Each year, scope of practice bills potentially impact radiologists’ work and the quality of patient care — and the ACR is helping state chapters fight back.
Nonphysician scope of practice (SOP) expansion bills are a growing concern among physicians, and the ACR’s Government Relations team tracks 120–150 pieces of legislation each year. These bills often grant independent practice authority to nonphysician providers (NPPs), such as APRNs and physician assistants (PAs), giving them the ability to order and sometimes interpret diagnostic imaging. Although advocates tout improved patient access to healthcare as a benefit to expansion of NPP scope, many radiologists are concerned that the risks to patient safety outweigh possible gains.
One issue is the difference in training between physicians and NPPs. A physician specializing in radiology will undergo a minimum of 10 years of comprehensive training beyond their undergraduate degree, including four years of medical school, a one-year clinical internship, and a four-year residency program. During this training, radiologists not only interpret thousands of imaging studies under the supervision of a practicing radiologist and complete 12,000–16,000 hours of clinical patient care but also study the principles of radiologic-pathologic correlation, radiation safety, and performance of imaging guided procedures. In contrast, most nonphysician programs include little-to-no radiology training, and their clinical hours (an average of only 2,000 hours of supervised practice) also pale in comparison to those of physicians.
Lack of training can lead to a variety of problems in care, including overutilization, says Leah C. Davis, DO, treasurer and member of the Michigan Radiological Society (MRS). Patients who use APRNs for their care are more likely to have an imaging test ordered than if they were seen by a physician. Images ordered by individuals with truncated training may also create issues, adds Davis. “The incorrect study may be ordered. In some cases that may mean repeating a study or doing an additional study, potentially exposing the patient to unnecessary radiation,” she says. Incidental findings are also a concern when NPPs review exams. Incidental findings may lead to additional imaging in an instance where no follow up is needed, Davis says.
Medicine is also a team-based approach that does best when the team works together, says Robert J. Rapoport, MD, FACR, member of the board of directors for the New York State Radiological Society (NYSRS). Physicians are often the leaders of these teams, and nonphysician independent practices remove them from the conversation.
Radiologists aren’t fighting this battle alone, however. “The ACR is an important resource and funding source to help its state chapters fight SOP expansion,” says Bonnie L. Litvack, MD, FACR, chair of the ACR State Government Relations Committee and former president of the Medical Society of the State of New York (MSSNY). The ACR’s Government Relations team monitors these bills and helps state chapters keep track of events as they arise. “They’re a valuable source of information,” says Rapoport. “NYSRS will often do calls to action in response to these bills. The ACR provides us a list of members in each district so that we can send out an email asking them to contact their legislators.” Adds Litvack, “The ACR also provides important model legislation when needed, allowing radiologists to present a unified message to legislators around the country.”
Davis highly recommends that radiologists interested in advocacy work join the ACR State Government Relations Committee. “Representatives from each state talk about the legislation they’re seeing, how they’ve fought it or other strategies they’re considering. That networking is important because it tells us what might come down the pipeline in our own states, as well as what’s working,” she says, recalling how MRS was able to take strategies used by the California Radiological Society to fight SOP bills in Michigan.
The ACR has also established the American College of Radiology Association® (ACRA®) SOP Fund. State chapters can apply for an ACRA SOP grant to educate lawmakers on this issue and to protect patient safety, and many state chapters are taking advantage.
Like many states, New York has seen an increase in proposed SOP expansion legislation. As a result, NYSRS has applied for several ACRA SOP grants to fight these bills when they arise. “Scope grants have allowed us to release an expanded number of advocacy memos, which explain NYSRS’s stance on bills we support or are opposed to,” says Rapoport. The grants have also helped NYSRS place advertisements in political publications read by legislators and aides.
Through the grant, NYSRS was able to expand its lobby day event from one day to two, as well as have a virtual meeting with the New York Commissioner of Health. “Each spring, we have an in-person annual meeting with the New York Commissioner of Health — often alongside MSSNY, our state’s medical society — where we go over issues we’re concerned about. Historically, it was only a single day, but now we have two,” says Rapoport. NYSRS often partners with MSSNY on issues they’re aligned with, particularly SOP. “It allows us to have more impact. MSSNY has a bigger footprint and more clout, so it’s critical that we establish longstanding relationships with them,” notes Rapoport. “We frequently work together, whether it’s on lobby days or letters of opposition,” says Litvack. “To be effective in respect to SOP, the house of medicine needs to speak with one voice.”
“ACRA SOP grants have also enabled us to fund residents who want to attend lobby days,” says Rapoport. He says resident attendance is an important part of these events. “We’re getting them ready so we can pass the torch to them one day and help them continue to fight these battles. Legislators also often want to hear directly from residents because they’re interested in what the next generation of physicians has to say,” Rapoport adds.
To be effective in respect to SOP, the house of medicine needs to speak with one voice.
NYSRS has also created a series of videos on a variety of topics, including what radiologists do, the training they undergo, and concepts like radiation safety. One video likens radiologists to orchestra conductors or the quarterback on a football team. “We use the videos to help legislators and the public get a better understanding of what we do. We’re showing them that you can’t just be another specialty or NPP and say you want to do radiology. You need the appropriate training and skillsets,” says Rapoport. NYSRS shares links to these videos in their communications and tracks metrics on how often they’re viewed.
The MRS has also faced its share of battles with SOP expansion, from nurse practitioners to chiropractors. As a result, Davis has learned to look at all SOP legislation, even if it may not directly impact radiology. “Almost every scope of practice bill ends up having a radiology component, even if our specialty isn’t directly mentioned,” she says, recalling several cases in which fine print or potential loopholes infringed on the interpretation and supervision of diagnostic imaging. For example, MRS encountered a bill regarding the expansion and independent practice of certified registered nurse anesthetists (CRNAs). “At first glance, it didn’t affect us at all. But we took a deeper look and saw that it included language saying CRNAs would be able to supervise radiology technologists and perform radiology-based procedures,” Davis says.
Advocacy has long been a cornerstone of MRS’s mission, with member physicians actively engaging in legislative efforts — whether through testifying on key bills, participating in lobbying campaigns, or meeting directly with lawmakers during advocacy days. Building a strong culture of advocacy within a state radiological society requires commitment, and it is only possible through the dedication of the volunteers. These physicians take time away from their demanding clinical schedules to champion policies that support not only their profession but their patients.
MRS has secured several ACRA SOP grants, the first of which was used to help increase the time their lobbyist was able to interface with legislators. A chance encounter prompted a different use for funds: an education campaign. During one of their advocacy days, MRS radiologists met with a state senator who was on the state health policy committee and was reviewing the latest SOP bill. After they’d introduced themselves, the senator commented that her niece was about to become a radiologist and had just finished training at the local community college. “We realized that she meant a radiologic technologist and had no idea what the difference was,” Davis recalls. “Our legislators were making big decisions that affect patient outcomes about who can perform procedures — and they had no idea who we were or what we did.”
MRS decided to create a social media campaign called “MI Radiologist” that educated the public on radiologists’ roles in patient care. MRS was able to hire a marketing firm using ACRA SOP funds. Since then, they’ve developed numerous graphics, op-eds, blog posts, email campaigns and other social media content. “We really wanted to ensure it was positive, especially since we’re coming out in opposition to these bills, which can be seen as negative,” says Davis. MRS shares the content with their legislators and their marketing firm tracks metrics on each post to determine how many people access the information. MRS plans to continue their relationship with the firm using grant funds, and they already have big plans for the future. “We’re working on a poll that captures how the public feels about SOP expansion — addressing questions like, ‘Do you approve or not approve of nurses interpreting imaging studies without a physician? — so that we have very specific data that we can share with legislators about their constituents,” Davis says.
The Iowa Radiological Society (IRS) represents fewer radiologists than many state chapters. There are only 240 practicing radiologists in Iowa, and only 160 of them are dues-paying members. Despite its size, IRS used ACRA SOP funds to build a strong presence among Iowa state legislators in 2023, when the state introduced a bill to give physical therapists independent authority to order imaging studies.
The IRS was able to hire a lobbyist — one it was already familiar with — using ACRA funding. In January of 2023, Joshua M. McDonald, MD, former president of the IRS, was contacted by a fellow member of the Iowa Medical Society (IMS), who told him about the physical therapist SOP bill and put him in touch with the IMS lobbyist. The lobbyist asked McDonald to give IRS’ perspective at the state House and Senate subcommittee hearings. With less than 24 hours’ notice and snow in the forecast, McDonald nonetheless made his way to the state capital despite living several hours away. “That started the beginning of our relationship,” recalls McDonald. “He escorted me to the meetings and introduced me so that I could speak.”
Although McDonald’s visit did not stop the legislation from passing, he’s still grateful he did it. “I learned the value of being able to speak my voice and be involved,” he says. “If I hadn’t shown up on that day, I never may have met the person who would one day work with us,” he observes. And that relationship has paid off for IRS. “Having a lobbyist has been so helpful,” says McDonald. “He keeps us informed on any upcoming legislation relating to radiology, and we’ve also been working together on getting radiology added to the State of Iowa Rural Primary Care Loan Repayment Program, a program designed to keep physicians in the state in rural areas by repaying their school loans.”
As SOP bills continue to arise in state legislatures, ACR will be available to provide critical resources to help state chapters with model bill language, expert policy analysis, grassroots advocacy tools, and strategic guidance. By leveraging ACR’s advocacy expertise and the help of dedicated volunteers, state chapters can be better prepared to protect radiology’s role in patient care and ensure legislative decisions are informed by physician leadership and evidence-based medicine. “We have such profound gratitude for the work we’ve done with the ACR Government Relations staff,” says McDonald. “I hope other state chapters and radiologists will continue to use all they have to offer.”
By Meghan Edwards, freelance writer, ACR Press
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