From the Chair of the Commission on Economics
Gregory N. Nicola, MD, FACR

There is a palpable shortage of radiologists in practices and academic departments across the United States, with more than 1,400 physician positions posted right now on the ACR job board. As the need for radiology exams and services has increased, the number of radiology and nuclear medicine physicians graduating from training programs has fallen behind. This may lead some to question why we do not simply train more radiologists to address our workforce shortage. 

To address this question, it is important to first understand how graduate medical education (GME) is funded. In 1965, the Social Security Act created Medicare, Medicaid and GME funding. Medicare still accounts for the largest source of GME funding, which amounted to $16 billion in 2020. Medicaid contributes about $4.3 billion annually, and there are smaller contributions from the Department of Veterans Affairs, Children’s Hospitals GME, Teaching Health Center GME and the Department of Defense. While Medicare makes substantial investments in training physicians, the payments are limited.

The two streams of funding are called Direct GME (DGME) and Indirect Medical Education (IME). DGME is intended to pay resident salaries and benefits, teaching costs and GME infrastructure for a hospital.  IME are the indirect costs of operating a residency that may result in higher patient costs, such as additional tests that may be ordered by residents compared with attending physicians. 

IME payments are often twice as large as those for DGME. The methodology for determining the DGME is based on a complex formula that includes the per resident amount (PRA), the adjusted rolling average full-time equivalent (FTE) count and the Medicare patient load at a hospital. The PRA was set in 1984–1985 and is updated for inflation annually. 

Residency position caps are allotted to hospitals, rather than being directed to specific specialties and departments within hospitals.

Congress limits the number of resident FTE it will support. In 1997, the Balanced Budget Act capped the number of fundable resident positions at each hospital to the number in training in 1996, resulting in a significant reduction in the growth of physicians training in subsequent years. Residency position caps are allotted to hospitals, rather than being directed to specific specialties and departments within hospitals. How the cap funding is distributed across individual residencies within each hospital is determined locally. 

Programs may grow by applying for increased resident complements from ACGME, but that does not guarantee funding if a hospital is already over its cap. While it is also possible to increase funded training positions by expanding into new “pristine” facilities that have never had residents on site where a new cap can be established, this route to growing our workforce is inefficient, and the number of pristine hospitals available to train radiologists is limited.

The Consolidated Appropriations Act of 2021 added 1,000 new Medicare-funded residency positions for the first time since 1997, and this was to be phased in by adding 200 positions per year for five years. CMS is prioritizing hospitals with training programs in geographic areas showing the greatest need for additional providers and services, based on a Health Professional Shortage Areas (HPSA) score. 

In 2022, the ACR sent a letter urging CMS to allocate radiology positions to ensure care for Medicare patients in rural areas. In July 2023, the initial 200 positions were mostly directed to primary care and mental health services, with only six positions for diagnostic radiology and 3.23 positions for interventional radiology. 

There is a well-described physician shortage in the United States, and this includes radiology. The number of students matching into radiology residency positions through the National Resident Matching Program was 1,084 in 2010, and in 2023 there were still only 1,006 matched into diagnostic radiology and 123 into interventional radiology, with 100% of positions filled. Census data shows the growth of the U.S. population over age 65 increased 38.6% from 2010 to 2020, suggesting that we are not training enough radiologists to meet the needs of our aging population.  

Many academic institutions already choose to train additional residents per year over their cap that was established in 1996. For example, about 18% of the residency positions in the state of Louisiana are not funded by the government. There has been little success growing the number of funded residency positions, so I believe future growth in our workforce will require self-funded positions by our health systems. Many future hires come from trainees in our own institutions, so it is a worthy topic for healthcare leadership to consider.

James M. Milburn, MD, MMM, FACR, serves as vice chair of radiology, residency program director, and director of neurointerventional services at Ochsner Medical Center in New Orleans. He is a professor of radiology for the University of Queensland Ochsner Clinical School, and he serves as chair of the neuroradiology committee for the ACR Commission on Economics.