Early in March, the ACR issued a statement describing scope of practice bills as "rampant" in state legislatures. Iowa, Missouri, Montana, New York, and Texas are among the states weighing proposals to increase the decision-making authority of non-physicians.

In order to better understand the policies and politics behind these proposals, HCB News reached out to Eugenia Brandt, ACR's director of Senior Government Affairs. Here's what she had to say.

HCB News: From a radiology perspective, what is at stake with this wave of bills that expand non-physician practice?
Eugenia Brandt: We are seeing an increasing number of bills seeking blanket expansion of scope of practice for non-physician personnel, especially for independent practice, authority to supervise use of ionizing radiation, and interpretation of diagnostic imaging or other tests. This is concerning as expanding scope of practice jeopardizes patient safety.

(Note: ACR is tracking these bills online).

Most radiologists undergo 10 years of comprehensive training beyond their undergraduate degree. Compared to physicians, the non-physician personnel education lacks standardization and, in a majority of cases, misses altogether the curriculum needed to supervise and interpret diagnostic imaging, especially more complex studies. Physicians specializing in radiology complete a rigorous educational and training framework that far exceeds those of non-physicians:

Graduate from medical school.
Serve a one-year clinical internship.
Complete four-year residency, during which radiologists: interpret tens of thousands of exams with practicing radiologist supervision and train in radiation safety, anatomy, pharmacology, pathophysiology, medical physics, radiobiology and more.
Complete a four-week (130 lecture hours) intensive radiologic pathology correlation course.
Pass a state licensing exam.
Complete a one-to-two-year fellowship of specialized training in a radiology subspecialty.

ACR supports a physician-led team approach within an integrated healthcare team. Proper supervision of procedures involving ionizing radiation and interpretation of diagnostic imaging exams by highly trained radiologist physicians is critical to accurate diagnosis and treatment of disease, injury and illness. Moreover, data shows that patients prefer a physician-led healthcare team. Per an AMA survey 95 % of patients polled said it was important for a physician" to be involved in their diagnosis and treatment.

HCB News: What is the problem (or problems) that states are trying to address with these bills?
EB: It can vary by state, but in testimony, proponents cite healthcare shortages and cost factors as a reason to expand scope of practice. However, while proponents point to healthcare shortages, the American Medical Association’s workforce map shows a more accurate and factual representation of what’s happening with the healthcare workforce across the states. The maps show that non-physicians tend to practice in the same areas of the state as physicians — regardless of the state's scope of practice rules — meaning expanding scope laws doesn’t result in non-physicians moving into rural areas. The overall theme of burnout and shortages in the healthcare system is not limited to physicians, we know that shortages exist across the workforce. Driving non-physician personnel, who may already be under a tremendous amount of pressure to perform, into clinical areas that their educational framework and clinical experience did not prepare them for can lead to an adverse cascading effect within the healthcare system.

Proponents also say that giving non-physician providers scope of practice expansion will lower healthcare costs, but the facts don’t support this assertion. A leading Medicare Accountable Care Organization (ACO) showed that patients with non-physician primary care providers had $43 higher spending per member per month compared to those who had a physician — translating into $10.3 million more in annual spending. We have also seen studies show that X-ray ordering increased 441% among non-physicians, resulting in increased costs.

HCB News: Are there sections, or portions, of any of these bills that the ACR considers a step in the right direction? Or is expansion of non-physician practice in any form a mistake?
EB: Scope expansion based on legislation rather than education is a mistake. Non-physician providers play an important role within their training and are valuable members on the healthcare team. However, sweeping expansion of scope of non-physician personnel into the field of radiology raises serious concerns related to patient safety and quality. If the goal is to reach a timely, accurate diagnosis, then ensuring the patient’s imaging is funneled through to the physician with intensive, specialized radiology training and experience is the way to achieve that goal.

The downward pressure on the overall system from the shrinking provider networks and decreases in physician reimbursement may also contribute to proliferation of bills to secure additional scope expansion for non-physician personnel in a race for "savings". We have repeatedly voiced concerns over the severity of the Medicare cuts associated with this year’s Medicare Physician Fee Schedule because, combined with the impact of high inflation, the impact is felt locally in many of the states. As physicians are forced to adjust to the new realities, many may leave the field (either through retirement or career adjustment), practices may be closed or sold, and a significant number of patients could lose access to a variety of physician specialties in their local communities. Sweeping expansion of scope for non-physicians is not a cure-all remedy within a healthcare system that is arguably ready to fracture in so many different directions because quality clinical performance hinges first and foremost on quality education and experience that can only be provided by physician team leaders.

HCB News: Can you think of other avenues policymakers could take to address the problem they are trying to solve?
EB: It depends on how policymakers define the problem — is it global/local/long-term or an immediate issue that needs to be resolved quickly. Some avenues that policymakers could look at:

Cost of medical education in the U.S.
Increasing the number of radiology residency program slots.
Telemedicine — radiology has some of the best use of telemedicine.
Look at the state climate and why they might be struggling to attract physicians — are there issues like medical liability reform, prior authorization bureaucracy, shrinking competition among insurers in a specific market, or a drawn-out licensure process?

HCB News: For facilities struggling with physician shortages, are there any non-legislative resources or solutions they should be tapping into?
EB: In broad terms, the states where hospitals/facilities and physicians work in concert toward a comprehensive healthcare reform see the most success. For example, we know that all physicians shoulder exhaustive hours of administrative burden due to ineffectiveness of a prior authorization system that seemingly exists to delay and deter use of services. Facilities have a large role to play in advocating for reductions of administrative bureaucracies for by lending their voice to the discussions in state capitols.