At the height of the COVID-19 pandemic, imaging volumes plummeted as elective imaging exams were deemed nonessential. The financial impact of this was severe for both physicians and healthcare facilities at large.

A recent study published in the journal Radiology revealed that radiologists have experienced a nearly 40% cut in compensation in 2020. What’s more, hospital margins were down 96% in the first seven months of 2020 compared to the same seven-month period in 2019, according to Kaufman Hall’s National Hospital Flash Report.

Although infection rates are spiking across the country once again, healthcare facilities are better equipped to handle them. From stringent cleaning routines to social-distancing protocols, people seem to be returning to their providers for care that they’d put off, and elective imaging exams (such as cancer screenings) are largely available.

As with the pandemic itself, the impact on radiology still leaves more questions than answers. HCB News spoke with a handful of physicians and other professionals on the frontlines who candidly shared the struggles and triumphs they faced and continue to face during this unprecedented time.

The consequences of declining imaging volumes
A study published in September in Academic Radiology found that radiology practices were losing 50% to 70% of their normal imaging volume between March 8 and April 30. Mammography and nuclear medicine were affected the most with a decrease in scans of 93% and 61%, respectively.

“Mammograms and nuclear medicine studies tend to be more outpatient-based than inpatient-based,” said Dr. Keval Parikh, diagnostic radiology resident at University Hospitals Cleveland Medical Center/Case Western Reserve University. “Outpatient studies tend to be considered lower acuity studies that have decreased likelihood of altering clinical outcomes compared to the higher acuity ED and inpatient studies.”

In March, the American College of Radiology (ACR) updated its guidelines to align with the Centers for Disease Control and Prevention (CDC) recommendations to postpone any non-urgent, outpatient imaging exams and procedures. As a result, hospitals were only taking patients that presented with suspected COVID-19 or emergency cases.

“I'd imagine all radiologists were put through something where volume shifted dramatically in a way that had never shifted in anybody's memory before and that had lots and lots of implications across the country,” said Dr. Eliot Siegel, professor at the University of Maryland School of Medicine and chief of radiology and nuclear medicine at the Veteran Affairs Maryland Health Care System.

He added that since a lot of hospitals and radiology departments operate on a fairly thin margin, the volume drop led to a major concomitant decrease in revenues for radiology departments across the country.

As a result, administrative personnel and technologists were furloughed or couldn’t be paid for a period of time. In addition, many radiologists saw a major salary cut since their pay was tied to the number of scans they interpreted.

As imaging volumes rose over the summer, the financial situation improved, but a second wave of infections is not the only thing imaging professionals are worried about. The Centers for Medicare and Medicaid Services (CMS) proposed changes that could result in a nearly 11% decrease in Medicare reimbursement for radiologists in 2021.

Siegel also foresees a long-term impact on hiring.

“There have been a number of radiology practices that were in the process of hiring, then rethought that and ended up rescinding offers or not making offers,” he said. “They decided that they really didn't need that extra radiologist or technologist in the department.”

With infections expected to rise again, and the possibility that imaging rates could drop because of it, there remains a reduced inclination to bring in new imaging staffers.

Imaging volumes on the rise
As of October, most healthcare facilities are running between 75% and 95% of pre-COVID imaging volume, according to Sandy Coffta, vice president of client services at Healthcare Administrative Partners, a medical billing and coding company.

“From the start of the pandemic, we realized that we have both a challenge and an opportunity in regard to COVID being an unprecedented situation,” she explained. “We decided that we needed to be an advocate for our clients to help guide them through this, beyond just getting the bills out the door.”

The company started by providing volume analysis on a daily basis. They then progressed to advising hospitals on how to recover successfully by offering insight on everything from safety policies to physical changes to the office space.

“There isn’t a one size fits all answer to any of this because areas that were hit harder are going to be more hesitant to ramp up quickly,” said Coffta. “Our clients outside of major metropolitan areas saw less of a hit and have been pretty fast at ramping back up because they don’t have the same case load that you see in New York, Philadelphia and Boston.”

Some of her client hospitals are booking mammograms two to three months out to accommodate the influx of patients seeking these exams. One practice is even running their MR unit at 93% utilization to get caught up.

“We have a number of facilities running extended hours or opening their MR on weekends,” said Coffta. “It takes some creativity because you still have to account for the extra time it takes to sanitize between patients and allow for social distancing. But you do want to get as many in the door as possible.”

Dr. Arun Krishnaraj, associate professor of radiology and medical imaging at the University of Virginia Health System (UVA Health), found that when his hospital reopened elective imaging exams over the summer, many patients were fearful of coming back into the hospital.

“People weren’t coming in even though they needed the test because they weighed the risk of coming in to be greater than the benefit of the exam,” he said.

UVA Health relied on its marketing team to distribute materials outlining the steps the hospital is taking to enforce wearing masks, screening upon entry, social distancing and cleaning. The health system also ran commercials and posted on different social media and mass media platforms to relay the message that they are open and to stress the importance of not delaying care.

“If people are wearing masks, social distancing and appropriately screened coming in, we can get back to some semblance of normalcy,” said Krishnaraj. “Medical imaging could be achieved safely if people practice those precautions.”

ACR is also working to educate patients on the safety of hospitals at this time and the consequences of not undergoing needed imaging exams, especially screening mammography.

According to a recent study published in Science, an estimated 35,000 breast cancer diagnoses could be delayed, potentially resulting in over 5,200 more deaths in the U.S. over the next decade. ACR is urging women over age 40 to schedule yearly mammograms that were postponed due to the pandemic.

At UVA Health, outreach efforts paid off as more patients started coming in for imaging exams in mid-to-late June.

Radiologists can work from home too
The pandemic has resulted in many professionals working remotely, and this trend has impacted healthcare too. While the value of telemedicine is becoming clearer than ever, radiologists are particularly well suited to interpret images from home.

“I think this is a trend that we're seeing everywhere in healthcare and outside of healthcare,” said Siegel. “The same way that people are not going into their offices in Manhattan to do the work that they're doing in the financial sector, I think we're starting to see more of a trend to not go into the hospital unless there are procedures that are being done or a particular reason to go in.”

In the past, many facilities refrained from having radiologists work remotely because of privacy and security concerns and bandwidth issues. But the pandemic forced the situation and many more radiologists are now interpreting from workstations in their homes.

He believes this is a trend that will continue even after COVID-19 is no longer a concern. One of the biggest benefits is the time saved that would have been spent on commuting to and from the facility.

Remote interpretation also allows for more of a lifestyle balance. Radiologists with children are finding that virtual education requires much more parental involvement during the day and they are able to provide that if they are working from home.

“There's always been hesitation to make that paradigm shift,” said Siegel. “Now that it's happened and people realize that one can still provide high-quality care, they'll provide the performance that's required. I think that there's going to be a much higher percentage of radiologists who are reading from home rather than reading at the office.”