RSNA: Are rad assistants getting pushed out of radiology?

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CHICAGO--While radiologist assistants (RAs) could potentially increase productivity and revenue within a practice, current reimbursement and licensure restrictions are constricting the field, based on a Nov. 28 presentation from Christine J. Lung, RT, vice president of government relations and public policy for the American Society of Radiologic Technologists (ASRT), at the annual Radiological Society of North America (RSNA) conference.

Currently, there are 200 American Registry of Radiologic Technologists (ARRT)-certified RAs. The highest populations are in Florida (21), Pennsylvania (15), California (13) and Texas (13). However, these statistics are not directly related to licensure freedoms. Florida is a RA licensure state; however, in Pennsylvania, RAs work under the physician delegation statute and in Texas and California, there is only partial licensure for RAs. Also, there are more than 380 Certification Board for Radiology Practitioner Assistants (CBRPA)-certified radiology practitioner assistants. Lung also noted that more RPAs are seeking certification from the ARRT.

In fact, based on an electronic poll taken of the audience in attendance, 52 percent was certified by the ARRT, with 16 percent certified by radiologist as the next highest stat.

Lung explained that the professional landscape has drastically altered over the past few years, as fewer radiologists are retiring and the shortage is abating. Concurrently, the radiologic technologist workforce is at full employment with new graduates having difficulty findings jobs, while other medical specialties are exploring hiring radiologist extenders or training ancillary personnel to perform imaging exams/procedures, such as physician assistants (PA) and nurse practitioners (NP).

“With fewer opportunities available, it will be incumbent upon the RA to demonstrate appreciable benefit to radiology practices, as well as to be able to compete with PAs and NPs,” said Lung, adding that PAs and NPs are “well-known entities” within the medical community and the state regulatory environment.

Currently, 28 states license, regulate or otherwise recognize RAs. While some states recognize both the RRA and RPAs, others are still working toward better acceptance. Plus, Alabama has prohibited radiology extenders—RAs and RPAs—from practicing in that state.

State licensure is becoming “increasingly important” and provides protection and legal recognition for radiologist extenders, according to Lung, who points to myths that the RAs are simply an extension of RTs. Now, some facilities are requiring state licensure for credentialing or privileging. Also, some private payors or third-party payors include licensure as a condition of payment, but not the Centers for Medicare & Medicaid Services (CMS).

“RA practice is not an extension of RT practice,” Lung stressed. “RAs provide services that are widely different from RTs, and the RA practice widely surpasses any RT scope of practice, which is why we really need legal authority to practice.”

The supervision levels continue to be a “very large problem” for RAs, Lung said. CMS has extended the supervision levels to hospital-based procedures—beyond physician offices and diagnostic imaging centers—as part of the HOPPS 2010 update. When CMS requested comments on the 2010 Physician Fee Schedule in July 2009 on the practice of RAs, the ASRT, ARRT, American College of Radiology (ACR) and National Society of Radiology Practitioners (SPRE) submitted documentation on the scope of practice, examination process and the educational process, but the agency took no action. The societies also have held numerous meetings (20-25) with CMS on this issue. At this time, CMS still is not taking action to rectify the HOPPS 2010 update.

Another reimbursement concern to RAs is that PAs and NPs can receive reimbursement for procedures up to 85 percent, and they are not held to the personal supervision requirement for those same codes, explained Lung. “As a result, some practices are refusing to hire RAs until the reimbursement issue is settled, and RAs are losing jobs and some programs are not accepting students because of it,” she said.

According to a second electronic poll of the audience, 78 percent said the top professional challenge facing RA is billing/reimbursement issues. The second-voted top issue was state licensure, according to 14 percent of the audience.

Other extenders, such as PAs and RNs, are seeking to amend state laws to allow them to perform fluoroscopy. PAs and NPs are well known in state legislatures and PAs have support from physicians and employers to broaden their scope of practice, according to Lung. However, the American Medical Association is examining the expansion this non-physician scope of practice.

In a 2008 study, titled “RAs Increase Productivity,” in Radiologic Technology, Wright and colleagues found:

  • RAs save radiologists 86.75 minutes a day in performing procedures and 13.52 minutes a day in patient management, which equates to 1.5 hours a day.
  • This time savings could generate an additional revenue of $94,785 annually for the practice.
  • Compounded with the additional time for radiologic interpretations for the radiologist, the practice can increase average annual revenue by approximately $335,000.
  • RAs help increase patient satisfaction by reinforcing the physician-patient relationship, as patients feel that they receive more personalized care and a higher level of education about their exam or procedure.

In 2011, the ASRT, ACR, ARRT and SRPE are addressing reimbursement through a legislative approach. Lung explained the ASRT and SRPE are holding an RA track on the legislative effort at the RT conference in Washington, D.C.; lobbyists are being retained by ARRT; and there is an opportunity for a collaborative effort, focused on a grass-roots campaign.

“While the environment is not favorable to continue a regulatory approach, the communication will continue with CMS,” she said. However, Lung cautioned that dictation has led to CMS scrutiny of radiologist extenders, adding that the scope of RA practice states: “provide initial observations to the delegating radiologist.”

However, Lung concluded that having more states recognize radiology extenders could embolden the legislative fight in Washington.