Two articles this quarter directly evaluate economic trends in radiologist reimbursement relative to other specialties. Despite a reduction in Medicare imaging costs by more than 30% since 2006, radiology has remained a target of cost-cutting efforts in recent years. In a Health Affairs Scholar study, HPI researchers looked at 12 years of data and found that imaging cost growth is significantly less than other areas of medicine, perhaps counter to widespread belief. A related research focus is the budget neutrality requirement in Medicare, which has resulted in unsustainable reimbursement declines for radiologists.

The recent HPI article in the journal, INQUIRY: The Journal of Health Care Organization, Provision, and Financing, found that radiologist reimbursement decreased by 25% per Medicare beneficiary, much more than the 2.3% decrease for physicians overall. We also found a dramatic increase in services delivered by nonphysician providers and their reimbursements.

Please read the spotlight of our valued collaborator, Lauren Nicola, MD, FACR, who discusses pressures on radiologist reimbursement demonstrated in our INQUIRY study, as well as another eye-opening study evaluating the Medicare Merit-Based Incentive Payment System (MIPS) and limitations for radiologists.

We appreciate your interest in HPI research and please continue to share our work with your network!

Stay up to date with HPI research and new opportunities at neimanhpi.org and X (formerly known as Twitter).

Elizabeth Rula, PhD
Executive Director, Harvey L. Neiman Health Policy Institute

Imaging’s Total Share of U.S. Healthcare Spending Declines as Others Record Gains

Medical imaging has previously been identified as a potential driver of U.S. healthcare spending growth. This HPI study evaluated the degree to which imaging has contributed to aggregate medical cost growth. This Health Affairs Scholar study found that between 2010 and 2021, imaging’s share of total healthcare spending fell from 10.5% to 8.9%.

“Between 2010 and 2021, overall healthcare spending increased 60.8%, but this growth differed substantially by type of service,” said Michal Horný, PhD, MSc, Assistant Professor at Emory University School of Medicine. “We found that spending growth was 35.9% for imaging while it was 63.7% for all other healthcare services. Hence, while imaging spending has increased, the growth in nonimaging services has been substantially higher. Therefore, imaging has become a smaller piece of the pie.” Read the summary.

Researchers Identify “Hidden” Interventional Radiologists in Data, Expanding Opportunities for Research

According to this HPI study supported by the Society of Interventional Radiology (SIR), 76% of interventional radiologists (IRs) identified using a new research method were mislabeled as diagnostic radiologists in Medicare data. This finding means that IRs are largely unidentifiable in healthcare claims data, which is widely used for population health and health-services research.

“Without a method that provides more complete and accurate inclusion of IRs in research, studies may produce nongeneralizable or biased results and conclusions,” stated author C. Matthew Hawkins, MD, Professor, Radiology and Imaging Sciences, Emory University School of Medicine. “This gap hinders researchers’ ability to study the value of interventional radiology in healthcare at a population scale.” Read in the Journal of Vascular and Interventional Radiology.

Low DXA Screening Rates Among Asian American Medicare Beneficiaries

New research in Skeletal Radiology reveals disparities in dual-energy X-ray absorptiometry (DXA) scan rates, an osteoporosis preventive screening test, and found minorities including Asian Americans have lower rates. The team of researchers at NYU Langone Health, Massachusetts General Hospital and the HPI found lower rates of osteoporosis screening among Asian American (15%) and other nonwhite Medicare beneficiaries (11–15%) in the U.S. when compared with the screening rate of white beneficiaries (18%). This study, funded in part by the RSNA Emerging Issues grant, was based on more than 3 million Medicare beneficiaries fee-for-service claims (2015–2020).

“Osteoporosis and DXA research in Asian Americans is limited and oftentimes conflicting, even though the National Health and Nutrition Examination Survey showed that Asian American populations — both men and women — have the highest age-adjusted prevalence of osteoporosis,” said Connie Y. Chang, MD, radiologist at Massachusetts General Hospital and associate professor at Harvard Medical School. “This group should really be scanned much more frequently in order to avoid osteoporosis-related fractures,” she concluded. Read the summary.

Radiologist Medicare Reimbursement — Stuck Between a Rock and a Hard Place

The Centers for Medicare and Medicaid Services (CMS) aspires to create payment models that incentivize value over volume of care to help reduce unsustainable expenditure growth while improving outcomes. Radiologists are primarily paid via a conventional fee-for-service model under the Medicare Physician Fee Schedule (MPFS). Changes in payments for services are constrained by budget neutrality, which requires that increases in Medicare payments in one area are balanced by decreases elsewhere. Programs such as Merit-Based Incentive Payment System (MIPS) provide opportunities for monetary incentives to improve quality of care, which, in theory, could offset MPFS payment cuts.

Lauren P. Nicola, MD, FACR, Chief Executive Officer, Triad Radiology Associates and Chair, ACR Commission on Ultrasound, is an expert in healthcare economics and value-based payment models in Medicare. Dr. Nicola collaborated with the HPI on two recent studies that investigate various factors influencing Medicare physician reimbursement. She is actively trying to pave a path for radiologists to participate meaningfully in MIPS. She is also concerned about the sustainability of the MPFS for ensuring patient access to care given the statutory requirement for budget neutrality without any inflationary adjustment.

One study from the collaborative research with Dr. Nicola, published this April in the American Journal of Roentgenology, investigated radiologist performance in MIPS and determined it was heavily influenced by their practice type. The researchers looked at the top ten quality measures reported most frequently by radiologists in each practice type. The results were striking — for radiologists in a multispecialty practice that wasn’t mostly radiologists, not a single radiology-focused measure was among that list. The results determined that radiologists in radiology-focused practices scored significantly lower in MIPS compared with those in practices where other specialties comprised a larger share of physicians and predominantly reported nonradiology MIPS measures.

“Our results clearly show that radiologists are at a disadvantage in the MIPS program, with very few available measures, most of which are topped out — meaning that scoring well isn’t possible because average scores are too high,” said Dr. Nicola. “Our study sends a clear message: The MIPS program in its current design won’t move the needle on quality in radiology. For MIPS to work as intended, physicians must report measures relevant to their specialty, which will require more measures that are applicable to radiologists.”

The research showing that radiologists have little opportunity for incentives based on their own performance is particularly problematic given Medicare reimbursement trends. Another study published this April in INQUIRY: The Journal of Health Care Organization, Provision, and Financing, investigated the influence of budget neutrality on Medicare payments for medical specialties. The study found that Medicare reimbursement to physicians has declined over the last 16 years, with radiologists among the biggest losers. Reimbursement per Medicare beneficiary after inflation adjustment fell 2.3% for all physicians, despite a concurrent increase of 45.5% in physician services to each patient. Radiology ranked 31st in a list of 39 medical specialties, organized by increasing to decreasing payments, and showed a 25% decrease. Conversely, reimbursement rose 207% for nonphysician practitioners.

“On one hand, radiologists have increasing clinical workloads and are still being reimbursed less by payors year over year. On the other hand, there is no viable path in a radiology-focused practice to recoup lost reimbursement with quality-based bonuses in MIPS,” explains Nicola. “Thus, radiologists are caught between a rock and a hard place, which places patient access at risk. We are using this HPI research to advocate for change in current policy to ensure access to quality care.”