Medicare’s experience of paying for outpatient imaging services, particularly expensive advanced imaging such as MRIs, CAT scans, and nuclear scans, has been tumultuous over the last 20 years. The period was characterised by substantial increases in performance of advanced imaging services, mainly in doctors’ offices, followed by a shift to hospital outpatient departments (HOPDs) and then a levelling off of utilisation. These trends were influenced by an extraordinary number of legislative and regulatory policy changes, most of which reduced payment amounts for services paid under the Physician Fee Schedule (PFS) in doctors’ offices. This likely contributed to a movement of services to HOPDs, with payment based on the Outpatient Prospective Payment System (OPPS) where rates have been less impacted by policy changes. The authors termed this policy making process 'dysfunctional' because there is no evidence that the results were anticipated or planned, despite the dramatic effect they have had on where advanced imaging is performed and at what cost. Moreover, they are not convinced that the current policy direction will result in a more coordinated and strategic approach.