Xin Li, MD Recipient of the ACR's 2024 James M. Moorefield, MD, FACR, Fellowship in Economics & Health Policy

The 1980s was a challenging period for radiology from an economic perspective. Aiming to reign in the exponential increase in healthcare spending, President Reagan’s 1987 budget proposal explored the possibility of establishing a diagnosis-related group (DRG) payment system for hospital-based specialists, radiologists included. If implemented, radiologists would have faced a potential 40% cut in payment. 

Rising to the challenges, James M. Moorefield, MD, FACR, led the ACR’s effort to establish a radiology-specific relative value scale (RVS). In 1988, HCFA (Health Care Financing Administration), now known as CMS (Centers for Medicare & Medicaid Services), accepted the radiology RVS recommendation in toto, which gave the field of radiology significant advantages over other specialties. 

Not only was radiology able to maintain the fee-for-service payment model, but radiology was also one of the few specialty-specific RVS recommendations included in the newly established resource-based RVS. In essence, Moorefield and ACR’s efforts ensured the financial viability of radiology for the next decade. 

Nearly four decades later, radiology is once again at the crossroads and faces a triple threat of reimbursement cuts, workforce shortages and uncertainties surrounding artificial intelligence. Central to the challenges is the dreaded budget neutrality, which in recent years has forced redistribution from specialists, such as radiologists, to primary care providers. 

Not only was radiology able to maintain the fee-for-service payment model, but radiology was also one of the few specialty-specific RVS recommendations included in the newly established resource-based RVS.

Without sounding pessimistic, 2024 started with bad news for physicians when Congress failed to prevent the full 3.37% cut to Medicare physician payment. However, there are reasons to be optimistic. My Moorefield Fellowship experience has shown me that the ACR is well-positioned to lead with its extensive institutional knowledge. It should also be emphasized that the ACR can no longer do it alone, and unquestionably needs robust membership participation to ensure the viability of radiology. 

To illustrate the importance of institutional knowledge, there is no better example than the continued radiology representation on the CPT Editorial Panel and RVS Update Committee (RUC). Although there have been areas of attrition — for example, bundling of imaging codes (payment cuts, in more plain terms) — the efforts by ACR staff and physician representatives have been largely successful and, at the same time, underappreciated. 

The uncomfortable reality is that for a variety of reasons, radiology codes are constantly being brought forward to the RUC for re-valuation (read: lower valuation) at no fault of our own. It should be emphasized that no other specialty has received the same level of scrutiny as radiology. Nearly the entire radiology code family was re-evaluated and sometimes double re-evaluated in the 2010s. There have been occasions where our RUC advisors were questioned in front of the RUC panel for hours on end. 

From my own observation, RUC advisors not only have to be well-prepared for potential questions but also must strike a delicate balance between brevity and verbosity. Codes presented in a sloppy fashion only invited more probing from the RUC panel, and the experience of RUC advisors was critical in effectively engaging the audience. 

With that in mind, it is remarkable that radiology has seen only a modest decrease in reimbursement. Without the heroic efforts of ACR staff and physician advisors, much more would have been lost during the RUC process. 

The value of our economics team is not limited to their participation in the RUC process. Code creation is an intricate play of risks and rewards. Keep in mind the budget neutrality rule, which dictates that any new code creation (and value) will translate into cuts for all other codes. Our experienced CPT staff and physician representatives have used many strategies to stave off code changes that would introduce inadvertent cuts to other codes in the same code family, or to preserve individual codes in category III status to prevent unwelcome re-evaluation. 

When the ACR puts forth or co-sponsors a code change application, careful consideration is undertaken to ensure there are no unintended consequences during the process. If the codes do not present well in front of the RUC panel, they are sent back to the CPT team for further refinement. 

Our institutional knowledge also means prompt responses to legislative challenges for radiology practices. More recent examples include the joint lawsuit from the ACR and other medical specialty societies to challenge the “No Surprises Act” rulemaking; ACR advocacy for changes to Merit-based Incentive Payment System (MIPS) regulations that inherently disadvantage radiologists; and ACR’s continued effort to mitigate across-the-board reimbursement cuts. 

However, the most important aspect of today’s advocacy landscape is robust membership engagement. As they often say at RUC meetings, “We live and die by the surveys.” These surveys are critical to accurately measure the physician’s effort for each radiology code. 

A current effort by the AMA is to collect updated practice cost information for each specialty through its physician practice information surveys (PPIS). The data gathered will be shared with CMS and, if implemented, may impact the technical (or practice expense) reimbursement for all specialties.  

Importantly, indirect expenses account for nearly 40% of radiology reimbursement. During the last PPI survey in 2007–2008, the radiology response rate was low and, subsequently, we fared poorly in the CMS practice expense update. Robust participation in the AMA survey process is encouraged to better reflect radiology interests in the upcoming update, as our response rate continues to be low. 

Moorefield’s pioneering efforts have ensured the financial viability of radiology during challenging times. Nearly four decades later, we are again facing significant headwinds from an economic perspective. 

There are reasons to believe we will come out ahead again, given the experienced and engaged physician volunteers and work of ACR staff. However, the importance of member engagement has never been more critical, especially concerning the ongoing AMA practice expense data collection effort. Members are encouraged to participate, so together we can work to ensure the financial viability of radiology in the coming decades.