The latest HPI study looks at how shrinking Medicare reimbursement rates are contributing to disparities in screening and patient care.
For years, the Harvey L. Neiman Health Policy Institute® (HPI) has quantified how declining Medicare reimbursement impacts radiologists and radiology practices by contributing to shrinking margins, consolidation and mounting pressure on an already-strained workforce. Those findings matter to our members, but this evidence is less compelling to policymakers than evidence for how patients are affected by eroding payments. Recently, we set out to close that gap by asking a more direct question: how do persistent reimbursement declines affect the people trying to get care?
Radiology and imaging are one of our areas of focus at HPI, but not every patient needs imaging. Every patient, however, should be seen at least once a year for a wellness visit, making "any physician care" a more universal yardstick for access than an imaging-specific measure would be. It also broadens the lens for stronger advocacy messaging. So for our new study, published in INQUIRY: The Journal of Health Care Organization, Provision, and Financing, HPI Research Director Eric W. Christensen, PhD, led our collaborative effort with ACR’s economic experts Lauren P. Nicola, MD, Gregory N. Nicola, MD, FACR, and Joshua A. Hirsch, MD, FACR, to determine whether Medicare's shrinking reimbursement rate (i.e., Conversion Factor) is associated with widening gaps in access to any physician or non-physician practitioner care. The study was based on nearly 33 million beneficiary-years of claims data from 2005 to 2023.
The mechanics of Medicare reimbursement is a longstanding challenge for healthcare providers. Medicare payment updates must be budget neutral; increases in spending in one area trigger CF cuts elsewhere. Therefore, as the Medicare population grows and new technology advances, physician payments are cut to balance the budget. We wanted to know whether those cuts, further degraded by inflation, are quietly eroding care access for the patients who can least afford to lose it.
We wanted to know whether those cuts, further degraded by inflation, are quietly eroding care access for the patients who can least afford to lose it.
The CF declined 14.6% from 2005 to 2025 from $37.90 to $32.35. Adjusting for inflation over that period, the CF lost 48.3% of its value. To put that drop in perspective, the 2005 CF with inflation would be worth $62.51 in 2025 — about $30 more than the actual 2025 CF.
We looked at Medicare data during the 2005 to 2023 study period and measured the gap in care-utilization between more and less advantaged Medicare beneficiaries, and how much of that gap was associated with declining payments. We found that the access gap widened substantially, whether "disadvantaged" was defined by rural residence, low community income, or high neighborhood deprivation. The community-income access gap alone grew three-fold, from 2.70 to 8.59 percentage points.
The analysis found that widening gaps in access to care were closely predicted based on the change in value of the CF using statistical modeling. In 2005, there was no gap in small town/rural areas compared to cities, and high deprivation neighborhoods actually had slightly higher access than their non-deprived counterparts. However, as the CF fell, a gap emerged and widened in both cases. Low-income communities took the hardest hit. There was already an access gap between low- and higher-income communities (<$25,000 versus $50,000+ median income) in 2005 that tripled by 2023, with 21% of low-income Medicare patients who did not visit any physician compared with 12% for high-income Medicare patients.
The specialty most affected wasn't radiology — it was primary care. As the CF declined, the access gap for primary care physicians grew by 10 to 13 percentage points across the three disadvantage measures — roughly five to ten times the effect size seen for most other specialties. That's a sobering finding given how much policy energy has gone into protecting primary care specifically, including the evaluation-and-management RVU increases in 2009 and 2021 that, ironically, contributed to further CF cuts affecting all care.
Radiology access wasn't immune. As reimbursement declined, gaps in access to radiology services grew by 1.9 to 6.0 percentage points depending on the disadvantage measure — smaller than primary care's change, but concerning, and consistent with what other HPI studies have shown. In JACR® last year, we found a similar effect in Medicaid. States with lower Medicaid reimbursement systematically have less Medicaid imaging utilization than higher-reimbursement states. Practices already operating on thin margins may be unable to absorb the financial losses associated with substantially lower Medicaid reimbursement, reducing their capacity to serve Medicaid patients.
In another study on mammography published in Radiology, Christensen, along with Jinel Scott, MD, and their coauthors, found that Black women or women in certain other minority racial groups were more likely to have mammograms at institutions that did not have the newest breast imaging technology (digital mammography introduced in 2005 and later tomosynthesis in 2011) compared with White women. These disparities can be explained by how the reimbursement mix shapes where practices first deploy new equipment. Medicare and Medicaid reimburse less than commercial insurance, so facilities serving mostly publicly insured patients have a difficult time covering costs, much less allowing for investments in new technology. Reimbursement policy, in other words, doesn't just determine what radiologists are paid — it determines who gets scanned and how soon a practice can afford to offer the newest, most accurate technology regardless of who their patients are.
ACR has made the case to Congress and CMS for years that reimbursement cuts threaten physician sustainability. This advocacy has succeeded in mitigating even worse Medicare cuts but hasn't been enough to prevent or change the downward trajectory of the CF. Our new study provides a critical piece of evidence to bolster the argument that payment trends aren’t sustainable: these cuts create a patient-access problem, disproportionately borne by rural, low-income and disadvantaged beneficiaries who already face the steepest barriers to care. Policymakers who may be unmoved by physician-focused economics may respond differently to evidence that their constituents are losing access to a primary care visit, a mammogram or a wellness exam. Given the results of HPI’s work on reimbursement, CMS should expect that its proposed rule for site-neutral payments will have negative consequences for patients, particularly patients on the margins for access.
Two concrete recommendations emerged from this work: indexing the Medicare CF to inflation and updating the 1992 budget-neutrality threshold. That threshold was set at $20 million and has never been adjusted — it would be $47.3 million today if it had kept pace with inflation. Neither idea is new but pairing them with hard data on widening patient-access disparities gives ACR and its partner societies a sharper, more durable case to bring to the Hill. This isn’t just about what physicians are paid; it’s about Americans’ health, which shouldn’t depend on whether they live in an affluent, well-resourced community.
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