The Radiology Outpatient Ordering Transmission Act is here to help aid workforce issues by improving radiologists’ decision-making environment.
FROM THE CHAIR OF THE COMMISSION ON ECONOMICS
Radiology has a productivity problem.
Not because radiologists are insufficiently productive, it’s quite the opposite. We have spent decades becoming more efficient, reading more images in less time and using technology to increase our capacity. Yet as imaging utilization continues to grow, our response has too often been to ask radiologists to do more, and faster. That model is reaching its limits, and we can’t read our way out of continuously increasing imaging demand.
The solution requires looking upstream at the amount of imaging entering the system and asking how we can reduce unnecessary examinations overwhelming worklists around the country. This does not mean that all low-value imaging can, or should, be eliminated.
In fact, the concept of “low-value” imaging is more complicated than it sometimes appears. An examination may provide value that is difficult to capture in a traditional appropriateness framework, such as a reassuring CT that may prevent a patient from returning to the emergency department for a follow up. Imaging may help an emergency physician triage a crowded department or rapidly exclude a dangerous diagnosis. In some settings where shortages of primary care, emergency medicine or other clinical personnel have strained the healthcare system, imaging may effectively substitute for portions of a traditional physical examination.
Patients themselves may place value on imaging simply because it reduces uncertainty and anxiety. Physicians sometimes order tests because they are managing imperfect information in a complex healthcare environment.
Those realities should make us cautious about simplistic efforts to drive imaging utilization to the lowest possible level. At the same time, recognizing that some imaging has value does not mean that every examination delivers the same value. Some clearly add less clinical value than others. When the supply of radiologists is constrained, the opportunity cost of low-value imaging becomes increasingly important.
In a workforce-constrained environment, inappropriate or low-value imaging becomes more than a healthcare spending problem. It becomes a capacity and access problem.
In a workforce-constrained environment, inappropriate or low-value imaging becomes more than a healthcare spending problem. It becomes a capacity and access problem. This is where the Radiology Outpatient Ordering Transmission (ROOT) Act becomes particularly relevant.
Introduced in both the House and the Senate, ROOT seeks to modernize the Medicare Appropriate Use Criteria (AUC) program created by the Protecting Access to Medicare Act. Rather than requiring a cumbersome real-time claims transaction, the legislation would require ordering physicians to attest that they consulted qualified, evidence-based AUC before ordering advanced imaging. Importantly, the physician retains clinical judgment; consultation does not require following the recommendation. The House Physicians Caucus agrees with the need for the ROOT Act as it has incorporated it in its broader healthcare legislative package, the Patients First Act.
The aim is to preserve physicians’ ability to order imaging when they believe it is clinically appropriate — while improving the decision-making environment in which those choices are made. Radiologists do not need to become gatekeepers for every examination. What matters is that the imaging entering the system is more likely to provide meaningful clinical value. ROOT won’t eliminate all unnecessary imaging. It can, however, reduce enough low-value utilization to meaningfully improve the capacity of the healthcare system.
The potential economic impact is substantial. ACR estimates that ROOT could save approximately $2 billion for Medicare and $1.5 billion for beneficiaries over 10 years. The benefits extend beyond a Medicare spreadsheet. Imagine a radiologist who has 50 examinations waiting in a worklist. If five of those studies could reasonably have been avoided or replaced by a more appropriate examination, the benefit is not simply the cost of those five scans. It is the opportunity to devote that radiologist’s limited cognitive capacity to the 45 patients whose imaging needs his or her full attention.
Our goal should be to maximize the value generated by each radiologist’s expertise. That is a more meaningful measure of productivity than the number of examinations each radiologist can interpret.
It is imperative that we find ways to manage the radiologist workload mismatch. Better workflows, more training of radiologists and eventually AI will help. Yet, none of these solutions can fully compensate for an imaging system in which demand continually expands faster than physician capacity.
Eliminating every marginally useful examination is neither practical nor desirable. Medicine does not work that way, and patient care is too nuanced for such a goal. We should instead recognize the limits of how much more efficiently a radiologist can work and look for opportunities to make the healthcare system smarter about the work we ask radiologists to do. The ROOT Act represents one step toward that goal.
If we are serious about addressing the radiology workforce shortage, improving patient access and building sustainable radiology practices, we need to tackle productivity from all angles. That means finding ways to improve technology and workflow, expand the workforce and, critically, ensure that radiologists are spending their limited time on imaging that provides meaningful clinical value.
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