, the College established the ACR AC to help referring clinicians make decisions regarding imaging appropriateness for a wide range of clinical concerns. Congress created the imaging Appropriate Use Criteria (AUC) program for Part B Medicare in the Protecting Access to Medicare Act of 2014 (PAMA), which requires an AUC consult be performed via a qualified CDS mechanism when a healthcare provider orders advanced diagnostic imaging for Medicare patients. CMS estimated that the program could save $700 million annually, though other estimates have been more moderate. However, perceived implementation challenges have resulted in repeated delays in this provision. In the 2024 Medicare Physician Fee Schedule Final Rule, CMS paused the program indefinitely, indicating that it was unable to implement the program as currently written in law. These delays have continued despite the availability of CDS systems that many sites have successfully integrated into workflows to achieve reductions in unnecessary imaging. “The ACR is actively working with Congress and CMS to modernize the PAMA AUC program and remove the real-time claims processing requirement that has resulted in the current pause,” says Katie Keysor, ACR senior director of economic policy.

The data are clear — without enough radiologists to absorb the increased volume, the workforce is stretched at the seams and is simultaneously being paid less. This is a recipe for burnout. It also could be seen as a red flag to medical students as they select their specialty. 

Expanding NPPs or AI to increase efficiency may help stem the tide, but policymakers and healthcare administrators need to follow through on PAMA and have systems in place to monitor imaging appropriateness. Efforts to bend the curve in volume are necessary to ensure that high-value imaging remains accessible to the patients who need it.