Sampling multiple reports creates an inference problem: how should sampled evidence be converted into a final decision, and does a better structured decision yield a better report? We study these questions through a framework that separates the decision signal, scoring objective, and feasible decision set, followed by text realization. On MIMIC-CXR and IU-Xray, controlled comparisons across 13 generator configurations per benchmark under grouped development/test evaluation reveal three findings. First, changing the objective under fixed evidence and rule capacity changes predictions and their held-out metric trade-offs. Second, relaxing candidate constraints has objective-dependent effects under shared signals and frozen scores. Diagnostics connect the IU macro-oriented assertion increase to near-zero label thresholds and show that limited candidate coverage coexists with selection headroom. Third, a controlled realization study with SFT-Qwen3-VL-8B shows that decision-level gains can be attenuated, amplified, or reversed. Change decomposition reveals that realization can remove incorrect assertions while losing correct findings, so target fidelity and reference accuracy need not improve together. Finding gains also do not consistently improve reference-based report quality. These results motivate separate evaluation of decision rules, candidate constraints, and realized reports.

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