HPC Corner: The Changing Landscape of Radiology and the Impact Deinstitutionalization May Bring

By: Jen Nathan, MD

Radiology may be one of the most innovative and dynamic specialties in medicine, with multiple factors that have changed how Radiology is practiced over the years.  The most obvious factor influencing change are technologic advancements such as new modalities/techniques, and more recently the development of machine learning/artificial intelligence. While we don’t yet know how this technology will change Radiology, we do know it’s coming, and in fact, there are already a few FDA approved programs such as QuantX, a program to detect breast abnormalities, and Aidoc, a program that detects intracranial bleeds.  Beyond technological advancements, payment reform, geared towards reducing the cost of health care has drastically altered the practice of Radiology.  Many have felt reform began with the Deficit Reduction Act in 2005 with additional policies/legislative actions following.  One recent example of potential payment reform has been the bundle payments for care improvement project (BPCI) by CMS, where essentially a price is set for an episode of care based on diagnosis.  This price combines payments for physician, hospital, and other healthcare provider services, with radiology getting a portion of the payment.

While technology and payment reform have markedly changed the landscape on how Radiology is practiced, a third process has also slowly been taking place in the background that many believe will drastically alter not only how Radiology is practiced, but the healthcare system overall.  This third factor is known as “deinstitutionalization.”  While you may not have noticed this occurring, it is happening at an increasing rate, with a growing trend of shifting patient care from the inpatient to the outpatient setting. The reason for this trend is multifactorial, including increasing pressures to reduce health care costs, consumerism, increasing technology, and evolving regulatory reforms.  A study conducted by the Deloitte Center for Health Solutions in 2018 found that visits to outpatient facilities, including urgent care centers, ambulatory surgery centers (ASCs), and retail clinics, increased by 14 percent from 2005 to 2015. During this time, total hospital outpatient revenue increased by 45 percent, from $1,352 per visit in 2010 to $1,962 per visit in 2015.  Outpatient care has proven to be a lower cost alternative comparing an average inpatient stay of around $22,000 versus outpatient costs on the average costing around $500.  To add to that, reports have also shown improved recovery outcomes with patients preferencing being at home with family and friends over a hospital stay.  Some reports have also cited decreased risk for hospital acquired infections, shorter wait times for a procedure, and convenience of scheduling online.  The shifting of imaging to the outpatient setting may prove to be harmful for Radiology, as this shift could mean less imaging studies are ordered with a reduction in volume and potentially less of a need for radiologists.  There may also be a reduction in costs as outpatient imaging centers are forced to compete for patients with other centers and to offer competitive pricing.  In addition, there is always the concern for expansion of site-neutral payments by CMS, whereby the reimbursement rate will be made equal regardless of site of service.

In a constantly changing specialty it is important to be aware of what changes may be coming and how we can work together to protect the health of our field and patient care.  For any questions or comments please contact me at jennifer.nathan@nih.gov .


  1. Deloitte Insights:  Growth in Outpatient Care-The role of quality and value incentives.  Arlington, VA.  Deloitte, 2018.