One For All?
By Beth W. Orenstein
Radiology Today
Vol. 20 No. 11 P. 22

What would Medicare for All mean for radiology?

“Medicare for All” is sure to be a hot topic during the 2020 presidential campaign. Led by Vermont Senator Bernie Sanders, a number of Democratic hopefuls have lent their support to a single-payer health care system, though they continue to debate how to pay for it. No matter which party wins, few are optimistic that Medicare for All could become law anytime soon, considering how hard it was for the Obama administration to get the Affordable Care Act passed and the Republican attempts to dismantle it that have followed.

“Medicare for All means a lot of different things to a lot of different people,” says Paul Chang, MD, FSIIM, a professor of radiology, vice chair of radiology informatics, medical director of pathology informatics, and medical director of enterprise imaging at the University of Chicago. “Right now, it’s a campaign slogan, and we don’t have a lot of details on it.”

That said, radiologists have opinions, and they believe everyone should pay attention to the idea because it could have some impact on the way health care is delivered in the future. Would that impact be positive or negative for radiology services? It’s hard to say, largely because it’s all hypothetical, radiologists agree. Most of the experts Radiology Today speaks with see both good and bad outcomes, should Medicare for All ever become the law of the land. A lot would depend on how the plan is designed and adopted.

“There are multiple proposals that fall under the phrase ‘Medicare for All,’ including Sanders’ plan to cover all citizens, and other plans, such as the plan from Michigan Democratic Senator Debbie Stabenow that proposes to lower the age requirement to 50, 55, or 60 years of age,” says Eliot Siegel, MD, FACR, FSIIM, a professor and vice chair of information systems at the University of Maryland School of Medicine; an adjunct professor of computer science at the University of Maryland, Baltimore County; and chief of radiology and nuclear medicine at the VA Maryland Health Care System in Baltimore. ”The impact of lowering the age below 65, say to 60, would probably be relatively low compared with a transition to a single-payer system for insurance for all Americans.”

Potential Pitfalls
The radiology experts we interviewed noted several potential negatives of a single-payer, government-run health care plan for all Americans.

Lower Reimbursements
Currently, reimbursements from private payers for radiology services are higher than those from Medicare.

“It’s roughly 87 cents to the dollar when you compare Medicare vs private payers,” Chang says. “So, it’s probably reasonable to assume reimbursements from Medicare would be lower.”

Ricardo Cury, MD, CMO of MEDNAX Radiology Solutions, says the concern isn’t as much about getting paid less as it is about how lower compensation would affect the ability to provide quality radiology services to patients. Medicare for All and the abolition of private insurance would have a dramatic impact on hospitals and physicians across the country and would likely result in medical services being restricted rather than expanded, Cury says.

“Hospitals in general already operate on low margins,” he says. “The same is true for physician practices and radiology groups. If they get lower reimbursements for their services, they could have a tough time investing in technology and machine learning and artificial intelligence, which they must if they want to keep moving forward and improving.” Also, Cury says, radiology practices could have trouble recruiting physicians, especially subspecialists, who are already in great demand, to the field.

“If you don’t have money to reinvest, how do you attract talent to the practice?” he asks.

Limited Choices
William T. Thorwarth, Jr, MD, FACR, CEO of the ACR, says he would be most concerned about limited health care choices under a single-payer system. The country has already seen consolidation among major health insurance companies, and that consolidation has resulted in fewer choices for patients and providers, he says. He believes a single-payer system would only limit patients’ choices of providers to a greater degree.

“It’s important to people who are insured that they are able to choose which providers and sites they feel most comfortable with,” Thorwarth says. “In a single-payer system, that goes away.” When it comes to health care, one size doesn’t fit all. “Patients need to be able to customize the care they feel they need, and providers need to be able to determine in what environment they want to provide that care,” he says.

In Thorwarth’s opinion, the combination of limited choices and lower reimbursements would be a disaster. “You would find that it significantly stifles the innovation that is going on right now—not only in radiology but all specialties—to improve on the health care system that so many rely on day to day,” he says.

Additional Bureaucracy
One of the other issues with regard to Medicare has been the relatively high amount of bureaucracy associated with decision making, Siegel says. The clinical application of nuclear medicine is a prime example, he says.

Thanks to Medicare bureaucracy, “there was the relatively long delay from the appearance of excellent, evidence-based literature about the superior efficacy of FDG PET in comparison to indium or technetium white blood cells or even gallium for detection of infection,” he says. “This resulted in a relatively large number of years in which we had to settle for a suboptimal, more expensive, and arguably less safe examination. This has now been rectified, but there was a long period of time when I was able to utilize FDG PET at the VA but not in my other practices that depended on the CMS’ [Centers for Medicare & Medicaid Services] decision process.”

Siegel is fearful that if Medicare were to write the rules for all, situations like this one would be all too commonplace.

More Politics in Health Care Decision Making
Another challenge is the inherently political nature of CMS and the potential for policies to change with different philosophies from one administration to another, Siegel says.

“One example of this could be the potential for regulatory sanctions from CMS for dispensing medical marijuana,” he notes. “The decision about whether to reimburse for the treatment of genetic diseases such as type 1 diabetes using embryonic stem cells is another area that could be greatly swayed by a political, rather than a purely medical, perspective.”

Siegel is confident there would be similar situations specifically in radiology services as well.

Less Innovation and Competition
“One of the advantages of the existence of private insurers is the ability to take advantage of competition in the reimbursement marketplace, which can lead to innovation and experimentation that would, in my opinion, be much slower in a Medicare for All system,” Siegel says.

He believes the creation of alternative reimbursement models that are data driven and tailored for specific geographic areas, patient populations, and subgroups of patients can result in a combination of cost savings and improved patient care. “Being able to react quickly to very rapidly changing advances in technology is more likely to be a characteristic of market-driven, private payers rather than a government-based system,” Siegel says.

Siegel’s areas of interest are in AI, theranostics, radiomics, and informatics, and he has seen them evolve at lightning speed within the past few years. “A large bureaucratic-based system is much less able to keep up with those advances, given its size, political influence, and the constraints on rapid change in the federal government,” he says. “A system that depends on a relatively dysfunctional budget process for its funding from year to year has major limitations on its ability to create medium- and long-term strategic plans.”

Thorwarth agrees. “We’re at a tremendously exciting time in radiology, especially with machine learning and artificial intelligence,” he says. “I’d hate to see that innovative thinking go by the wayside because of a one-payer system. It’s going to result in the government dictating what care is going to be provided, and innovation will get stifled as a result.”

Longer Wait Times
Siegel has observed substantially longer waiting times and fewer state-of-the-art scanners per patient in radiology and nuclear medicine in countries such as Canada and England that have single-payer health care systems where all residents are insured. Thorwarth says he too has been told by leadership of radiology organizations in the United Kingdom (UK) that it can take four to five weeks for a scan to be read. Residents of the UK may have coverage, Thorwarth says, but they don’t have health care delivered in a timely fashion.

Possible Benefits
However, not all radiology experts see gloom and doom when it comes to possibly enacting a Medicare for All plan or a single-payer system. There are some potential positives as well.

Less Uncompensated Care
While Medicare reimburses all services, including radiology, less than private payers, Medicare for All would provide at least some health insurance for all Americans, significantly reducing the number of patients with no coverage. While reimbursements may be lower, the amounts could be offset by volume and at least some compensation for all care, Chang says.

“At the University of Chicago, we have a busy level 1 trauma center on the South Side of the city. We don’t receive any compensation for a significant portion of those patients because they have no health insurance,” Chang says. “So, the Medicare for All debate is not as simple as ‘Oh my gosh, the sky is falling! There will be less reimbursement!’ Per case, perhaps, but there will be significantly less uncompensated care as well.”

Sandy Coffta, vice president of client services at Healthcare Administrative Partners in Media, Pennsylvania, says radiology groups that practice at hospitals where there are a large number of self-pay patients could actually see more compensation under a Medicare for All system. “Hospitals that have busy emergency departments can’t turn away patients, and if they have a high volume of emergency services for self-pay patients, this could be beneficial,” Coffta says. Self-pay patients usually go to hospital emergency departments, rather than to private imaging centers where they would be asked to pay up front, she adds.

Fewer Insurance Companies
Coffta says the biggest positive for radiology services would likely be that they would only have to deal with one payer. Under Medicare for All, she says, “there would be only one system of authorization and clinical decision support, as opposed to what we have now, which is dealing with all the individual payers and their rules for when imaging services are recommended or covered.”

Better yet, she says, Medicare’s rules for what is and isn’t covered are clear cut. “Medicare tends to publish their medical policies and make them easily available,” Coffta says. “You can go online and see the policies regarding imaging services, which would simplify the process even further.”

Easing of Licensing Requirements
Currently, radiologists need to have licenses in states where an imaging study is acquired as well as where the radiologist is interpreting the study. As demand for teleradiology services—particularly subspecialty radiology—rises, Cury says, it’s quite cumbersome for teleradiology practices to secure the necessary licenses for their radiologists. If health care were centralized by Medicare for All, it could minimize the licensing requirements in different states. Medicare for All could be a way to improve access to care and improve coverage, especially in underserved areas today, Cury says.

Coffta agrees that under a Medicare for All system, some radiology practices could see fewer enrollment denials for their providers. “If you have to only enroll them with Medicare, which can be done fairly quickly online, and they backdate payments to the date you submitted the application, you’re going to see fewer enrollment denials,” she says. “If you have a practice that has high turnover, you’re frequently bringing in new doctors, and, again, that could be a positive. Practices that are stable aren’t going to feel this benefit as much.”

Better Population Studies
Wearing his informatics hat, Chang says he sees a positive in having more lives covered. Radiologists would be able to do more comprehensive and accurate population studies because they wouldn’t be limited to just those who have health insurance. “We could actually look at comprehensive populations and look at risk factors and stratify populations accordingly,” he says.

Chang believes that health care needs to be more evidence driven. “And it’s challenging to be evidence driven when you’re only seeing a subset of the population, if I’m only following people who can afford health insurance,” he notes. “So, one potential benefit of Medicare for All and having everyone covered is that we can actually look at what these cohorts are.”

More Impetus for Leveraging Big Data
Medicare for All will increase the demand “for us in radiology to leverage information technology, advanced IT, and big data and other impactful IT tools, as we will be asked to do more with less,” Chang says. “We will have to be more evidence driven and have to be intelligent in our utilization of imaging and imaging tools. We will have to use AI and hope it will improve our efficiency and the quality of services we provide.”

Beth W. Orenstein of Northampton, Pennsylvania, is a regular contributor to Radiology Today.



There’s no question that Medicare for All is going to be front and center in the next election cycle, and there will be no shortage of opinions on the topic. Here are additional thoughts about Medicare for All from some radiology experts:

Eliot Siegel, MD, FACR, FSIIM, a professor and vice chair of information systems at the University of Maryland School of Medicine; an adjunct professor of computer science at the University of Maryland, Baltimore County; and chief of radiology and nuclear medicine at the VA Maryland Health Care System in Baltimore:

“It is important, before we consider adopting Medicare globally, that we try to look at it critically for ways in which to fix some of the substantial limitations/challenges of the current program, particularly in radiology and nuclear medicine. I’m much more optimistic that fixing/fine-tuning the current Medicare system before any major expansion is the most prudent course of action moving forward.”

William T. Thorwarth, Jr, MD, FACR, CEO of the ACR:

“All radiologists should stay informed about what the political dynamics are. The ACR closely monitors legislative issues and keeps its membership informed with articles on its website. The ACR doesn’t tell people what to think but wants to make sure they’re well informed. There’s lots about the current system that can be improved, and we’re working hard to make those improvements.”

Paul Chang, MD, FSIIM, a professor of radiology, vice chair of radiology informatics, medical director of pathology informatics, and medical director of enterprise imaging at the University of Chicago:

“None of this is completely new. We’ve been experiencing significant components of Medicare for All without calling it that because Medicare currently ‘influences all.’ The private payers take their lead from Medicare. Since Medicare influences all, we have already experienced less reimbursement and are asked to do more with less. It’s too early to know what’s going to happen, but we’d better prepare.”