The ACR state government relations (GR) staff is ready to back state chapters for another busy year of battling non-physician scope-of-practice (SOP) bills that have drawn the ire of some radiologists nationwide. An ACR-funded SOP grant program has been assisting state radiological societies in grassroots efforts to educate lawmakers, fund lobbyists and fight SOP legislation doctors say could negatively impact patient care.1
There has been confusion over SOP throughout the U.S. around the reimbursement of non-physician radiology providers (NPRPs).2 Doctors maintain that proper supervision and interpretation of imaging exams by trained radiologists is critical to the accurate diagnosis and treatment of disease, injury and illness. To protect patient access to safe, high-quality care, the College’s state chapters have tracked and acted on hundreds of bills nationwide since 2020 — including those around SOP.
The ACR works with state chapters to advocate at the legislative, regulatory and administrative levels for clear, sensible definitions of scope for health professionals. The College and like-minded state and national medical associations believe patients are best served when medical imaging is provided only under a physician’s supervision and when radiologists interpret medical imaging studies.
Radiologists are uniquely educated, trained and qualified to practice radiology — including imaging supervision and interpretation. Most radiologists undergo 10 years of comprehensive training beyond their undergraduate degrees.3 The ACR maintains that NPRPs do not have comparable training or experience and should not independently supervise or interpret imaging exams.
NPRP societies — among them associations representing advanced practice RNs (APRNs) and physician assistants (PAs) — have ramped up their fight to increase their members’ SOP and gain independent practice, particularly at the state level. State and federal agencies have encouraged use of these physician extenders — especially during the height of the COVID-19 public health emergency. Radiologists believe this must now be countered.4
Across the country, state chapters have been advocating on behalf of members to protect radiologist-led teams from SOP creep by NPRPs. The following is a sampling of what a handful of states have done — and will continue to do — to combat the problem. These states submitted proposals for ACR grants for their advocacy efforts. They have met with challenges, successes and some losses on a variety of issues related to SOP and have shared their stories.
Partnering for a Punch
The biggest SOP issue facing patients and practices in Kansas has involved APRNs. Recently passed legislation in Kansas now allows APRNs to prescribe medications (including controlled substances) and durable medical equipment without physician oversight, eliminating the physician-authorized prescribing protocol or collaborative practice agreement. To combat the situation, the Kansas Radiological Society (KRS) has joined forces with some allies for combined firepower.
“The Kansas Medical Society has employed lobbyists along with senior staff for decades,” says John H. Lohnes Jr., MD, FACR, chair of the Kansas RADPAC and former KRS president. “To facilitate
their activities — for which there has been a long track record of success and access — we chose to help fund that position rather than attempt to go it alone. This also provided us increased visibility for radiology within the ‘house of medicine.’
“To have access to a known lobbyist, one with a record of success, makes your ideas and needs that much more likely to have success in the debate over public policy,” Lohnes says. “The levers of government are many. Developing access to them is not a one-off. It requires a sustained, purposeful approach to cultivate those contacts and trust. Just as in our daily lives where we have to speak the language of our referring physicians, so it is in politics.”
With the adoption of the APRN legislation, the Kansas Board of Nursing has sought to expand its SOP beyond what was passed. “This is the next hurdle we face,” Lohnes says. “Their methodology mimics the definition of the practice of medicine as defined by the state. They are seeking full autonomy, beyond the legislative intent.”
A desire to develop reimbursement opportunities over the protection of patients is also an ongoing battle, he says. Within various practices throughout medicine, the desire and need to maintain levels of compensation result in the distribution of responsibilities in the guise of efficiency. “Within the house of radiology, it is incumbent that we as physicians acknowledge and promote the appropriate stratification of services within our practices — with appropriate safeguards for our patients.”
Relying on Lobbyists
The Michigan Radiological Society (MRS) also has turned to lobbying efforts to go to battle against a bill that would increase the scope of non-physicians. The initiative seems to be working, says Mark Weiss, MD, FACR, president of the MRS.
“ACR grant monies helped our lobbyist in Michigan devote more time and effort to making certain the Nurses Scope of Practice Bill did not pass in its current version,” Weiss says. “This appears to have been successful during the prior term. In Michigan, if a bill is not passed or voted on during a term, it automatically sunsets. However, it is likely that the bill will be reintroduced during the new legislative period this year. MRS, with the help of the ACR, will stay vigilant in its efforts regarding this Nurses Scope of Practice bill.”
The MRS has approached SOP limitations and balancing the services of non-radiologists against the expertise of radiologists from three perspectives. “The first is education,” Weiss says. Nurses receive a lesser amount of training. Total nursing school education after basic requirements is three years maximum. Nurses do not receive training in imaging and supervision. “Radiologists receive a minimum of four years of radiology training, and most radiologists have an additional year of fellowship training. This is after four years of medical school and a one-year internship,” he adds.
“The second is safety. Radiologists are trained in radiation safety,” Weiss says, “while nurses and other NPRPs do not have radiation safety training. This puts patients and their staff at risk.”
The third, he says, is use of imaging and cost. “Nurse practitioners and physician extenders tend to order more studies in an attempt to get assistance in making a diagnosis,” Weiss says. “This will increase utilization and, ultimately, the cost of medicine. In addition, more patients will unnecessarily receive radiation.”
MRS plans to continue its engagement with in-state lobbyists. “In addition, MRS board members will be reaching out to their respective representatives from various parts of the state to educate their representatives and make themselves available to answer any questions representatives may have about this issue,” Weiss says.
Additionally, MRS board members will be reaching out to the governor and state senators to educate them about the pitfalls associated with the bill that was introduced in the last legislative session. “MRS is concerned, since the bill had bipartisan support,” Weiss says. MRS is working hand in hand with subspecialty societies to avert this legislation’s passage in its current form.
The New York State Radiological Society (NYSRS) operates under the adage, “There’s strength in numbers.” Several initiatives help the organization mobilize radiologists to join the cause and speak out in one voice against scope creep of non-physicians.
“SOP limitations are important to ensure our patients have the best physician specialists performing and interpreting their imaging exams — to minimize radiation exposure, maximize image quality and provide the most accurate professional interpretation,” says Robert J. Rapoport, MD, FACR, a member of the NYSRS board of directors and co-chair of the organization’s Governmental Affairs Committee. “For medical imaging, radiology is the specialty with the longest length of training, the most in-depth training for image interpretation, and the most education and expertise in radiation safety.”
Convenience should not outweigh the standard of care, Rapoport says. “In some cases, clinicians have in-office imaging, which they provide for patient convenience — so the patients don’t need to go to a second location with a separate appointment. In such instances, to maximize quality and safety, these images should still be interpreted by a radiologist, not the clinician. The radiologist should be the primary decision-maker in setting up protocols, educating technologists and being involved with a quality assurance program.”
Patient safety and fair reimbursement are both key issues within the SOP debate, Rapoport says. “When other clinicians try to extend their SOP into radiology, they are trying to perform imaging studies with less training and professional expertise when compared to radiologists.” That risks lower exam quality, higher radiation dose, and less attention paid to other safety issues, such as intravenous contrast administration and MRI safety, he says.
“We are fortunate to have an excellent, experienced lobbyist,” Rapoport says. “He is aware of all bills as soon as they are submitted to the Assembly or Senate. He evaluates those pertinent to NYSRS and advises us on how to proceed.”
The residents hear about SOP issues on a regular basis by participating in our board and all-members meetings and in ACR's RFS. This is an opportunity to be part of advocating for their profession.
Some are the same bills from prior years, and others are new and unexpected. “At times when we need to act quickly, we have found that the ACR Government Affairs team can overnight send out a ‘Call to Action’ email targeting radiologists by ZIP code of their legislator — and with a convenient link to send an email to their elected official with opinions on a piece of legislation.”
Having a Political Action Committee (PAC) is also an important part of lobbying. “We have been and will continue to reach out to radiologists statewide for support and have been working with practice leaders to contribute on behalf of their entire practice,” Rapoport says. “In 2023, we expect to send out emails to members asking for support, make announcements at our all-members meetings (and provide a link in the chat box for secure online donations), and work with practice leaders to donate for their entire practice. Our board leads by example, and annually board members
contribute to the PAC. We are appreciative of the support we receive statewide, and all of these PAC donations allow us to best represent the members.”
The NYSRS also has an annual Spring Lobby Day, which has focused in recent years on SOP bills. Board members, NYS radiologists and residents head to the state Capitol to meet with lawmakers and their staffs. This gives residents real-world experience in the importance of lobbying and the value the ACR and state societies bring to the specialty.
“The residents hear about SOP issues on a regular basis by participating in our board and all-members meetings and in ACR’s RFS,” Rapoport says. “This is an opportunity to be part of advocating for their profession.”
Over the past several years, NYSRS has recognized the growing importance of working collaboratively with the Medical Society of the State of New York and physician specialty societies, particularly in opposition to SOP expansions desired by PAs and nurse practitioners.
“We are extremely fortunate that Bonnie L. Litvack, MD, FACR, a board member and the co-chair of our Governmental Affairs Committee, is a recent past president of the Medical Society of the State of New York and has helped facilitate this. We will work to expand these relationships,” Rapoport says.
The organization has created six short videos, with financial support from the ACR SOP grants and spearheaded by NYSRS President Robert J. Pizzutiello Jr., MS, FACR, and past Presidents Kimberly N. Feigin, MD, FACR, and Atul K. Gupta, MD, FACR. The productions, available on the organization’s YouTube channel, are about one to three minutes each in length and discuss important aspects of radiology.
The group will continue to disseminate the videos to advocate for the profession by educating elected officials and their staff members. Rapoport explains why this is essential: “They should understand the importance of preventing other providers from impinging on our SOP.”
Educating the Public
“There is a recognition by leaders in the Pennsylvania Radiological Society (PRS) that many patients are unaware of radiological practices and the extent that a radiologist is part of their care,” says John Kline, executive director of the PRS. “Our efforts have been necessarily not to teach people about the specialty, but to shed light on how our physician members’ work impacts patient care.”
The idea, chapter leaders say, is that bringing to light the SOP in radiology will positively impact patient safety and fair reimbursement. “We have used some ACR grant monies to: 1) increase the SOP knowledge of patients and the public, as well as public officials; 2) use social media to build an advocacy mechanism; and 3) use social media to ask viewers and users to contact elected officials at the state level to encourage passage of an important bill making its way through the Pennsylvania Senate,” Kline says.
PRS contracted with a communications specialty company in Harrisburg, which prepared a visual vignette clearly explaining the duties of a radiologist and how nearly all medical cases involve radiology. The public relations campaign (available at bit.ly/PA-SOP-ad-campaign) ran for several weeks in state senatorial districts of decision-makers who were controlling the outcome of the bill.
The campaign’s message was concentrated in the geographic regions of specific legislative leaders, Kline says. “After a few weeks, the information was modified to ask viewers to contact their respective senators to help pass a bill that would benefit radiology, patient safety and privacy. The response was excellent,” he notes. More than 70 constituents sent in letters electronically urging passage of the bill.
“Unfortunately, the bill did not pass because of one legislative committee chair,” Kline says. “Nevertheless, the results were very good, in our opinion, and the subject will be easier to address in this year’s legislative session.” PRS plans to use this tool in the future whenever advocacy from constituents is needed.
Focusing on Safety
Wisconsin Radiological Society (WRS) leaders have employed tactics similar to those their counterparts in other states have used, but they’ve honed their message to focus on patient safety. A flurry of activity has helped the group get out its message and make an impact.
“Funds provided by the ACRA SOP grant enabled the WRS to have one of its most active legislative sessions to date,” says Ian A. Weissman, DO,FACR, president of the WRS. In addition to lobbying in favor of breast-cancer supplemental-screening legislation, WRS also spent considerable time and effort to defeat APRN independent practice legislation.
“WRS actively participated in a coalition of physician organizations, provided financial assistance to Wisconsin Doctor Day, drafted and deployed several action alerts to members, and lobbied our governor to veto the bill,” Weissman says. “These efforts, in fact, resulted in our governor vetoing the APRN independent practice legislation, despite intense pressure from the nursing lobby.”
“As physicians who interpret imaging studies, we have seen firsthand how the dramatic growth in the number of APRNs and PAs working in Wisconsin in recent years has already led to a rise in the ordering of unnecessary, expensive imaging exams, such as CT and MRI scans,” Weissman says. “We are deeply concerned that APRN independent practice will exacerbate this dangerous trend, with detrimental impacts on patients.”
The key to the battle in Wisconsin has been in educating lawmakers — with help from the WRS government relations team led by Gregg A. Bogost, MD, FACR, and Blumenfeld & Associates. “Our messaging in the fight against APRN independent practice focused on the differences between physician training and non-physician training. We affirm that NPRPs are a critical part of the care team,” Weissman says. “However, they simply do not have the in-depth clinical training and experience needed to justify allowing them to practice in the same manner as a physician.”
In his veto memo, Wisconsin Gov. Tony Evers wrote, “I object to altering current licensure standards for APRNs, allowing practices functionally equivalent to those of physicians or potentially omitting physicians from a patient’s care altogether notwithstanding significant differences in required education, training and experience.”
Allowing APRNs to practice independently after less than two years of working under physician supervision is fundamentally a patient safety issue because of the tendency of APRNs and PAs to over-order imaging exams, Weissman says. “Ordering unwarranted imaging studies exposes patients to unnecessary radiation. One of the key talking points we used when lobbying against the
APRN bill was that it removed the important patient safety guardrail of physician collaboration.”
WRS plans to fight against APRN independent practice once again with the hope of expanding the state’s grassroots engagement and building public awareness of the patient safety implications of SOP expansion.
Same Fight, New Year
In statehouses across the country, efforts are underway to legislatively undermine healthcare teams — a trend doctors say puts patients at risk. This is not peripheral to radiology, Litvack says. The language of the proposed bills wrongfully includes the authority to order, perform and interpret imaging.
“The ACR is deeply committed and actively engaged in defending patient access to team-based and physician-led care,” she says. “The College will continue to support states through grants to fund efforts to fight scope creep — including independent practice, direct billing by non-physicians, and reductions in radiologists’ oversight. It’s all about our expertise.”