Essay 02 · Writing · The Missing Ledger series

The value of radiology is measured by the wrong yardstick

A position paper on volume, value, and what imaging is actually worth

measured here, valued there

Radiology is paid by the study and valued by the decision, and those are not the same thing. A health system can tell you to the cent what it spent on imaging last year. It cannot tell you what that imaging was worth — how many treatments it redirected, how many unnecessary procedures it prevented, how many well people it correctly reassured. We have built a precise meter for the input and left the output unmeasured. That is not a small accounting quirk. It shapes every investment decision in the specialty, and it shapes them wrongly.

The invisible outcome

The European Society of Radiology named the core defect: mainstream value-based healthcare frameworks treat the diagnosis as invisible. In those models, the diagnostic process is disregarded unless it goes wrong — counted only as a source of error or complication — when in truth a correct diagnosis is the first outcome that matters to a patient [S6]. Everything downstream, every treatment whose success is measured, depends on that diagnosis being right. Yet because the frameworks do not score it, the diagnosis contributes nothing to the value dashboards that increasingly drive funding.

The consequence is predictable. What is not measured is not valued, and what is not valued is under-resourced. If your metrics reward reading more studies faster, you will get more studies read faster — not the unhurried second look that catches the opportunistic bone-density read [S8][S10], the incidental aortic calcification, the early liver fat [S12], the finding that was not the reason for the scan but changes the person's life. The volume meter and the value it obscures pull in opposite directions.

Where value actually lands

Radiology's worth shows up in three places, none of which a per-study tariff can see.

It lands in the redirected decision. A report is worth nothing in itself; it is worth the change in what happens next. A calcium score that moves someone from intermediate to high risk and starts preventive therapy [S1][S2] is worth many multiples of the scan fee — but only the fee is recorded.

It lands in the scan that does not happen. A confident, correct read closes the question and prevents the confirmatory cascade. Value-based radiology counts that avoided imaging as a gain [S6]; fee-for-service counts it as revenue foregone. This is the incentive problem stated at its sharpest: the current model pays radiology most when it resolves least.

And it lands in the confident negative. A definitive all-clear ends anxiety, closes an episode of care, and stops downstream spending. That is real economic value produced by finding nothing — and it is invisible to any system that only pays when something is found.

The counter-case, held honestly

I am wary of "value" as a word, because it is easily abused. It is simple to assert that radiology adds value and hard to prove it in a given case, and the metrics for a radiologist's contribution to outcomes remain immature. More than 80% of patients across a 22-country survey had never heard of value-based radiology or value-based healthcare [S7] — a reminder that this is still largely a conversation the profession is having with itself. There is a genuine risk that "value" becomes a rhetorical container each party fills with what it already wanted: more screening for the advocate, less spending for the payer.

The discipline that keeps the argument honest is to tie every value claim to a measured change in a decision or an outcome, and to say plainly, where that evidence does not yet exist, that we are measuring an input and calling it a result. There is also a tension the specialty rarely voices: you cannot ask radiologists to add value and simultaneously pay them only to add throughput. A model that rewards speed alone is not, on its face, a model that rewards the judgement that produces value.

What I argue for

Stop trying to compress the value of imaging into a single reimbursable number, and instead instrument the chain: did the report change the plan, did it prevent a downstream study, did the finding get actioned and by whom. That is a governance and data problem before it is a payment problem, and it is solvable — the organisations that solve it will be the ones that stop treating radiology as a cost centre priced by volume and start treating it as a decision engine valued by outcome. The yardstick is wrong. Changing it is one of the more consequential unglamorous reforms available in health economics, and it is the one I keep arguing for.

References

Dr Lisa Sorger is a consultant radiologist, healthcare executive, medical administrator, company director and founder of myradiologist.ai. She writes on the economics and ethics of preventative imaging and diagnostic radiology. Every claim in this paper is sourced to the public record.

All views expressed here are my own personal opinions and are not medical advice. General information only — not clinical or financial advice. myradiologist.ai · ABN 29 692 758 115 · ACN 692 758 115