ACR Bulletin

Covering topics relevant to the practice of radiology

Radiology Reimbursement and the Next 100 Years

Technology and those who operate it will only increase in demand as the specialty continues to evolve.
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Gregory N. Nicola, MD, FACR

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

October 23, 2023

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

The title of this article is intriguing but misleading. The truth is that no one can predict how payment for a technology-centered profession will evolve over the next 10 years, let alone 100 years. What we can do is discuss the perceived value of our profession and review the barriers for widespread seamless and safe growth of imaging technology. This is an important exercise as history has proved that problems are solved and efficiencies are gained by technological evolution.

For example, communication has been revolutionized with massive gains in efficiencies by the advent of the telephone. While controversy exists on who is the rightful inventor, there is no doubt that the electronic transmission of voice has been historically significant. Telephones have unified families and globalized businesses by allowing for real-time, seamless communication across long distances.

Of course, telephones have evolved since the first Bell telephone from 1875. Our phones have advanced from the original primitive voice communicators to devices that are now full-blown pocket computers able to send disparate types of real-time data across the globe instantaneously. Phones are now extensions of the human mind, serving as our sources of communication, entertainment, knowledge, validation and escape from reality.

Those who used the first iterations of the telephone had little idea how profoundly this device would evolve, just as we have little ability to imagine the future iteration of radiology.

I personally cannot imagine a future 100 years from now in which patients aren’t initially evaluated by a futuristic scanner.

The value of medical imaging and radiologists defined by economics is murky and depends on who is defining it. We hear repeatedly from those who pay for healthcare that medical imaging is expensive, with large amounts of waste.

Waste, in those terms, means that the patient’s outcome would have been the same with or without imaging. Yes, payors also acknowledge the high value of imaging as well, but good luck hearing them say that!

The other stakeholders who define medical imaging and radiologist value are the ordering clinicians and patients. Both these cohorts have overwhelmingly driven demand for imaging into the stratosphere.

The reasons are extensive. Imaging seems to have nearly completely replaced the nuances of a physical exam in busy emergency departments. Ordering providers in many practice settings value a negative imaging study far greater than the payors. Patients use technology in many aspects of their life and may now view it as a necessary data point in determining their health status.

The reasons are countless, but can you imagine a future in which this technology does not become safer, more reliable and more pervasive? Certainly, our fantasy sci-fi writers do not; have you ever seen a futuristic movie in which physicians don’t use some type of next-generation scanner to evaluate a sick patient? I personally cannot imagine a future 100 years from now in which patients aren’t initially evaluated by a futuristic scanner.

Some of the barriers to more widespread applications of medical imaging are safety, namely from radiation and contrast exposure; false positives; overdiagnosis; and management of incidental findings mixed in with the task of balancing cost effectiveness.

As our technology becomes safer and cheaper, and the management of incidental findings becomes more cost effective, it would be hard to imagine a world in which imaging is used not only on sick patients, but also on healthy patients in screening for a variety of conditions. Screening and early intervention for chronic disease is the holy grail of improving the quality and quantity of human life.

The difficult questions surrounding screening center on who to screen and how to manage false positives. These questions will likely be answered for many screening populations over the next 100 years, and medical imaging and medical imaging experts will play a vital role.

Finally, the evolution of technology historically has another profound effect we must consider: democratization of the operator. As technology becomes safer and easier to use, this often sets forth a cascade of events that rapidly expand the demand for use — hence the demand for the operator and interpreter of the technology.

Many clinician types will seek training for use and interpretation of advances in imaging technology. Radiologists will lose and gain skills during this evolution, and the job will not look like the current profession in 100 years. But neither will any other job on the planet — or perhaps the solar system.