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Three Questions: Radiology Coverage Agreements

By Zachary Doolin and Lyle Oelrich, Jr

Are you asking the right questions when assessing the value of a radiology coverage agreement? The field of radiology is much more complicated than traditional diagnostic radiology. Comprehensive radiology coverage includes multiple subspecialties and various types of coverage models. To appropriately understand the value of a radiology coverage arrangement, you must fully understand all services being provided, how they are being provided, who is providing them, how radiology is different from other hospital-based specialties, and arrangement alternatives. In this article, we will discuss several questions to consider when appraising the value of radiology coverage.

Question 1: Subspecialties
When evaluating a radiology coverage agreement, the first question to ask is, “Which subspecialties are clinically required?” Each subspecialty of radiology has unique characteristics that are important to understand and impact the value of the services. For example:

  • Diagnostic radiologists interpret a wide range of imaging studies to diagnose conditions in organ systems throughout the body. Diagnostic radiologists can provide coverage on-site or virtually.
  • Interventional radiologists perform minimally invasive procedures using imaging guidance. These procedures typically occur in hospitals (often in dedicated interventional suites or operating rooms) and sometimes in specialized outpatient centers. The services are usually performed on-site, rather than virtually.
  • Breast and mammography radiologists focus on screening and diagnosing breast diseases, particularly breast cancer, by using imaging studies and biopsies. The screening and diagnosis are often performed in breast imaging centers, outpatient radiology facilities, and cancer centers (which may require special valuation consideration).

Other subspecialties of radiology include pediatric, musculoskeletal, gastrointestinal, cardiothoracic, nuclear medicine, neurointerventional, and more. The value of each is as unique as the service itself. For example, pediatric radiology and neurointerventional radiology treat distinctly different patient populations, have different training requirements, and treat patients from different payer environments.

The unique attributes of each radiology subspecialty can lead to different valuation approaches and results, impacting the total value of a radiology coverage agreement. The reimbursement for pediatric radiology, for instance, may be lower than that of adult radiology.

Question 2: Coverage
Once the type of radiology specialty coverage is determined, the next question to ask is, “How is the specialty coverage being provided (eg, on-site, off-site [ie, remote/virtual], on-call)?”

  • On-site vs off-site: The benefits of on-site coverage can include enhanced clinical collaboration, more direct patient interaction and education, increased oversight and quality control, and reduced turnaround times, which can be especially important for emergency care. Alternatively, the inherent flexibility of off-site coverage, usually for diagnostic work, allows for increased accessibility to care, particularly for patients in rural or underserved areas where radiologists with specialized expertise might not be available locally. The increased flexibility of off-site staffing can also lead to lower costs. Many radiologists also consider off-site coverage a more desirable type of coverage for nights and weekends. Nevertheless, certain subspecialties, such as IR, necessitate on-site work due to the nature of the subspecialty procedures. As such, the cost to hospitals of on-site IR coverage is often higher than other types of radiology coverage that can be provided off-site.
  • Off-site vs on-call: Off-site services and on-call services are distinctly different. The variances between them are important when determining the value of a radiology agreement. A radiologist working an off-site shift is typically performing the same services they would perform on-site. For example, a diagnostic radiologist may provide interpretations either on-site or off-site from 7 AM to 5 PM, Monday through Friday. During this time, the radiologist will work to complete all radiology requests. Providing on-call radiology, however, is different because the coverage is typically after hours and only as needed. An on-call radiologist may perform no radiology interpretations or provide several during the on-call shift whose volume is often dependent upon emergency department requests. Thus, the value of on-call coverage is dependent, in part, on understanding the typical burden of the on-call shift, including being available whether or not clinical services are performed.
  • Outsourcing vs Advanced Practice Providers (APPs): Two other common methods of providing radiology coverage that impact the value of the arrangement are outsourcing nighttime radiology and using APPs. Many facilities and private practices outsource diagnostic radiology coverage to external radiologists or teleradiology services during nonbusiness hours. This model helps ensure continuous radiology coverage, especially for hospitals, clinics, and urgent care centers that require 24/7 diagnostic services but may not have the resources to staff radiologists around the clock. Outsourcing coverage may be more cost effective for facilities than employing additional full-time radiologists or paying high on-call fees, especially during times of low patient volume (ie, at night).

Using APPs in radiology coverage is an emerging model, bringing increased cost effectiveness with it, due to the lower costs associated with compensating APPs compared with physicians. APPs can play a key role in assisting radiologists, managing imaging workflows, performing case triages, and helping with tasks traditionally performed by physicians (ie, certain interventional procedures under the supervision of a physician). Important nuances, however, should be considered regarding APPs’ scope of practice and the types of services they can provide. For example, APPs are not licensed to independently interpret complex imaging studies, so their use in radiology coverage typically supplements, but does not replace, the use of physicians to promote cost savings as well as improve efficiency in radiology.

Question 3: Market Dynamics
The radiology market is undergoing significant changes and challenges that affect the value of radiology services. The third question to ask, therefore, is, “What are the unique dynamics impacting radiology coverage in this particular market?”

  • The gap is growing between the number of radiologists and the increasing demand for radiology services, driven by factors such as an aging population, advancements in technology, outpatient care, and rising chronic diseases. Staffing shortages have led to an increase in compensation demands, and a desire to work at home has led many newly graduated radiologists to teleradiology, which offers continuous coverage and cost-effective solutions compared with in-person models.
  • The radiology market is also facing declining reimbursement. One example of declining reimbursement is the 2025 Medicare Physician Fee Schedule, which recently reduced payments, affecting high-volume modalities like CT and MRI scans.
  • Despite declining reimbursement, total compensation for the majority of radiology subspecialties has increased, straining margins of private practices and increasing requests for financial assistance from health systems.
  • AI is increasingly used in radiology, enhancing image analysis, decision support, and workflow efficiency. As AI technology advances, it will play a larger role in radiology, potentially alleviating staffing shortages and reducing costs for health care organizations.

The radiology specialty market is complex and constantly evolving, influenced by various subspecialties, coverage models, and market dynamics. Assessing the value of radiology coverage agreements requires asking the right questions about the services provided, their delivery, and the current market conditions.

Factors such as the growing demand for radiology services, staffing shortages, the rise of teleradiology, declining reimbursement, increasing compensation, and the integration of AI all play crucial roles in shaping the value of radiology coverage. By understanding these elements and their impact on the value of an arrangement, health care organizations can make informed decisions to optimize their radiology coverage arrangements.

— Zachary Doolin is a principal with PYA, a health care consulting firm.

— Lyle Oelrich, Jr, is a principal with PYA.