The 2017 state legislative season featured many of the same clinical, economic and legal issues that were prominent in 2016. Proposed changes to the federal health care reform prompted the states to explore state-level solutions to many of the questions facing the future of the health care delivery in the country. Heath system reform, physician payment reform, mergers between health insurers and out-of-network billing legislation were hotly debated in many state capitols.
The staff tracked more than 500 radiology-relevant bills addressed by the state legislatures in 2017. As shown on the legislative calendar, many states had wrapped up this year’s legislative activity, and some are meeting in special session to discuss budget-related business. See a state-by-state report powered by StateScape.
Since 2005, a total of 32 states with mandatory disclosure or breast density notification: AL, AZ, CA, CO, CT, DE, HI, IA, IN, KY, LA, MA, MD, MI, MN, MO, NC, ND, NE, NJ, NY, NV, OH, OK, OR, PA, RI, SC, TN, TX, VA and VT. In Utah, notification is suggested, and in Maine, radiologists have agreed to provide information without a legislative mandate.
In 2017, governors of Colorado, Iowa, Kentucky and Nebraska signed breast density related notification bills into law. Mississippi’s governor signed a bill into law to authorize the department of health to adopt regulations to specify the information to be provided in the written report furnished to patients receiving mammogram services. Additional bills were filed in Florida, Georgia, Kansas, Maine, New Mexico, Washington and West Virginia.
Insurance Coverage for DBT
Support for mandatory private insurance coverage of digital breast tomosynthesis (DBT) has increased along with the growing weight of evidence demonstrating its ability to detect breast cancer in patients with dense breast tissues. During the 2017 legislative session Arkansas and Maryland were successful in securing coverage for digital breast tomosynthesis. On May 30, Texas House bill 1036 was sent to the governor’s office, and the governor has 21 days to sign the bill into law or it will become law without his signature. With the addition of Texas, states with digital breast tomosynthesis coverage will then include AR, CT, IL, MD, NJ, PA and TX. Several states have bills pending on tomosynthesis coverage: MA, NH, NY and OH. Additionally, New Jersey is looking to expand coverage for DBT when screening for breast cancer in women 40 years of age and over and for diagnostic purposes in women of any age.
The California Radiological Society has been actively engaged in educating the community and legislators about benefits of DBT through bifurcated legislative and regulatory campaigns. A National Public Radio (NPR) affiliate in Sacramento produced a segment that focused on both the benefits of DBT in screening and the class action suit filed by a Sacramento woman against Anthem for failure to cover tomosynthesis. CRS Executive Director Robert Achermann was interviewed along with Karen Lindfors, MD, chief of breast imaging at UC Davis. In March of 2017, Anthem Blue Cross of California removed their policy related to denial of DBT as experimental or investigational.
Scope of Practice
Non-physician medical personnel in several states continue to pursue an expansion for scope of practice that would allow them to operate (or supervise use of) X-ray equipment. In particular, registered nurses and nurse practitioners sought to expand the scope of their authorized medical privileges for use and supervision of fluoroscopy in pain management settings. In 2016, a Department of Veterans Affairs (VA) issued a proposal to allow advanced practice nurses at its health care facilities to practice without physician’s clinical oversight, regardless of individual state law. More specifically, the proposal sought to allow CNPs and CRNAs to “order, perform, supervise, and interpret … imaging studies.” In its comments, the College reiterated concerns for the quality of care administered to the nation’s military veterans and urged the VA not to adopt the proposed rule. In its final rule, the Department of Veterans Affairs (VA) opted not to grant advanced practice registered nurses (APRNs) authority to perform, supervise and interpret medical imaging exams. Instead, the VA specified that the APRNs can “order laboratory and imaging studies and integrate the results into clinical decision making.”
Certificate of Need
Several states considered legislation that proposed modifications to their existing Certificate of Need regulation of medical business practices in 2017. Existing statutes on Certificate of Need (CON) regulations were put in place to control the growth of hospital infrastructure and medical device acquisition, to lessen proliferation of specialty care centers and to limit inappropriate medical imaging utilization. Opponents of CON seek to make significant changes or to dismantle the CON programs altogether. During the 2017 legislative session, the CON issue was in the spotlight in AK, CT, GA, NC and VA. Additionally, bills on patient referrals and utilization management were considered in six states (Arizona, Connecticut, Maryland, New Jersey, New York and Pennsylvania).
Network Adequacy and Out-of-Network Payment
In 2017, numerous versions of bills related to out-of-network provider billing, network adequacy, transparency, notification and disclosure or accuracy of provider directories were under consideration in 32 states (AK, AZ, CA, CO, CT, FL, GA, HI, IL, LA, ME, MA, MN, MS, MT, NV, NH, NJ, NM, NC, ND, OK, OR, PA, RI, SC, TN, TX, UT, VA, WA and WV.)
The insurance companies are closely tracking the profitability of their product offering and are constantly reevaluating their matrices of in-network providers and hospitals. Physicians and hospitals, seeking to be participating as in-network parties with an insurer, are examining the fairness of contract offerings available to them. Health insurers set and adjust the number of providers in their managed care networks, but they often limit the number of providers within their networks to control costs or maintain affordable premiums. As a result, carriers will create narrow provider networks that may offer beneficiaries authorized access to few specialty providers. Although “narrow” networks are an accepted way of operating a preferred provider organization (PPO) on a set budget, “inadequate”networks result in a cascading effect of problems for both patients and providers.
State-level policymakers have to balance the multifaceted interests of stakeholders and while patients are becoming more educated about their choice of providers within the advertised network, gaps in insurance coverage remain a problem. State legislatures are addressing this issue by seeking to enact laws that ensure that provider networks established in their respective states are “adequate” to provide reasonable access to primary care and specialty physicians for their members.
As health insurers continue to scale down their provider networks, the coalition of hospital based specialty physicians and the AMA are actively campaigning for health plan accountability and are urging state action to strengthen network adequacy rules to establish adequate access to specialty provider care. To secure a balanced solution, the states must be committed to working with all stakeholders in finding solutions that protect the patients from insurance gaps, hold insurers accountable for advertised coverage, and retain appropriate incentives for in-network participation contracts.
RT Licensure and RRA
A registered radiologist assistant (RRA) is an advanced-level radiologic technologist who works under the direct supervision of a radiologist to enhance patient care. Selected chapters of the American Society of Radiologic Technologists (ASRT) are working with state radiological societies and the American College of Radiology (ACR) on the radiologist assistant (RA) issue.
Thirty-one states license or recognize the RA through legislation or regulation: AZ, AR, CO, CT, FL, GA, IL, IA, KY, MD, MA, MN, MS, MT, NH, NJ, NM, NY, ND, OH, OK, OR, PA, RI, TN, UT, VT, VA, WA, WV and WY. A resolution has been filed in New Jersey in 2017 to urge the State Board of Medical Examiners (BME) to adopt rules and regulations, within one year after the resolution’s effective date to allow radiologist assistants to practice in New Jersey.
Bills for radiologic technologist licensure have been filed in AK, ID, KY, MO, OK and TX. The ACR expects more radiologic technologist licensure and RRA bills to be introduced in upcoming 2018 legislative session.
Medical Liability Legislation
Nearly 30 states have statutes placing a limit damages in medical liability actions; however, in several states, the state Constitution explicitly prohibit caps on damages. Opponents challenge existing statutes on caps in almost every legislative session. The AMA and state chapter affiliates are the best resources for information related to medical liability legislation in your state.
Interstate Medical Licensure Compact
Developed by the Federation of State Medical Boards (FSMB), the Interstate Medical Licensure Compact (IMLC) offers an expedited review of applications filed by physicians who are seeking to obtain licenses in multiple states while preserving individual state licensure requirements. Eighteen states now have laws to join an interstate compact and additional six have introduced legislation to speed up the licensure process. A state-by-state rundown of the status of the FSMB Interstate Medical Licensure Compact is covered in this interactive map.
State Legislative Bill Tracking
The ACR continues its collaboration with StateScape to offer comprehensive automated reports on legislative bills to state chapter leaders. The new vendor offers an “opt-in” feature enabling ACR state affiliates to receive weekly email reports during legislative session that keep them informed about the status of legislation in every state. Please let ACR staff know if you would like to opt in to receive optional legislative notifications for your state.
To assist preparations for next year legislative sessions, ACR staff can help facilitate “guest caller” interaction during quarterly State Government Relations Committee discussions on various legislative issues affecting radiologists across the country. During the calls, ACR chapter members who have questions or are experiencing difficulties with state legislation can communicate with their colleagues to take away important feedback for their chapters’ strategy.
If you need further information on working with state legislators and how to get more involved in state legislative affairs with the ACR, please contact Eugenia Brandt, director of state affairs, via email or by phone at 703-715-4398.