The Fiscal Pressure Behind Medicare Payment Trends

Gregory N. Nicola, MD, FACR, Chair, ACR Commission on Economics was a guest columnist for this piece.

As radiologists, we are often demoralized by the reimbursement headwinds affecting our practices. But to understand the broader forces shaping Medicare physician payment policy — including annual conversion factor reductions, absent inflationary updates and statutory mandated healthcare reform — it is essential to step back and examine the economic stress faced by the Medicare program itself.

Radiology Under Pressure: Policy Responses and Payment Impacts

Over the past decade, Medicare Part B expenditures have nearly doubled, rising from an estimated $220 billion in 2011 to approximately $400 billion by 2021. This reflects not just an aging beneficiary population but also higher use of outpatient services, increased adoption of advanced imaging and diagnostics and the growing cost of physician-administered drugs. These are core components of Medicare Part B, but it should be noted that this growth is not tracking inflation. According to projections by MedPAC, Part B spending is expected to increase at an average annual rate of 4.2% above general inflation over the next decade. Meanwhile, Medicare beneficiaries are bearing more of the cost burden reflected by increasing premiums often beyond Social Security inflationary updates. In this environment, policymakers face mounting pressure to contain spending. For a radiologist who delivers services largely through Part B, understanding these macroeconomic dynamics is critical.

Against the backdrop of rising Medicare Part B expenditures, radiology remains in the crosshairs of federal cost-containment strategies. Although imaging represents only a small fraction of total Medicare spending, it continues to be viewed as a “re-evaluable” service category. In 2023 and 2024, the conversion factor was repeatedly cut or minimally updated. For 2024, the conversion factor fell 3.4% from the previous year, largely due to budget neutrality adjustments required under law resulting from upward re-evaluation of payments for face-to-face office visit. The offset for the upward adjustment came from all other clinician services in the MPFS.

These cuts disproportionately affect radiologists because we do not frequently bill for face-to-face office visits. On top of that, radiology has seen reduced professional work RVUs for several core procedures, primarily resulting from mandated bundling of services performed together more than 75% of the time. When combined with rising practice costs, work-force shortages and inflation-exempt payment rules, many radiology groups are feeling a significant economic squeeze.

The Growing Crisis in Primary Care Access: Implications for Radiologists

The U.S. is grappling with a critical shortage of PCPs, a structural weakness that threatens the stability of our entire healthcare system. As radiologists, we are not immune to the ripple effects of this crisis. The degradation of primary care access affects downstream referrals, chronic disease management, imaging appropriateness and health equity. Understanding the scale, causes and implications of this shortage is essential for forecasting radiology reimbursement. The Health Resources & Services Administration estimates a deficit of approximately 68,000 full-time equivalent PCPs by 2036. This dwarfs the total number of actively practicing radiologists, resulting in policymaker attention being shifted away from a radiologist shortage to a primary care shortage. This is not just a statistic; it represents millions of individuals navigating a fragmented health system without consistent guidance or preventive oversight.

Several interrelated factors contribute to this shortage, including an aging U.S. population that requires more complex and ongoing care, nearly half of the current physician work force approaching retirement and caps on federally funded residency slots that limit the inflow of new physicians. These factors are certainly familiar to radiologists who share the same struggles. The high cost of medical education deters students from entering lower-paid primary care fields. Burnout, administrative burdens and moral injury are driving physicians out of the work force or into part-time practice. The biggest difference between the work-force struggles of radiologists and PCPs is entry-level salaries, potentially attracting more candidates to radiology over primary care. This has also made radiology a target.

The Burning Platform for Radiologists

Given the primary care crisis, as well as the reactions of policymakers, it is essential that radiologists have a voice in Washington, DC. The daunting financial situation of our healthcare system is an indicator that we may be forgotten. ACR membership is our voice — and how we warn policymakers that they have gone too far. It is how we inform these key decision-makers of the vital role we play in emergency care, oncology care and the general care of parents and their families, as well as the vital role we play in preventing disease through robust screening programs. It is critical that we protect imaging reimbursement and access to radiological care. Using the wise words of our former CEO William T. Thorwarth Jr., MD, FACR: “ACR membership is like mandatory auto insurance. We all have a responsibility to pay into a plan which protects access to our services and expertise.”

Innovation in radiology is key to expanding our importance in healthcare. Research that aims to expand the use and application of imaging technology, as well as radiologists’ expertise and diagnostic capabilities, has served our profession well and will continue to be the cornerstone of our success.

Artificial Intelligence: False hope or Lifeline?

The rise of AI in radiology has sparked both optimism and debate about its potential to transform radiology innovation, clinical workflow and economics. As reimbursement pressure intensifies under Medicare Part B, AI is often seen as a tool to help radiologists improve throughput, standardize quality and manage growing imaging volumes with fewer human resources. Yet, these technologies have not significantly impacted interpretive efficiency or reduced turnaround times. Still, high hopes remain for AI to drive down the cost per RVU, effectively amplifying the productivity of the radiologist.

But AI is not a financial panacea. Currently, most AI applications are not reimbursed. Furthermore, initial investment, integration costs and liability concerns remain barriers, especially for small and mid-size practices. Without specific CPT® codes or value-based payment frameworks that recognize AI’s contribution, its impact will remain confined to cost avoidance rather than revenue enhancement. In short, AI represents a strategic operational lever but not an exit ramp from broader economic constraints.

The radiology community must pair AI adoption with policy advocacy to ensure these tools are recognized and rewarded within the evolving Medicare ecosystem. ACR is acutely aware of the importance of fostering this innovative technology. To answer this urgent call, the ACR Commission on Economics is consolidating AI resources across the College with the creation of a new ACR Artificial Intelligence Economics Committee to be chaired by Frank J. Rybicki, MD, PhD, FACR. 

Radiology must continue to demonstrate value, push for fair resource accounting and engage in forward-looking advocacy strategies. As chair of the ACR Commission on Economics, I can say with confidence that our specialty’s ability to thrive under these financial constraints will depend not only on defending individual code values but also on reshaping the broader economic narrative. Policymakers must understand that imaging is not a driver of runaway Medicare costs — it is a clinically essential, cost-efficient tool that often prevents unnecessary downstream spending. By engaging proactively with CMS, MedPAC and congressional stakeholders, we can help ensure that radiology remains appropriately reimbursed, accessible to patients and central to the future of value-based care.