The radiology profession continues to grow in spite of hard times. According to data from the American College of Radiology (ACR), Reston, Va, there are currently more than 30,500 practicing post-training radiologists in the United States (including both diagnostic radiologists and radiation oncologists). That’s a jump from 26,800 in 2003 and 25,600 in 2000. But James Borgstede, MD, vice chairman of the Department of Radiology at the University of Colorado, Denver, and past president of the ACR, still sees a shortage of US radiologists.

“We need more radiologists, and we’re trying to increase training programs and attract the best and brightest medical students into our radiology specialties,” noted Borgstede.

Part of the problem may be that more and more current radiologists are reaching retirement. The ACR reported 6,500 retirees in 2007; that’s a steady increase from the 5,870 retirees in 2004 and the 5,100 at the turn of the millennium. Though studies show that radiologists retire approximately 2 years after the average American worker at the age of 64, statistical data indicates that, if anything, they may be retiring earlier on average than they did a decade ago.

Anecdotal evidence suggests that retired radiologists may be rejoining the workforce under the aegis of teleradiology service providers, which equip clinical staff to work from home on a full- or part-time basis. And as older radiologists retire, they are not being replaced sufficiently by a new generation. The ACR reports 4,500 radiology and radiation oncology residents in 2007, down from 4,670 in 2004 and equal to the 4,500 reported in 2000.

Another way the ACR tracks the radiologist shortage is by monitoring job vacancies. The College says the job market in 2007 was “intermediate” compared with the highs and lows the industry has seen over the past two decades; while filling vacancies is easier, finding highly desirable positions has become more difficult with time. Interventional radiology and breast imaging are the subspecialties in which academic positions are most difficult to fill, while positions in neuroradiology and nuclear radiology are easiest. (The College notes that these findings can generally be considered accurate for community practice, as well.) Job listings per job seeker in both community and academic positions were 0.72 for 2007 compared with approximately 1.1 to 1.2 for 2003 to 2006.

According to the most recent available data, 18% of US radiologists are women, while 24% of radiology residents-in-training are female. Thirty-nine percent of female radiologists work part-time, compared to 16% of their male colleagues; women are most strongly represented in academia and breast imaging and underrepresented in interventional radiology and neuroradiology. In situations where radiologists are likely to be practice owners, fewer women than men are owners.

Though 69% of post-training, actively practicing radiologists subspecialize to some degree, only 31% spend at least 70% of their clinical work time on a single subspecialty. The most common areas of subspecialization in the United States are interventional radiology, breast imaging, neuroradiology, and body imaging. Among radiation oncologists, 48% subspecialize to some degree, but only 11% spend more than 70% of their clinical work time in a single area. The most common fields of specialization for radiation oncologists are prostate and breast radiation oncology, as well as brachytherapy.

Though fewer medical students are choosing to enter the radiology field, radiologists in the United States report a high level of satisfaction with their careers—higher, on average, than most other specialist groups. More than 90% say they enjoy their work “very much” or “somewhat,” while citing medicolegal climate, workload, and reimbursement/financial pressures as the three most prominent reasons for any decreases in satisfaction over time.

James Borgstede, MD, Vice Chairman, Department of Radiology, University of Colorado, Denver

Technologist Statistics

Information from the Annual Staffing Survey compiled by the American Society of Radiologic Technologists (ASRT), Albuquerque, NM, reveals that significant progress has been made in addressing the tech shortage, which, according to some reports, has prompted techs to take traveling jobs in order to better address deficiencies. (In a survey conducted by MedTravelers Inc, Irving, Tex, 25% of responding imaging department managers reported a need for temporary technologists, most commonly to supplement existing staff.)

As of March 2008, there were 279,125 ASRT-registered technologists in the United States, a steady increase from 254,838 in 2005 and 227,300 in 2002.

Meanwhile, vacancy rates for techs have declined accordingly: in 2003, ASRT-measured vacancy rates were as high as 10.3%, a figure that fell to 5.4% by 2005 and is now down to 3.39%.

“In terms of absolute number of vacancies, the Radiology Staffing Surveys provide the mean number of vacant-and-recruiting FTEs per facility,” noted John Culbertson, research manager for the ASRT. “To translate the per-facility mean into a national total, we would need to know the total number of radiology facilities in the United States. SK&A [SK&A Healthcare Information Solutions, Irvine, Calif] attempts a census of such facilities, both hospital-based and freestanding. Their 2008 database listed 10,319 separate facilities, probably an underestimate, given that no census is ever 100% complete. Since 89.4% of the facilities in our sample report that they provide radiography services, that translates into about 9,225 radiographer-employing facilities in the United States. The mean number of radiographer FTEs that were vacant and recruiting in 2008 was .38, which translates into about 3,506 FTEs worth of vacancies for radiographers—again, probably an underestimate.”

The ASRT’s Enrollment Snapshot Report takes a look at the number of students entering educational programs in radiologic sciences for an idea of how many technologists can be expected to be available in the future. These numbers are also on the rise. “Our most recent data indicates that 16,612 students entered radiography programs for 2007,” said Culbertson. “Taking attrition rate and pass rate into account, radiography is adding an estimated 13,045 to the profession per year.” That’s up from 11,800 in 2005 and just 8,530 in 2003.

When Axis Imaging News looked at the radiologic technologist profession as part of its 2005 “State of the Industry” report, the ASRT was predicting that the United States would not meet the US Bureau of Labor Statistics (BLS) projection for an estimated 72,000 additional radiologic technologists through 2012. The most recent Enrollment Snapshot Report has some good news: “The best current estimate is that radiography programs are producing new practitioners substantially [about 33%] above the rate to meet the 2006-2016 demand estimated by BLS, while radiation therapy programs will almost double and nuclear medicine programs will almost triple the BLS-projected demand.”

But Culbertson injects a note of caution. “There are signs that enrollment will not stay at a constant rate over the next few years,” he said. “The percent of programs in these three disciplines that are operating at full enrollment declined in 2007 after having increased steadily since the first enrollment report [in 2001]. Program directors might be adjusting based on declining vacancy rates.”

Portrait of DIs

The number of diagnostic imaging centers (DIs) continues to rise, but the rate of growth has slowed considerably. In 2000, Verispan LLC, Horsham, Pa, identified 3,337 DIs; that number had increased to 5,163 by 2003 and 5,769 in 2004. Today Verispan identifies 6,455 DIs in the United States, an 11% growth in 4 years. (Between 2000 and 2004, the number of DIs grew by almost 73%.)

Florida currently hosts 676 DIs, the most in the country, while Vermont brings up the rear with just two. Other leading states include California (637), New York (525), and Texas (514), while New Hampshire hosts just nine and North Dakota boasts only seven.

But though the number of DIs in the country is still growing, albeit slowly, the number of radiologists employed has actually decreased, according to Verispan. In 2004, the group identified 10,232 radiologists reading for freestanding imaging centers, a moderate growth of about 3% since 2003. Today, Verispan identified 8,895 radiologists employed by DIs, a decrease from last year’s figure, 9,098.

Technologist employment, on the other hand, has grown, painting a mixed picture of the state of freestanding imaging centers in the United States. DIs employed 22,049 full- and part-time technologists in 2004; today they employ 25,747 full-time techs and 2,814 part-time techs for a total of 28,561. That’s an average of 4.4 techs per center, compared with 3.8 in 2004. Radiologists per center, on the other hand, have decreased from 1.77 in 2004 to 1.37 today.

One reason could be the growing number of DIs represented in a chain. Imaging centers are now more likely to be part of a larger business than they were just 3 years ago, before the DRA. In 2005, according to Verispan, 55% of US DIs were part of a chain; that figure has risen to 73% in 2008.

Another reason could be the mounting popularity of teleradiology. In 2005, remote reading by anonymous radiologists was still a new concept; today it’s a booming business, an “essential part of the practice of radiology,” according to one New England Journal of Medicine editorial. The reasons for choosing a

teleradiology service over nighttime staff, or even daytime subspecialist staff, are familiar: quality of services, convenience, and, most of all, competitive pricing.

According to a poll taken at the 2007 Economics in Diagnostic Imaging Conference, there are now 23 teleradiology companies providing services to nearly 50% of US hospitals, and two of these 23 companies, NightHawk Radiology Services, Coeur D’Alene, Idaho, and Virtual Radiologic, Minneapolis, are trading publicly. While an additional 25% of hospitals are shopping for a service provider, Virtual Radiologic is reporting Q108 revenue growth of 29%, and NightHawk is reporting 61% revenue growth since Q107. NightHawk notes that new service offerings, including daytime final reads, represented 21% of total revenue for Q108, while final reads revenue represented 11% of total revenue, up from 8% in Q407.

Utilization Snapshot

According to the most recent available data from the Centers for Medicare and Medicaid Services (CMS), utilization of imaging services is on the rise among Medicare beneficiaries. This data has been used by the ACR to estimate nationwide utilization. The most common class of procedures performed, by far, is general radiography (including mammography); estimated country utilization was 292 million procedures in 2006. The next most common modality is ultrasound (136 million procedures), followed by CT (72 million), nuclear medicine (41 million), interventional radiology (33 million), and MR (23 million).

Number of ASRT-Registered Technologists













Since 1998, utilization of advanced imaging modalities has increased rapidly, while utilization of radiography has remained relatively stagnant. Data from Verispan confirms this finding. According to Verispan, there are currently 6,455 diagnostic imaging centers in the United States. Nearly 3,000 of 5,757 responding facilities report that they have radiography equipment installed as of 2008—just over 50%, a figure that has actually decreased since 2002, when around 61% of responding facilities had radiography equipment. Ultrasound is also on the decline as a modality: 54% of responding facilities reported owning ultrasound equipment in 2002, compared with this year’s figure of 48%. Mammography, always a challenged modality, has declined from 53% to 41%.

Increased utilization from other areas of medicine could be one reason for the shift away from basic imaging services. “We need to get beyond the concept that one specialty owns imaging exclusively,” said Borgstede. “Imaging is the property of anyone who can compete at a high level for high-quality imaging for the best interest of the patient.”

Meanwhile, physician self-referral for advanced imaging services is on the rise, according to a report from Jean M. Mitchell, PhD, professor of public policy at Georgetown University, Washington, DC. By analyzing billing records for ambulatory services rendered to beneficiaries of a large private California payor, Mitchell was able to identify the prevalence and scope of self-referral arrangements for MRI, CT, and PET.

The report shows that around 33% of providers who submitted either global or technical bills for MRIs were nonradiologist physicians practicing self-referral; 22% of these submissions for CT came from nonradiologists, and 17% of submissions for PET. “Almost 61% of the 340 nonradiologist physician providers who submitted global bills for MRIs did not own the equipment, nor was the machine located on site,” the report continues. “Nearly 64% of the self-referral CT providers who worked in small- to medium-size groups billed the insurer but had either a lease or payment-per-click arrangement.”

A more recent report from Mitchell, published in the May issue of Medical Care, uses the same evidence pool to take a more granular look at utilization trends for advanced imaging procedures. Analyzing data from a large California payor, Mitchell and team examined these trends for MRI, CT, and PET between 2000 and 2004, looking for insights into the effects of self-referral on rates of use.

The findings of the study will come as no real surprise to those in the radiology industry: over the 4-year period, MR and CT utilization increased by more than 50%, while PET utilization shot up by a stunning 400%.

“People still see the technical component as lucrative,” said Borgstede. “Meanwhile, the government is much more aware of problems with increased expenditure on imaging. The government doesn’t want to spend the money, and then you’ve got other people continuing to inappropriately utilize.”

Borgstede sees this issue as a major challenge facing radiology today, particularly in light of the growing prevalence of radiology benefit managers (RBMs), which automatically review physicians’ imaging study referrals for prior authorization before allowing coverage. Sounds helpful, but Borgstede warns that RBMs are primed for abuse by payors.

“It’s very easy for these utilization management firms to ratchet down authorization to create the savings the payor wants,” he said. “If a payor tells the utilization management firm they want a 5% savings, the firm embeds that in the computer ordering system, stopping people from being able to order given examinations. We can talk about inappropriate utilization of imaging, but imaging should be rationed based on its appropriateness for the patient, not on its ability to save the insurer money. That’s going to be a gigantic issue that we’ll face down the road.”

Looking Forward

There’s bad news and there’s good news for the radiology industry, according to Borgstede. “We’re in the DRA landscape,” he said. “Things have changed rather dramatically because the technical component has decreased.” And so far there has been no relief in the form of legislation—in both 2006 and 2007, the congressional year ended without a vote on either year’s version of the Access to Medicare Act.

“The President has made it clear that he intends to cut hospital reimbursement, and that links to the Medicare fee schedule technical component,” said Borgstede. “Within the TC reimbursement, there will be questions regarding interest rates and rate of amortization of equipment. We’re going to have to be prepared to defend appropriate interest rates for the leasing and purchase of equipment and to defend the actual utilization rate.”

For a breakdown of diagnostic imaging centers in the United States by state in 2007 and 2008, download this PDF.

Borgstede urges radiologists to consider better customer service as a means to remain competitive. “I don’t think radiologists have embraced patient contact like they should,” he noted. “The face of radiology is interventional and breast imaging. I think that radiologists who don’t improve patient contact are shortsighted. If we expect patients to pay their bills and respect us as part of their physician team, we’re going to have to interact more and more with them.”

But it’s not all gloom and doom, Borgstede says, as we move into a landscape of heightened utilization scrutiny. “Radiologists know how to operate in an appropriateness realm,” he said. “You’re going to see private payors, the government, and Congress push for appropriateness criteria in imaging. You’re going to see a big drive for the use of pay-for-performance metrics. Radiologists function very well there—the MQSA [Mammography Quality Standards Act] is a good example. So in the post-DRA era, not everything is bad. We just have to realize that everybody wants some cost savings and continue to drive for optimal care for our patients.”

Cat Vasko is a contributing writer for Axis Imaging News. For more information, contact .