Neiman Institute highlights key policy issues and solutions in radiology

The institute also has found a correlation between increased imaging utilization and care provided by nurse practitioners and physician assistants, particularly in emergency departments. While the research does not identify a specific cause, Rula said the findings suggest nonphysician providers may rely more heavily on imaging to support diagnoses.

Appropriate use criteria could reduce prior authorization burden

Rula said prior authorization remains a growing concern, particularly in Medicare Advantage, where providers frequently experience administrative burden and delays in patient care.

Rather than relying on prior authorization programs, she pointed to clinical decision support systems built around the American College of Radiology Appropriate Use Criteria as a more effective approach. These tools can be integrated into electronic health record systems to alert ordering providers when imaging requests may not align with evidence-based guidelines.

"We think that is probably the most important solution that could be broad-based and make a really big difference," Rula said.

Such systems could reduce unnecessary imaging while minimizing the administrative workload associated with prior authorization reviews.

Increasing the radiology pipeline and retaining physicians

Addressing workforce shortages also will require increasing the number of residency and fellowship training positions, Rula said. Most graduate medical education funding continues to come through Medicare, although privately funded residency programs have expanded in recent years.

However, increasing training capacity alone may not solve the problem. The Neiman Institute has documented a significant increase in radiologist turnover during the past decade. According to Rula, attrition rates have doubled in less than 10 years and surged amid the COVID-19 pandemic, without returning to previous levels. Burnout appears to be a major contributor.

"We hear time and time again that burnout is a real issue with the volumes that radiologists are dealing with now," she said.

Industry consolidation also may be contributing to physician departures by creating opportunities for practice sales and earlier retirement among overloaded radiologists.

Research influences Medicare coverage of CT colonography

Among the institute's recent policy successes was research supporting Medicare coverage for CT as a colorectal cancer screening option.

For years, Medicare declined to cover the exam, despite evidence supporting its effectiveness. Working with researchers at Northwell Health, the Neiman Institute evaluated the cost-effectiveness of CT colonography and found it could be particularly beneficial among black Medicare beneficiaries.

The research also demonstrated that before coverage was available, higher-income patients were more likely to pay out of pocket for the exam, creating disparities in access.

Rula said the findings helped support policy changes that expanded Medicare coverage and increased screening options for patients who may be unwilling or unable to undergo traditional colonoscopy.

"There are a lot of barriers for certain populations," she said. "So it was exciting to be able to provide that evidence back to Medicare."

Protecting the clinical role of interventional radiologists

Another area of focus is demonstrating the value of clinical care delivered by interventional radiologists. Because diagnostic imaging often generates higher revenue per hour than clinic visits, healthcare systems facing workforce shortages may be tempted to assign interventional radiologists more diagnostic reading responsibilities at the expense of patient consultations.

Recent research published in the Journal of the American College of Radiology found a strong relationship between clinical evaluation and management activities and the complexity of procedures performed by interventional radiologists.[1] The findings support the argument that maintaining clinic time is essential for interventional radiologists to provide high-value, complex procedures.

"It is more of the trade-off of the reimbursement per time that is the challenge," Rula explained.

Declining pediatric radiology workforce raises concerns

While the overall radiologist workforce continues to grow, pediatric radiology represents a troubling exception. Research from the Neiman Institute indicates the number of pediatric radiologists is declining, raising concerns about access to specialized imaging expertise for children. 

Studies also have shown that pediatric radiologists are more likely to use lower-radiation imaging modalities, including MRI and ultrasound, when appropriate. Whereas general radiology tends to use more CT and X-ray.

"That is concerning as we consider the safety of imaging for our children," Rula said.

Lung cancer screening and opportunistic AI detection

The institute also is examining ways to improve participation in lung cancer screening programs.

One recent study evaluated the impact of shared decision-making visits required by the Centers for Medicare and Medicaid Services (CMS) before a patient's first low-dose CT lung screening exam. Researchers found that those who completed the shared decision-making visit were 30% more likely to continue annual screening over a four-year period.[2] The findings helped inform policy discussions at the American Medical Association focused on increasing screening adherence.

Looking ahead, Rula sees significant opportunities for artificial intelligence-automated opportunistic screening using existing imaging studies. One example is analyzing CT scans obtained for other clinical reasons to assess bone density and identify patients at risk for osteoporosis without requiring a dedicated DEXA scan. Studies also are ongoing looking at incidental findings for coronary calcium scoring or lung cancer screenings in any type of chest exam. Some AI for opportunistic screening options are already cleared by the U.S. Food and Drug Administration.

AI could expand the value of every scan

Overall, Rula sees artificial intelligence playing an increasingly important role in extracting additional clinical value from imaging exams.

AI tools are already being deployed to identify coronary artery calcium, lung nodules and other findings from scans obtained for unrelated purposes. She believes AI could help radiologists identify and document incidental findings that might otherwise be overlooked while reducing reporting burden.

"I think it's a huge opportunity for AI," Rula said. "If there is a separate AI looking for everything else surrounding the finding of interest in that exam, that could really help with efficiency and prevent situations where some of those incidental things are missed."

As radiology continues to face workforce constraints and growing imaging demand, Rula said evidence-based policy solutions, improved screening strategies and targeted use of AI will be critical to maintaining access and quality of care.