How We Got Here

Radiologists in the United States have a history that is different from that of other physicians — and understanding this history is important to the future of radiology.how we got here

Health care and payment policy are evolving rapidly in this country. New laws and regulations are voluminous, and the decisions we make are far-reaching.

With so many detailed decisions, it is important that we understand how we got to this place. In this column, I describe why the advocacy role of physicians, particularly radiologists, is different in the U.S. than the rest of the world.

The U.S. health care marketplace is different from that of the rest of the industrialized world. Nowhere else in the world is there such a sizable contribution of employer-sponsored health care. World War II is the reason for that. In the 1940s, the U.S. government was concerned about the economic effects of the post-war inflation that had devastated Europe. The government's solution was wage and price controls. Workers responded with threats to strike. At the same time, the war had made hiring in the U.S. tight because of a decreased labor pool and an increased demand for goods. As a concession to workers, the National War Labor Board exempted employer-paid health benefits from the wage freeze.

This action allowed employers to provide robust health care plans as a benefit and provided for an attractive tax advantage. This trend drove a large demand for employer-provided health insurance. Later, when the government tried to move to a single-payer system, it was too late to overcome the considerable size of the private insurance market. This is relevant for physicians, because we are required to influence payment policy across a spectrum of different payers and geographic domains. Government payment policy is important, but it cannot be our only focus.

What we do over the coming years could define our specialty for decades to come.

The structure of our government allows physicians sizable influence in health care policy. The founders of our country purposefully created a constitutional division of government with checks and balances in place. As such, no single branch of government can unilaterally implement policy on matters as significant and far-reaching as health care policy. This division of government enables influence of stakeholders at multiple levels, including both houses of Congress and the executive branch. One could argue that this is sometimes a strength and sometimes a hindrance, but the circumstance cannot be ignored. For example, the Affordable Care Act took a remarkable set of political circumstances in order to become law. And the recent inability of a republican-led government to pass the American Health Care Act shows how quickly outcomes can swing the other way. This circumstance gives us the opportunity, and the responsibility, to influence policy to a greater degree than physicians in other industrialized nations.

External perceptions of quality are especially relevant. In my March column, I discussed how policymakers perceive the quality delivered in U.S. health care — and how they do not necessarily believe that physicians have done a sufficient job of ensuring patients receive high-quality care. They think we need help. We can complain and resist the myriad quality metrics being forced on us, but the push to prove quality is not going away. Policymakers are giving us a chance to do this ourselves.

The CMS Quality Payment Program (QPP) is the most significant vehicle for us to influence quality. The QPP is complex, and its regulations are very much being formulated in the early years of the program. Since MACRA mandates special considerations for specialties such as radiology, our ability to influence the metrics that will affect radiologists and their patients is consequential.

Where we find ourselves is this: We have a heterogeneous payer system, a sizable ability to influence policy, a mandate to improve quality, and a calling to represent our specialty. The Affordable Care Act and MACRA are significant efforts by the government to gain greater control over health care. The call for action is as great as it has ever been to shape radiology delivery. What we do over the coming years could define our specialty for decades to come. Understanding the history that brought us to this place will help enable decisions that are in the best interest of our specialty and of the patients we serve.


dr silvaBy Ezequiel Silva III, MD, FACR, Chair

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