With baby boomers continuing to retire throughout the next 10-15 years, by some estimates the U.S. is expected to have a shortage of more than 35,000 radiologists by 2034. The move toward retirement has only accelerated during the pandemic. For imaging professionals, these factors are contributing to a state of uncertainty regarding the future, and differing opinions on the best way to move forward.

“Some radiologists, having worked remotely from home during the pandemic, are reluctant to return to a hospital setting,” Dr. Vijay Rao, David C. Levin Professor and chair in the department of radiology at Thomas Jefferson University, told HCB News. “This, coupled with growing imaging utilization is creating a shortage of workforce. Reimbursements are also dropping and adding additional challenges in retention and recruitment of radiologists.”

The result is a supply and demand issue that often becomes a bidding war for higher salaries. Additionally, managing the resumption of delayed imaging and pressures from reimbursement cuts and calls to adopt more value-based care practices are also weighing heavily on practices and radiology departments. HCB News sat down with some insiders and experts to talk about these stresses and what approaches should be taken to address them.

Retiring now rather than later
According to the American College of Radiology, one third of full-time practicing radiologists were 55 and over in 2019 and expected to retire in the next decade. Dr. Christopher Filippi, radiologist-in-chief at Tufts Medical Center, has seen the pandemic pushing those retirement plans up. It isn’t just concerns for health and safety; some radiologists are struggling with burnout and dissatisfaction. Even before the pandemic, radiologists ranked sixth among medical specialists who were burned-out, according to Medscape’s National Physician Burnout & Suicide Report 2020.

“I think the shortage of radiologists will be exacerbated,” said Filippi. “That’s something I worry about in the back of my mind.”

Working from home has also become a preference for some over returning to work on-site, according to Rao. She says this is not completely feasible. “Radiologists are needed on-site to consult for appropriateness of imaging, supervise studies, monitor for contrast reactions and perform image-guided procedures. There is a lot of work that is done by radiologists that is patient facing. So it becomes a pressure point for us as radiologists when we don't have enough people on site.”

Another factor is the expanding role of AI, which is likely to change how radiologists practice. As many older radiologists are not as computer savvy as younger radiologists, this technological shift may spur earlier retirement, says Filippi. He adds, however, that the “overwhelming” nature of AI also makes some younger radiology students hesitant to pursue the profession for fear of job insecurity.

“It is not unreasonable to imagine that increasingly sophisticated AI programs may be developed that can read certain imaging exams as well as radiologists, so that there may be a need for fewer radiologists in the future,” he said.

Higher than normal imaging
With hospitals and practices short on radiologists, managing imaging workloads can be difficult, even among organizations relying on additional outside help, says Sandy Coffta, vice president of client services for Healthcare Administrative Partners. “Some of the teleradiology companies being leaned on to pick up this extra volume are short-staffed. We have seen a couple of examples where the teleradiology company has said, ‘Sorry, we can’t add any volume to your service for the next three to six months.’”

These volumes are higher than normal and continuing to grow, as radiologists juggle exams delayed by the pandemic with new patients. As a result, imaging providers nationwide are being forced to play catch-up in the face of large backlogs and heavier workloads. Further complicating matters, delays in imaging have resulted in patients coming in with more advanced disease states that may have been easier to treat in earlier stages had they been seen then, says Rao. “The complexity of cases has gone up. That definitely has had an impact on all the physicians, not just radiologists.”

As always, there is pressure on radiologists to utilize imaging appropriately and only administer exams that are deemed clinically necessary. “We need to improve access for patients,” says Rao. “We need to do a good job of managing utilization so we are doing only medically indicated appropriate studies and reducing waste to the system to control cost.”

At the same time, discussions around value-based care are taking place, but not enough has been done to establish best practices for diagnosis in radiology, says Filippi. “We do need to think carefully about this because you can’t just continue to image people 24/7. It’s not cost effective and it may not actually be better for patient care.”

While delays and cancellations in costly procedures have contributed to the financial strain on radiology practices, they are a symptom of a shift in patient behavior. Many patients, for instance, are now inclined to visit the urgent care for their imaging needs rather than a hospital, says Coffta. “Due to Covid, they are deciding that the ER isn’t the place to be. They say, 'Maybe I’ll go to urgent care and call my doctor in the morning.' Things that in 2019 would have been a 'no question' ER trip maybe aren’t now.”

Faced with potential reimbursement cuts
Working in one of the most profitable departments in hospitals, radiologists often face pressure to meet target volumes and reduce lengths of stay for patients to bring in more revenue. This pressure is expected to increase over the next year due to a new rule in the 2022 Medicare Physician Fee Schedule. Under the new rule, wages will increase for clinical labor staff. Because the schedule is budget-neutral, payments for medical supplies and equipment costs will decrease, according to Dr. Gregory Nicola, chair of the commission on economics for the American College of Radiology.

When adjusted for the conversion factor in calculating reimbursement, mandated sequestration and cuts to practice expense values, updating the labor wages is estimated to levy a 5% cut to interventional radiology and 1% cut to diagnostic radiology, after adjustments made by CMS. While more severe for interventional radiology, cuts to diagnostic radiology are further compounded by Medicare cuts made the year before that were originally supposed to be 10%-11% but later downgraded to a 4% cut. The remaining portion of the original cut, however, is set to go into effect as part of the upcoming 2022 schedule, according to Coffta.

This could make it harder to recruit staff for weekend and off-hour shifts and for radiologists to maintain their offices or upgrade equipment. “We are wary of buying technology when our payment structure isn’t stable,” says Nicola. “We’re wary of hiring staff to help us cover difficult shifts or subspecialty care that we may have a need for but don’t want to hire because the money is tight.”

While Nicolas agrees that clinical labor staff wages should be increased, he says that the timing is off due to the pandemic and that the money should not come at the cost of reducing reimbursement for radiologists and other specialists.

Bob Still, executive director for the Radiology Business Management Association, says the formulas used to form the Medicare Physician Fee Schedule rely on survey factors that may not be accurate, as the sample is too small. “When Medicare does new surveying on these practice expense areas and clinical labor cost, they need to do it in a way that is inclusive, fair and statistically valid.”

How to push back
Radiologists today are living in a time of disruption, fueled by advances in technology, an ongoing global health crisis and changes in payment models; and the profession must do whatever it can to stay at the forefront of these transitions. “We have to embrace change and look for opportunities to practice differently,” says Nicola. “That will allow us to be innovative and not disruptive. I just encourage our community to do that.”

Rao says better utilization of imaging and managing rising exam volumes starts with discussions about optimization and unifying best practices. “We want to maintain quality by standardizing our protocols across the enterprise. We want to improve access, improve quality and lower cost. That’s what’s going to help us succeed in the value-based system.”

Another way of helping in this endeavor is to train future radiologists for tomorrow’s care continuum. “In order for radiology to transition to value-based care, we need to train medical residents differently,” said Filippi. “There needs to be more attention given to the cost of certain exams, the appropriateness of certain exams to make a diagnosis and to look at the comparative effectiveness and cost effectiveness of imaging strategies.”

He also says that finding ways to deal with the rising volume of imaging exams and the daily tasks faced by radiologists may help, in the long-term, bring more people into the profession and reduce the number looking to retire early. “There hasn’t been a recognition of how much more difficult the work environment is for radiologists. I think that this has contributed to a kind of burnout which is talked about a great deal both in the private sector and on the academic side.”

For addressing financial woes and impacts on reimbursement, Coffta says it will take a team approach and discussing what each person can do to help and how radiology as a profession can update its reporting and scheduling to make it easier to care for patients and get paid for the services it is providing under a value-based system.

She adds that it is essential for radiologists to stay up-to-date with any developments within their hospital or health system. "The most important thing is keeping in communication with your healthcare system because largely they are driving the bus on bundled and value-based care. Whatever arrangement they get into with Medicare and other payers will affect how radiologists are compensated. If you're not at the table, you may get left out or get the smallest piece of the pie."

Still says that preventing further cuts and combatting impending ones requires educating the healthcare industry about the important contribution that radiologists make to the care of patients. “On a grassroots model, we need radiologists, individually and collectively, practice administrators, CEOs, to be able to tell the story about radiology and how it’s brought so much value and saved money over the years through the use of the Appropriate Use Criteria.”