Breaking the Mold: Is it Time for IR Autonomy?

By: Raif Erim, Briauna Driggers, and Stevie Zarle 

Interventional radiology (IR) and diagnostic radiology (DR) have long coexisted under the umbrella of single radiology groups. Recently, subtle differences between the subspecialties have progressed into open discussions about a potential split for IR and DR practices [2] [1]. IR has evolved into a primary specialty with its own residency pathway and a more clinical, patient-facing role, while DR has been handling ever-growing imaging volumes [1]. This evolution has contributed to rising tension between the subspecialties, with some voices now calling for formal separation of IR from diagnostic radiology groups. ​

In late 2023, the American College of Radiology (ACR) and Society of Interventional Radiology (SIR) co-hosted a town hall attended by over 400 radiologists to address the “elephant in the room” – whether IR and DR should practice separately [4]. This article explores the strategic, operational, and financial implications of officially separating the subspecialties from both sides of the debate.  ​

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​The Difference Between Interventional and Diagnostic Radiology 

Interventional and diagnostic radiology increasingly function as distinct service lines with different workflows and business models. Diagnostic radiologists focus on interpreting imaging studies—often in high volumes and frequently in remote or asynchronous settings. Their work is central to fast-paced hospital workflows, and their productivity is often measured in terms of work Relative Value Units (wRVUs).  
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Interventional radiologists, by contrast, are proceduralists who engage directly with patients in both inpatient and outpatient environments. They perform biopsies, drainages, embolization, and other hands-on interventions that require direct clinical care, follow-up, and interdisciplinary collaboration [3]. This longitudinal care model means IRs act as treating physicians, often following up with their patients before and after interventions, rather than solely offering consultative opinions [3].  ​

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​The Difference is in the Details 

Scheduling and Staffing:  
DR sections operate on a shift work schedule to cover reading 24/7, whereas an IR service line must accommodate both scheduled elective procedures and unpredictable emergent cases (e.g., trauma embolization or acute hemorrhage control) with on-call coverage.  

Equipment and Space:  
DR primarily needs reading workstations and robust IT infrastructure, while IR requires procedure suites, recovery beds, and clinic exam rooms.  ​

Referral Patterns:  
DR workloads are driven by imaging orders from other physicians (often without direct physician-to-physician interaction), whereas IRs rely on referrals and direct consultations – for instance, a surgeon or oncologist might refer a patient for image-guided therapy. Building those referral networks and maintaining a reputation for good clinical care is critical for IR growth. ​

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​IR and DR Reimbursement Models 

​Diagnostic radiology is usually compensated via professional fees for interpreting imaging studies. High-volume diagnostic radiology generates substantial wRVUs and revenue solely from read fees, independent of facility charges. Diagnostic radiologists can thrive on professional fees alone [3].  

In contrast, interventional radiology often involves both professional and technical components. The professional fees for complex IR procedures may be modest compared to the time and personnel involved. Additionally, Medicare reimbursement for IR procedures has faced cuts due to the bundling of codes and payment reforms, reducing IR professional revenue [2]. This disparity raises cross-subsidization concerns within radiology groups – the idea that high-volume imaging may be subsidizing the less volume-driven IR side. 

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​Pressures Prompting Discussions of Separation 

The movement toward separation is driven by both clinical divergence as well as practical tensions in shared practice settings.

Desire for Autonomy and Clinical Identity: As IR has matured into a more differentiated, stand-alone, clinical specialty, many interventional radiologists feel constrained within traditional radiology group models. They desire the freedom to deliver comprehensive longitudinal care – running outpatient clinics, managing inpatient consults, and building multidisciplinary practices – a challenging task when they are also expected to cover general radiology duties including often substantial diagnostic worklist responsibilities [1]. The creation of the dual IR/DR certification and integrated IR residencies has produced a generation of IRs who identify primarily as interventionalists, not diagnosticians. In fact, a survey revealed that over half of the IR respondents found it challenging to practice in environments where they were required to perform extensive diagnostic work. Additionally, many younger IR professionals have a more favorable view of independent IR-only practice models.  [6] [10]. Culturally, these IRs see themselves as akin to surgical specialists. They want to market their services directly to referring physicians and patients, and they value developing niche expertise [e.g. interventional oncology or vascular disease] under their own brand. This ambition can strain against the confines of a general radiology group where IR is merely one section among many. 

Efficiency and Productivity Pressures: In large radiology groups, RVU production is often a key performance metric. Diagnostic radiologists can rack up RVUs rapidly by reading high volumes of studies. Interventional radiologists are fewer in number and often tied up with procedures, naturally contributing fewer total RVUs to the group’s bottom line. In some private practices (especially those backed by private equity), IRs report pressure to spend more time reading images to “keep up” with productivity benchmarks [11].  

From an efficiency standpoint, a radiology practice focused solely on imaging could maximize throughput and avoid the “inefficiency" of half-day procedures. Conversely, an independent IR practice could concentrate on growth areas, like outpatient interventions, without being measured against diagnostic RVU metrics. Thus, operational efficiency goals on each side suggest that each specialty might benefit from focusing independently on their own areas of expertise.  

Contract and Business Model Flexibility: The traditional exclusive contract between a radiology group and a hospital often ties IR and DR services together, which can be a double-edged sword. While including IR services helps radiology groups secure and maintain hospital contracts—83.8% of radiology leaders in one survey felt that IR services stabilized their contracts—the same exclusivity can limit IR service delivery [6]. Many radiology groups have been slow or unwilling to adapt their business models to support robust IR practice development [4]. For example, establishing an outpatient IR clinic or office-based lab might be strategically beneficial but could conflict with a group's focus on hospital-based imaging or the terms of its contract. ​

As one radiology executive observed, the specialty is facing a “perfect storm” of factors: a newly established IR training track, a radiologist workforce shortage, and reimbursement cuts drastically affecting IR [5]. Together, these conditions are forcing group leaders to rethink whether the traditional IR-DR marriage best serves their future. ​​

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​Barriers to Separation: Legal, Contractual, and Cultural Constraints 

For all the talk of an IR-DR split, breaking up is hard to do. Significant barriers – legal, contractual, and cultural – make separation complex: ​

• Exclusive Contracts and Non-Competes: Non-compete clauses and restrictive covenants in employment agreements often restrict IR physicians from launching new practices in the same region. 
• Economic and Operational Dependencies: Radiology groups rely on an internal equilibrium: high-margin diagnostic imaging work subsidizes lower-revenue (but essential) IR work, while the presence of IR has helped secure contracts that allow the group to earn those imaging fees. Separating could upset this balance. 
• Regulatory Hurdles: Regulatory considerations, strict corporate practice of medicine laws, hospital bylaws requiring coverage levels, and the need for coordinated care between new IR and remaining DR groups complicate the separation.
• Cultural and Professional Opposition: Many radiologists support maintaining a unified "house of radiology" to preserve collective bargaining power, advocacy effectiveness, and patient care coordination. 
• Practical Patient Care Considerations: In an integrated group, seamless hand-offs between diagnostic and interventional radiologists ensure smooth consultations and follow-ups, but separation would require formal coordination, access to shared systems, and clear communication protocols.  

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​Rural Markets: A Distinct Challenge 

​The rural context presents an entirely different and distinctly more complicated equation. Many smaller markets lack the volume to support full-time IR, making it impractical to separate into its own service line. In these areas, the same physician may be responsible for both diagnostics and interventions, and IRs may need to rotate between multiple sites to stay productive [8]. 

Recruiting to these areas is also notoriously difficult. According to data from the ACR and Society of Interventional Radiology, only about 15% of U.S. counties have a practicing IR, and nearly one-third of the population lives in a county without one [7]. Younger IRs often decline rural roles that require significant diagnostic coverage, and DRs may lack training in even basic interventional procedures [8]. These staffing gaps create access challenges for patients and operational strain for health systems. 

In the long term, the delivery of IR in rural areas may become a new frontier for innovation—but full separation remains unlikely without major structural shifts [9]. 

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​Planning for the Future of IR and DR Collaboration 

​Some industry leaders have speculated about a national or regional IR contractor model—similar to outsourced anesthesia or hospitalist services—that would provide interventional coverage to hospitals independent of DR groups. This model could help facilities address IR staffing shortages and give IRs the autonomy they seek.  

However, such models face significant barriers to scale. Unlike teleradiology, IR requires physical presence and clinical infrastructure. Hospital loyalty to existing radiology groups, credentialing complexities, and logistical demands all make widespread implementation difficult. Still, the emergence of outpatient IR networks signals that new business models are gaining traction—and group leaders should be alert to their competitive potential. 

Separation between IR and DR is not a foregone conclusion, yet the current model may not be practical in every situation. The gap in practice models, reimbursement, and physician identity is widening. Radiology leaders who scenario plan now, invest in IR capabilities, and maintain strategic flexibility will be best positioned to thrive in either model. Position your organization for future shifts by staying agile. This may mean renegotiating contracts, investing in new service lines, or even facilitating a friendly spin-off if it benefits all parties. The tone should be one of collaboration and flexibility: whether IR remains in-house or becomes a partner organization, the objective is to ensure patients receive top-notch, integrated care. 

The future of interventional and diagnostic radiology will likely involve dynamic realignment. By anticipating changes and working together, radiology leaders can turn a potential source of division into an opportunity—one that refines how radiology services are provided and ultimately improves care. Whether your organization remains unified, reconfigures roles internally, or supports IR through a new venture, the future is not about choosing sides. It’s about preparing for what’s next. Those who plan ahead will lead the transformation, not be caught reacting to it. 

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References:

1. ​Radiology Business. “Should diagnostic and interventional radiologists practice separately? Imaging groups to discuss at town hall.” November 2023. https://radiologybusiness.com/topics/healthcare-management/medical-practice-management/should-diagnostic-and-interventional-radiologists-practice-separately-imaging-groups-discuss-town#:~:text=%E2%80%9CAs%20IR%20has%20evolved%2C%20including,%E2%80%9D
2. Radiology Today. “Headed for Divorce? Interventional and Diagnostic Radiology.” September 2012. https://www.radiologytoday.net/archive/rt0912p22.shtml#:~:text=Sometime%20late%20next%20year%2C%20the,establish%20their%20own%20clinical%20practice
3. Line Monkey MD. “IR and DR: The Dirty Truth.” December 2023. https://linemonkeymd.com/ir-and-dr-the-dirty-truth/#:~:text=Diagnostic%20radiologists%20are%20one%20of,view%20that%20as%20dangerous%20or
4. ​Strategic Radiology. “ACR-SIR Virtual Town Hall: DR and IR – Better Together or… Not?” January 2024. https://www.strategicradiology.org/hub-newsletter/8811/acr-sir-virtual-town-hall-dr-and-ir-better-together-ornot#:~:text=%E2%80%A2%20continue%20to%20support%20the,practice%20barriers%20for%20IRS%3B%20and
5. Journal of the American College of Radiology [JACR]. “IR Workforce Shortages in Small and Rural Practices – SIR/ACR Task Force Report.” October 2022. https://www.jacr.org/article/S1546-1440(22)00578-6/fulltext#:~:text=%E2%96%AA   
6. American Journal of Roentgenology [AJR]. “Challenges of Providing IR Services to Rural Hospitals.” July 2018. https://www.ajronline.org/doi/full/10.2214/AJR.18.20092#:~:text=group,in%20a%20rural%20setting%2C%20and 
7. Radiology Business. “Nearly one-third of the US population does not have access to an interventional radiologist in their county.” November 2023.  https://radiologybusiness.com/topics/healthcare-management/healthcare-economics/nearly-one-third-us-population-does-not-have-access-interventional-radiologist-their-county?utm_source=related_content&utm_medium=related_content&utm_campaign=related_content#:~:text=%E2%80%9CInterventional%20radiology%20finds%20itself%20in,to%20all%2C%E2%80%9D%20they%20added%20later
8. IR Quarterly. “The Next IR Frontier: Small practices and rural deserts.” February 2025. https://irq.sirweb.org/sir-50th/the-next-ir-frontier/#:~:text=In%20the%20United%20States%2C%20many,1
9. Radiology Business. “Medicare pay for most interventional radiology procedures has declined in recent years.” July 2022.  https://www.radiologytoday.net/archive/rt0912p22.shtml#:~:text=The%20imaging%20industry%20has%20seen,a%20result%2C%20he%20thinks%20new
10. Journal of Vascular and Interventional Radiology. “Results of an American College of Radiology-Society of Interventional Radiology Membership Survey on Exclusive Contracts and the Attitudes of Interventional Radiologists.” September 2023. https://www.jvir.org/article/S1051-0443[23]00261-0/abstract  
11. Line Monkey MD. “Steps the SIR Can Take to Improve the Ability for Independent Interventional Radiologists to Obtain Hospital Privileges.” October 2023. https://linemonkeymd.com/steps-the-sir-can-take-to-improve-the-ability-for-independent-interventional-radiologists-to-obtain-hospital-privileges