ACR Bulletin

Covering topics relevant to the practice of radiology

Matters of State

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The ACR backs state chapter efforts to preserve and advance critical issues in radiology.

When the scope of practice of a mid-level practitioner can be changed in one state, it sets a fire that can spread to other states.

—Loralie D. Ma, MD, MA, PhD, FACR
August 31, 2021

“As Washington’s partisan divide continues, many state legislatures are increasing their activist legislative policymaking,” says Cynthia R. Moran, ACR’s executive vice president of government relations and health policy. “This just underscores our need to ramp up our state- level activities. The ACR is willing to commit the resources to work with our state chapters even more aggressively than in the past.”

The ACR will continue its partnership with its active, well-organized chapters and commit new resources to those chapters who have been less focused on advocacy, Moran says. “Expansion of non-physician scope of practice is a major issue facing state legislators, but other challenges include Medicaid coverage of imaging services, as well as coverage battles by private payers using punitive prior authorization programs, are a few other issues facing not only radiologists, but most other providers (and specialists in particular),” Moran notes.

“The ACR chapters are very diverse, not only in membership-size, but also in size of practices, prevalence of academic members, radiology subspecialties, business models, hospital affiliations, and local politics,” says Eugenia Brandt, ACR’s director of state affairs. “If radiology is considered well-positioned politically in any state, in large part it is because the chapters in that state have a long history of volunteers who have dedicated their time and worked diligently to build on successes.”

There is a pattern to state success stories, Brandt says. “While political fundraising is a critical part, it’s only one part. Being successful in state-level advocacy takes consistent effort, a proactive strategy, and linking arms with colleagues in other specialties to present a unified front,” she says.

There are many important issues that affect radiology, and state chapters are involved in most of them. “To be successful,” Brandt says, “we have to join or form coalitions. There are issues that face the house of medicine as a whole, and our chapters cannot exist in a vacuum.”

In many instances, if a state chapter does not have a lobbyist, the chapter leaders shoulder the responsibility for representing radiology interests in their state, Brandt says. “They are in the trenches, and we tailor our support to amplify and recognize their hard work,” Brandt says. “The ACR also supports the grassroots efforts of state chapters and their leaders in their endeavors in local politics, local partnerships, and local diversity efforts. This is where the rubber meets the road.”

“This is a critical time for the ACR to partner with all of our physician colleagues, across all specialties, to present a united front against national organizations that are using states to expand their own agendas,” Moran says. “The ACR has always worked with our membership to advocate for what is best for our specialty and our patients, and adding new resources for our chapters to access will increase our existing effectiveness.”

“We recognize the vital role that state chapters have in our advocacy strategy,” says Howard B. Fleishon, MD, MMM, FACR, chair of the ACR BOC. “More initiatives are being decided in local jurisdictions that can become models for other states and even federal legislation. Our commitment is to represent radiology and our patients at every opportunity to promote access to quality medical imaging by radiologist-led teams.”

State advocacy leaders who work with the ACR face constant challenges to the best practice of radiology for the patients in their states. The Bulletin has highlighted the work of a handful of diverse states — in their own words — to show the depth and results of ACR chapter advocacy.

The ACR has been really great about getting all of the state societies together to talk about the issues in each state — because there’s a wave of things that come through the country. If there’s an issue here in New York, something similar may happen tomorrow in Nevada. Coming together helps states stay ahead of the curve."

—Bonnie L. Litvack-Penn, MD, FACR

Taj M. Kattapuram, MD


Each year, multiple bills are introduced in the state of Colorado that could significantly affect radiologists. It is important to note that while some bills can be very specific to imaging, a large number of bills affect the entire house of medicine.

During the 2021 session, a standardized health benefit plan was introduced, HB21-1232. It was attractive in its intent of creating a new coverage option for Colorado residents, but the bill would have had a significant impact on reimbursement and physician practices. As introduced, the bill language included a premium rate reduction and a mandatory provider participation provision. Private insurers and hospitals potentially could use the reduction to leverage future reimbursement negotiations in their favor with private physician practices. Mandatory participation involved a punitive stipulation — non-participation by physicians triggered a reporting requirement to the state regulatory board which, in turn, prompted fines on physicians in annual fees. The potential loss of revenue and possibility for disciplinary action fueled strong opposition from physicians. The Colorado Radiological Society followed the lead of the Colorado Medical Society and our lobbyist teams collaboratively to modify the measure prior to passage. As a result, all enforcement, fines, and reporting to regulatory boards for healthcare providers were removed from the bill. The cumulative premium reduction target for the plan was reduced to 15% from 18%.

Additionally, there was a bill introduced to alter supervision requirements for physician assistants in Colorado. Again, while noble in intent, it would have increased the scope of practice for non-physicians in healthcare. Radiologists are feeling the brunt of this increasing scope and independent practice movement as imaging orders are on the rise. Together with the support of many representatives within the house of medicine, we strongly opposed this bill. Our lobbyists joined forces with the Colorado Medical Society again. After extensive testimony from radiologists — along with other specialty physicians, trainees, and medical students — the bill was defeated.

I urge all ACR members to get involved in a broad range of issues, not limited to insurance and economics and not solely imaging related, like cancer screenings. You may have heard the saying, “If you don’t have a seat at the table, you risk being on the menu.” When radiologists share meals with the entire house of medicine, non radiologists are more likely to support state legislation that is specific to imaging. Sharing resources and working together has fostered incredible relationships. The Colorado Radiological Society encourages radiologists in other states to participate in their state medical societies and be on the lookout for other collaborators in radiology advocacy.

Loralie D. Ma, MD, MA, PhD, FACR


In the last five years, we have faced multiple scope of practice issues — in medicine in general, but with implications for radiology in particular. One of our recent issues in Maryland involved registered cardiovascular invasive specialists (RCIs), who assist cardiologists but have less training than nurse practitioners or physician assistants.

Cardiologists argued that the RCIs should be able to operate fluoroscopy independently, with only a cardiologist on site, and not in the room. They also wanted the RCIs initially to be able to order and interpret diagnostic imaging examinations. I should add that, in the state of Maryland, physician assistants are not permitted to operate fluoroscopy, the state requires a radiographer license.

After a two-year legislative battle, we won our case on this issue. The RCI is able to help position the patient for fluoroscopy, but only a physician or RT can push the peddle and operate the fluoroscopic equipment. The ordering or interpretation of diagnostic imaging by RCIs is not allowed.

On the general medicine front, we have faced repeated bills from naturopathic doctors who want to prescribe prescription drugs, including opioids. We argued that residency training and a more extensive pharmacologic background should be required for anyone seeking to prescribe.

In addition, this year the podiatrists in our state wanted to change their name to podiatric physicians. Although they testified that a name change was inconsequential, we felt it was important that anyone identifying themselves as a physician should complete the full coursework required from a medical school. This bill did pass in the Maryland House; however, we were able to win this battle, in part because of our close relationships with legislators on the Senate side and in large part because we have a dedicated team of physicians who volunteer their time for advocacy efforts and who excel in educating lawmakers about our profession. Having great lobbyists is also extremely important.

Ongoing close relationships with legislators are very important because legislators will be less receptive to your issue if you have not established a level of familiarity and trust. As physicians, we can provide valuable information to our legislators, and we need to take the time to build and strengthen these bonds.

Scope of practice issues will continue to dominate the legislative landscape. So much of this is at the state level rather than the federal. When the scope of practice of a mid-level practitioner can be changed in one state, it sets a fire that can spread to other states. For example, Connecticut had a big win recently by having a radiology resident testify on scope of practice. The legislators were greatly swayed by a young person in training, who testified to the extent of the training and asked what it would mean if the training were simply unnecessary to do their job.

I believe that for us to win scope of practice battles, we must be creative and reach out to our legislators to explain who we are, how much we have trained in medical school/residency/fellowships, and what we do on a daily basis to provide the best possible care to our patients — before the change occurs. We make use of the ACR’s centralized scope of practice website to track what is going on in other states and learn from successes and losses (see sidebar on page 9). On that website, you can track scope of practice bills under consideration in your state or others, find out how to support the ACR and state chapter efforts regarding such bills, and read about the ACR’s efforts, in conjunction with other societies, against physician extender scope of practice expansion.

We are all in this together. Let’s work to protect patient access to safe, high-quality, radiologist-led medical imaging care.

Maryellyn Gilfeather, MD, FACR


Around 85% of the two million citizens of Utah live within a 15-mile range along the Wasatch Front — a string of cities in the north-central part of the state. Outside of this moderately dense section, the large rural areas in our state face unique healthcare issues and challenges.

Our state has an active but small ACR chapter, with about 150 members. We are a tight group that closely follows what happens at the state level — and always manages to get their teeth into the tough issues that may impact radiology. Although we are too small to have our own lobbyist, we have developed a workaround — we have a longstanding relationship with the Utah Medical Association, which provides lobbying help whenever we need it.

This year, an issue came up around the physician assistants (PAs) in Utah attempting to increase their scope of practice. A proposed bill, SB27, included a line that stated: PAs would be permitted to order, perform, and interpret diagnostic studies and therapeutic procedures. The PAs were looking to increase their scope of practice with the argument that in Utah we have large underserved rural areas that would benefit from PAs working independently. The Utah Radiological Society had several members at the hearing who were able to educate legislators about the language in the bill and its reach. In the end, the bill passed — but without that  language.

Beyond being in the legislative fight for best possible outcomes for radiology, we have other sources of pride here. Our state society does really well in donating to RADPAC®, the bipartisan political action committee of the ACR Association®. We have won the RADPAC award for highest participation in donating several times.

The Utah Radiological Society has an active RFS — and we encourage our members to be aware of and become involved in state advocacy and our Society has achieved a great track record with participation of young physicians. We are also very involved in the work of the ACR RFS Journal Club. The club covers AI and economics issues and allows trainees to interact directly with ACR leaders to gain perspectives on their areas of expertise. I help the residents and fellows network with radiology groups in Utah — those who are looking for jobs and want to stay in Utah.

I also take three residents to Washington, D.C., every year to attend the ACR Annual Meeting. I’ve been doing it long enough that I see former residents — who joined me in Washington — who are now attending ACR meetings on their own and who have become very active in their state societies.

Gaurang V. Shah, MD, FACR, FASFNR


The Michigan Radiological Society (MRS) was established by pioneering radiologist Preston Hickey, MD, who was also the founding editor of the AJR. The MRS has always maintained a strong legislative presence including committing a portion of the membership dues towards hiring a full-time attorney and lobbyist.

The Michigan Radiology Political Action Committee (MRPAC) was established in 1994 to support the advocacy efforts of MRS and the society prides itself on generous contributions to MRPAC, which in turn regularly supports our initiatives during electoral battles. We also observe a legislative day in the fall when a team of radiologists visits numerous state senators and congresspersons to acquaint them with issues important to radiology. The residents have their separate legislative day, making many of the same rounds and attending a session of the state Congress not only to get familiar with the legislative process but to have a younger generation of leaders joining the legislative battles.

MRS fights many legislative battles, and things don’t always work out the way the radiology advocates would like. For instance, we fought a corporate practice law that ended in a court decision and appeals court assertion that we are not an entity and so couldn’t be considered under the law. The ACR provided invaluable legal resources during the push to change the corporate practice law — even advising after the appeals court outcome. We decided to fight the battle another day. Then there are the victories — the legislative fruit of your labors.

One of the most recent battles was SB 481, a bipartisan bill citing a shortage of physicians in the state and seeking to grant wide powers to advanced practice registered nurses (APRNs) across multiple specialties. Proponents claimed the legislation would increase access to healthcare services for rural and remote communities. The bill was supported by a coalition of the Michigan Nurses Association, a few public health foundations, and multiple healthcare corporate entities.

The bill proposed that APRNs should be able to “order, conduct, supervise and interpret” imaging, independent of supervision by radiologists. While there was no particular provision in the bill to serve remote communities, there were plenty of economic opportunities for corporate entities — including insurers and hospitals. As written, the bill would have empowered APRNs to start their own radiology service and we had concerns about the ability of APRNs to provide independent imaging interpretations.

SB 481 was a clarion call for the MRS and MRPAC, prompting many of the members to contact their local legislators and to express their opinions. The MRS joined a coalition of medical societies in opposing the bill and coordinating legislative efforts. Radiologists also volunteered to testify in front of the state’s health policy and human services committee. In my role as the government relations chair for the society, I did a lot of research and put together potential talking points for the bill and the scope of work of APRNs. We were able to argue against the bill on the basis of the difference in training, lack of radiological safety perspective, and likelihood of increased healthcare costs (backed by published research).

Our grassroots efforts were great and included a media campaign. A local newspaper covered our point of view. We pushed an email campaign — in which many radiologists participated — and many Michigan citizens emailed their state legislators. Nevertheless, the headwinds were strong, and the bill passed on the floor of the Senate. Without losing hope, we doubled our efforts on the House side.

The sands started to shift when the bill was presented in the House Health Policy Committee. With our strong opposition, the committee deleted the provision related to radiology services and we were pleased that the committee members shared our concerns about the quality of the patient care the residents of Michigan deserve. Still, we continued our efforts in the coalition with other specialty medical societies. In the end, the bill’s one-year clock ran out and there could be no vote. We survived an existential crisis for our specialty by being vigilant, prepared, engaged, and committed.

Tilden L. Childs III, MD, FACR


In 2021, the Texas Radiological Society (TRS), working with our allies at the Texas Medical Association and the other specialty societies, realized one of the most productive legislative sessions in recent memory. The many years that TRS members and TRS PAC contributors have spent building relationships with influential legislators and backing good candidates for office who support our patients are really paying off in a big way.

Top priorities for the TRS include continuing to monitor the implementation of the SB 1264 balance billing legislation from the previous legislative session, including having been prepared to actively participate in any discussions regarding this issue in the recently completed 2021 legislative session. Additionally, we continue to be vigilant on scope of practice issues, particularly the issue of independent practice of non-physician practitioners, such as the California AB 890 regarding expanding the scope of practice for nurse practitioners that became law last year. We are also monitoring and participating with the Texas Medical Association on prior authorization,  telemedicine/telehealth, and Medicaid expansion.

By the time the TRS concluded its 2021 legislative session in May, bills that seemed like longshots just a few years ago had been passed and signed into law. These included bills to expand mandatory coverage for diagnostic imaging for breast cancer and screenings for colorectal cancer, bills to limit health plans’ use of prior authorization and utilization review to deny and diminish payments for radiology services, and legislation to clarify that the utilization of third-party billing services for medical claims submission would not be subject to sales tax in the state of Texas.

The TRS has played some really good defense as well, keeping our opponents from realizing their own legislative agendas. For example, the TRS and its allies were not only successful in defending against the continued attacks from the health plans and their allies on payment issues, but we were also able to stop the mid-level providers from realizing their misguided efforts to authorize the independent practice of medicine without direct oversight of a physician.

The ACR plays an integral role in the accomplishments of our chapter’s legislative efforts. It is very valuable to have the ACR’s dedicated tracking of all bills that are relevant to radiology and dedication to keeping states updated regularly. Having the ACR staff available for assistance to check proposed legislation against College policy, get state-by-state updates on legislative activities, or even just to talk things through is particularly beneficial.

Bonnie L. Litvack-Penn, MD, FACR


Our top legislative priority in the New York State Radiological Society (NYSRS) at this point is scope of practice of non-physician personnel and I think that scope of practice is a prominent theme in state legislatures throughout the country. At NYSRS, we believe the best way to deliver healthcare is through physician-led teams. Unfortunately, there has been an increasing number of disruptive measures introduced in the state capitol that seek to dilute the physician-led teams. In response, the NYSRS has been working very closely with the Medical Society of the State of NY on numerous issues related to scope of practice. The ACR has been terrific in its support and has helped defeat the non-physician personnel expansion of scope proposals.

The regular 2021 state legislative session in New York recessed in June. The top priorities for the NYSRS were protecting patient health by defeating scope of practice expansions for non-physicians, opposing legislation to increase medical malpractice liability premiums, supporting prior authorization reform, supporting collective negotiations by healthcare providers, and educating elected officials about concerns with single-payer legislation.

Medical liability is an issue that’s always on the docket for the NYSRS — both the cost associated and the arcane system around medical malpractice. One of the recurring legislative proposals the physicians oppose every year is regressive liability, a measure supported by the trial lawyers to increase the discovery date in the existing medical liability statute. Another theme that’s been coming back over the last few years is a proposal to reduce physicians’ due process rights when it comes to the Office of Professional Medical Conduct of the NY State Department of Health. Under the current structure, anyone can send a complaint to that department, but only 2–3% of cases are deemed actionable. While the meetings of the state regulators evaluating complaints are currently closed-door, a proposal this year aims to make all of the complaints discoverable to the general public in the state of NY — without any vetting process. If this measure passes, this could cause significant damage to physicians’ reputations, careers, and practices. The proposal was defeated this session, but the issue seems to come back year after year.

The ACR has been really great about getting all of the state societies together to talk about the issues in each state — because there’s a wave of things that come through the country. If there’s an issue here in New York, something similar may happen tomorrow in Nevada. Coming together helps states stay ahead of the curve and better equips us to adapt and respond appropriately. It is a very important part of what the ACR does for the states — to make sure that the practice environment for radiologists is improved throughout the country.

Author Interviews by Chad Hudnall, senior writer, and Cary Coryell, publications specialist, ACR Press