Download Bill Id - Around The Capitol

AB 352
Page 1
Date of Hearing: May 3, 2011
ASSEMBLY COMMITTEE ON BUSINESS, PROFESSIONS AND CONSUMER
PROTECTION
Mary Hayashi, Chair
AB 352 (Eng) – As Amended: April 15, 2011
SUBJECT: Radiologist assistants.
SUMMARY: Enacts the Radiologist Assistant Practice Act (Act), which requires licensure and
regulation of radiologist assistants (RAs) by the Medical Board of California (MBC) and
prescribes the services that may be performed by an RA under the supervision of a qualified
physician and surgeon. Specifically, this bill:
1) Provides that a RA licensed pursuant to this bill may perform those medical services as set
forth by the regulations of the MBC when the services are rendered under the supervision of
a qualified physician and surgeon, as specified. Medical services performed by a RA shall
include, but not be limited to, obtaining patient consent prior to beginning an examination or
procedure and obtaining medical imaging necessary for diagnosis and providing initial
observations to the qualified physician and surgeon.
2) Requires a RA and his or her qualified physician and surgeon to establish written guidelines
for the adequate supervision of the RA, which can be satisfied by the qualified physician and
surgeon adopting protocols for some or all of the tasks performed by the RA. RAs shall not
interpret images, make diagnoses, or prescribe medications or therapies. Protocols must
comply with the following requirements:
a) A protocol governing procedures shall set forth the information to be provided to the
patient, the nature of the consent to be obtained from the patient, the preparation and
technique of the procedure, supervision of radiologic technologists (RTs) by the RA in
the performance of medical imaging procedures, and follow-up care;
b) Protocols shall be developed by the qualified physician and surgeon or adopted from, or
referenced to, texts or other sources;
c) Protocols shall be signed and dated by the qualified physician and surgeon and the RA;
and,
d) Protocols shall be available at each practice site.
3) Permits the MBC to establish other alternative mechanisms for the adequate supervision of
the RA.
4) Permits a licensed RA to supervise a RT in the performance of medical imaging procedures
using fluoroscopy, and exempts licensed RAs from current law and regulation governing the
certification of healing arts licentiates for the purposes of administering or using, or
supervising the administration and use of, certain imaging techniques, as specified.
AB 352
Page 2
5) Provides that a licensed RA shall be eligible for employment or supervision by any qualified
physician and surgeon, who must possess a current and valid license to practice medicine and
may not be on disciplinary probation for improper use of a RA or subject to a disciplinary
condition imposed by the MBC prohibiting employment or supervision of a RA.
6) Prohibits a qualified physician and surgeon from supervising more than two RAs at any one
time.
7) Permits a RA to perform medical services as specified in 1) through 4), above, during any
state of war emergency, state of emergency, or local emergency, and at the request of a
responsible federal, state, or local official or agency, or pursuant to the terms of a mutual aid
operation plan, as specified, regardless of whether the RA’s qualified physician and surgeon
is available to supervise the RA, so long as a licensed physician and surgeon is available to
render the appropriate supervision, as specified.
8) Prohibits any person other than a licensed RA from practicing as a RA or in a similar
capacity to a radiologist or hold himself or herself out as a "RA."
9) Requires the MBC to adopt regulations for the consideration of applications for licensure as a
RA and for the certification of approved programs for the education and training of RAs, no
later than July 1, 2013.
10) Requires, beginning July 1, 2013, or as soon as possible thereafter, the MBC to issue a
license to each RA applicant who meets all of the following requirements:
a) Provides evidence of successful completion of an approved program;
b) Is certified as a RA by the American Registry of Radiologic Technologists (ARRT) or as
a radiology practitioner assistant (RPA) by the Certification Board for Radiology
Practitioner Assistants (CBRPA);
c) Is certified by the State Department of Public Health (DPH) as a diagnostic RT and holds
a RT fluoroscopy permit;
d) Is not subject to denial of licensure under current law or provisions of the Act; and,
e) Pays all fees required under the Act.
11) Requires, beginning July 1, 2013, or as soon as possible thereafter, the MBC to recognize the
approval of training programs for RAs approved by a national accrediting organization. RA
training programs accredited by a national accrediting agency approved by the MBC shall be
deemed approved by the MBC under the Act. If no national accrediting organization is
approved by the MBC, the MBC may examine and pass upon the qualification of, and may
issue certificates of approval for, programs for the education and training of RAs that meet
MBC standards. The MBC may examine and issue certificates to approved programs that
satisfy the requirements of the regulations adopted pursuant to provisions of the Act.
12) Requires the applicant to provide evidence satisfactory to MBC that an application has been
filed and accepted for the examination, and that the organization certifying RAs has been
AB 352
Page 3
requested to verify the applicant’s certification status to MBC in order for the applicant to
maintain interim approval. The applicant shall be deemed to have failed the examination
unless the applicant provides evidence to the MBC within 30 days after scores have been
released that he or she has passed the examination.
13) Creates the Radiologist Assistant Fund (Fund) and requires, within 10 days after the
beginning of each calendar month, the MBC to report to the Controller the amount and
source of all collections made under the Act and at the same time pay all those sums into the
State Treasury, where they shall be credited to the Fund. All money in the Fund shall, upon
appropriation by the Legislature, be used to carry out the purpose of the Act.
14) Requires the MBC to set RA application, licensure, and renewal fees in an amount sufficient
to cover the reasonable and necessary costs of implementing and administering the Act. The
MBC must report to the appropriate policy and fiscal committees of each house of the
Legislature whenever the MBC approves a fee increase.
15) Establishes a license expiration schedule requiring all RA licenses to expire at 12 midnight of
the last day of the birth month of the licensee during the second year of a two-year term, if
not renewed.
16) Requires the MBC to establish, by regulation, procedures for administering the birth-date
license renewal program, including, but not limited to, the establishment of a system of
staggered license expiration dates.
17) Requires a licensee to renew an unexpired license by applying for renewal on or before the
date of expiration of the license on a form provided by the MBC, accompanied by the
prescribed renewal fee. The MBC must require, as a condition of license renewal,
completion of not more than 50 hours of continuing education every two years as the MBC
deems acceptable.
18) Provides that a suspended license is subject to expiration and requires an expired license to
be renewed as specified, but states that renewal does not entitle the holder of the license,
while it remains suspended and until it is reinstated, to practice or engage in the activity to
which the license relates, or engage in any other activity or conduct in violation of the order
or judgment by which the license was suspended.
19) Provides that a revoked license is subject to expiration, as specified. If the license is
reinstated after expiration, the licensee, as a condition to reinstatement, shall pay a
reinstatement fee, as specified.
20) Permits the MBC to deny, issue with terms and conditions, suspend or revoke, or impose
probationary conditions upon a RA license for unprofessional conduct, as specified, that
includes, but is not limited to, a violation described under current law governing
unprofessional conduct of businesses and professions generally, a violation of the Act, a
violation of the Radiologic Technology Act, a violation of the applicable regulations adopted
by the MBC, or a breach of an ethics rule established by a recognized national certification
organization of RAs. The MBC may order the licensee to pay the costs of monitoring the
probationary conditions.
AB 352
Page 4
21) Permits the MBC to deny, approve with terms and conditions, suspend or revoke, or impose
probationary conditions upon an approved program after a hearing, as specified, for a
violation of the Act or regulations adopted pursuant to the Act.
22) Requires any proceedings involving the denial, suspension, or revocation of the application
for licensure or the license of a RA or the application for approval or the approval of an
approved program to be conducted in accordance with current law governing administrative
adjudication hearings for state departments and agencies. The MBC may hear the matters, or
may assign them to a hearing officer, as specified.
23) Permits a person whose license has been revoked or suspended or who has been placed on
probation to petition the MBC for reinstatement or modification of penalty, as specified, after
a period of not less than the following minimum periods has elapsed from the effective date
of the decision ordering that disciplinary action:
a) At least three years for reinstatement of a license revoked for unprofessional conduct,
except that the MBC may, for good cause shown, specify in a revocation order that a
petition for reinstatement may be filed after two years;
b) At least two years for early termination of probation of three years or more; and,
c) At least one year for modification of a condition, reinstatement of a license revoked for
mental or physical illness, or termination of probation of less than three years.
24) Requires the petition to state any facts as may be required by the MBC. The petition shall be
accompanied by at least two verified recommendations from qualified physician and
surgeons licensed either by the MBC or the Osteopathic Medical Board of California
(OMBC) who have personal knowledge of the activities of the petitioner since the
disciplinary penalty was imposed.
25) Provides that the petition may be heard by the MBC, which may assign the petition to an
administrative law judge designated in current law. After a hearing on the petition, the
administrative law judge shall provide a proposed decision to the MBC that shall be acted
upon in accordance with the Administrative Procedure Act.
26) Provides that the MBC or the administrative law judge hearing the petition may consider all
activities of the petitioner since the disciplinary action was taken, the offense for which the
petitioner was disciplined, the petitioner’s activities during the time the license was in good
standing, and the petitioner’s rehabilitative efforts, general reputation for truth, and
professional ability. The hearing may be continued as the MBC or administrative law judge
finds necessary.
27) Permits the MBC or administrative law judge, when hearing a petition for reinstating a
license or modifying a penalty, to recommend the imposition of any terms and conditions
deemed necessary.
28) Provides that no petition shall be considered while the petitioner is under sentence for any
criminal offense, including any period during which the petitioner is on court-imposed
probation or parole. No petition shall be considered while there is an accusation or petition
AB 352
Page 5
to revoke probation pending against the person. The MBC may deny, without a hearing or
argument, any petition filed within a period of two years from the effective date of the prior
decision following a hearing under the bill.
29) Provides that nothing in this bill shall be deemed to alter current law governing the actions a
licensing agency can take if it determines that its licentiate’s ability to practice his or her
profession safely is impaired because the licentiate is mentally ill, or physically ill affecting
competency.
30) Provides that a plea or verdict of guilty or a conviction following a plea of nolo contendere
made to a charge of a felony or of any offense that is substantially related to the
qualifications, functions, or duties of the business or profession to which the license was
issued is deemed to be a conviction within the meaning of the Act. The MBC may order the
license suspended or revoked, or shall decline to issue a license when the time for appeal has
elapsed, or the judgment of conviction has been affirmed on appeal or when an order
granting probation is made suspending the imposition of sentence, irrespective of a
subsequent order under current law allowing the person to withdraw his or her plea of guilty
and to enter a plea of not guilty, or setting aside the verdict of guilty, or dismissing the
accusation, information, or indictment.
31) Provides that any person who violates 1) through 4) or 8), above, shall be guilty of a
misdemeanor punishable by imprisonment in the county jail not exceeding six months, or by
a fine not exceeding one thousand dollars ($1,000), or by both.
32) Provides that, whenever any person has engaged in any act or practice that constitutes an
offense against the Act, the superior court of any county, on application of the MBC, may
issue an injunction or other appropriate order restraining the conduct, as specified.
33) Provides that qualified physicians and surgeons licensed by the OMBC may use or employ
RAs provided that: each RA so used or employed is a graduate of an approved program and
is licensed by the MBC; and, the scope of practice of the RA is the same as that which is
approved by the MBC for RAs in the same or similar specialty. Any person who violates this
provision shall be guilty of a misdemeanor punishable by imprisonment in a county jail not
exceeding six months, or by a fine not exceeding one thousand dollars ($1,000), or by both
that imprisonment and fine.
34) Administers the Act by establishing a RA Advisory Council (Council) of the MBC, which
shall create and appoint the Council consisting of qualified physician and surgeon licensees
of the MBC in good standing who are not required to be members of the MBC, and members
of the public who have an interest in RA practice. At least one-half of the Council members
shall be RAs certified by the ARRT or RPAs certified by the CBRPA. The Council shall
make recommendations on matters specified by the MBC, as specified.
35) Permits the Council to convene from time to time as deemed necessary by the board.
36) Provides that it shall be the duty of the Council to do all of the following:
a) Make recommendations to the MBC concerning the establishment of standards and
issuance of approval for programs;
AB 352
Page 6
b) Make recommendations to the MBC concerning the scope of practice for RAs using the
guidance of the American Society of Radiologic Technologists, the ARRT, the American
College of Radiology (ACR), and the CBRPA; and,
c) Adopt regulations pursuant to 9), above.
37) Permits the MBC to adopt, amend, and repeal regulations as may be necessary to enable it to
carry into effect the provisions of the Act, as specified.
38) Requires the MBC to employ within the limits of the Fund all personnel necessary to carry
out the provisions of the Act. The MBC shall make all necessary expenditures to carry out
the provisions of the Act from the Fund. The MBC may accept contributions to effect the
purposes of the Act.
39) Provides terms and definitions, including:
a) “Approved program” means a RA program or a RPA program for the education and
training of RAs that has been formally approved by the board for the licensure of RAs;
b) “Medical imaging” means any procedure intended for use in the diagnosis or treatment of
disease or other medical conditions, and includes, but is not limited to, X-rays, nuclear
medicine, and other procedures, and that excludes echocardiography and diagnostic
sonography;
c) “Qualified physician and surgeon” means a radiologist or another physician and surgeon
supervising a RA within his or her specialty or usual and customary practice. A qualified
physician and surgeon shall either hold, or be exempt from holding, an operator
supervisor permit pursuant to the Radiologic Technology Act for ionizing radiation,
fluoroscopy, or the use and handling of nuclear medicine material, as appropriate for
procedures that are being supervised;
d) “Radiologist” means a physician and surgeon licensed by the MBC or by the OMBC and
certified by, or board-eligible for, the American Board of Radiology;
e) “RA” means a person who meets the requirements of the Act, as specified;
f) “Radiology practitioner assistant” (RPA) means a person who is certified by the
Certification Board for Radiology Practitioner Assistants;
g) “Supervision” means the qualified physician and surgeon is physically present on the
premises and available to the RA when medical services are rendered and oversees the
activities of, and accepts responsibility for, the medical services rendered by the RA.
40) Provides intent language.
EXISTING LAW
AB 352
Page 7
1) Regulates and licenses physicians and surgeons, including radiologists, under the MBC
within the Department of Consumer Affairs (DCA).
2) Establishes within DPH the Radiologic Health Branch (RHB), which is responsible for
licensing of radioactive materials, registration of X-ray producing machines, certification of
X-ray and radioactive material users, inspection of facilities using radiation, investigation of
radiation incidents, and surveillance of radioactive contamination in the environment.
3) Requires certification or licensure for any person who administers or uses diagnostic or
therapeutic X-ray.
4) Specifies examination requirements for obtaining a RT certificate and requires passage of
DHS-approved examination in diagnostic radiologic technology.
5) Provides for granting of limited permits to persons to conduct radiologic technology limited
to the performance of certain procedures or the application of X-rays to specific areas of the
human body, except for mammography.
FISCAL EFFECT: Unknown
COMMENTS:
Purpose of this bill. According to the author's office, "Since 1992 the number of procedures
radiologists perform every year has increased over twenty-five percent. This takes them away
from interpreting the results from an imaging device and from making diagnoses. Radiologists
are becoming overwhelmed with the volume of other procedures that need to be performed in
their field.
"AB 352 will put California in line with other states that license and regulate radiologist
assistants. It will allow a licensed, educated, and trained professional to perform some of the
functions of a radiologist. This will relieve radiologists of some of their workload so they can
concentrate on interpreting imaging test results and making diagnoses, thereby increasing the
quality of care for patients throughout California."
Background. According to the ACR, an RA is identified as an "advanced-level radiologic
technologist who works under the supervision of a radiologist to enhance patient care by
assisting the radiologist in the diagnostic imaging environment. The Radiologist Assistant is not
a radiologist nor a physician assistant but rather a valuable addition to the radiology team who
can enhance quality patient care by performing advanced level radiological services under the
supervision of a radiologist."
"The term was developed during a series of meetings between the American Society of
Radiologic Technologists (ASRT) and the ACR during the spring and summer of 2002. The two
groups have been meeting to consider the development of an advanced-level radiologic
technologist to address workforce shortages among radiologic technologists and radiologists."
According to ASRT, several universities pioneered the idea for RA programs in the 1970s, but
the concept did not take hold. "The shortage of radiologists, along with growing demand for
imaging services, motivated the American College of Radiology (ACR) to look for alternative
AB 352
Page 8
ways of continuing to provide high quality patient care. The ASRT was looking for ways to
extend the career path of radiologic technology in order to support recruiting and retention
efforts. The two initiatives found a common solution in the radiologist assistant concept."
Currently, there is no RA license in California. There is only the RT practice, which is certified
by DPH. RTs must complete an educational program approved by RHB and pass a state
examination, or a national examination, for certification.
RTs generally obtain a two-year associate's degree in Radiologic Technology. After obtaining
their degree, students are eligible to take the state examination for a diagnostic or therapeutic RT
certificate. They are also eligible to take the national examination for a therapeutic radiologic
technology certificate. Both examinations are given by the ARRT. Successful passage of either
the state or national examination qualifies RTs to x-ray any part of the body. Those who obtain
state certification may also apply for additional certificates, such as the Radiologic Technologist
Fluoroscopy Permit or the Mammographic Radiologic Technology Certificate, if they meet
appropriate educational requirements. RTs may also become certified in radiation therapy
technology through the ARRT.
A document published in 2003 by the Center for the Health Professions at the University of
California San Francisco (UCSF) identified a shortage of diagnostic imaging professionals. A
2001 American Hospital Association study reported a 15.3 % vacancy rate for imaging
technologists and technicians, with the highest rate at 17 % on the west coast. The study also
revealed that 20% of hospitals reported vacancy rates of more than 20% for imaging
professionals. UCSF also stated that California was experiencing particularly severe shortages
of diagnostic imaging workers. In 1998, the state ranked 49th in per-capita employment of
radiologic technicians, and 43rd in employment of nuclear medicine technologists. According to
the Employment Development Department, jobs for RTs and RT technicians are expected to
increase by 21.2 %, or 3,400 jobs, between 2008 and 2018.
ARRT is a national certification organization that develops and administers standards to assess
the qualifications of individuals in medical imaging and radiation therapy. It was founded in
1922 and registers individuals as RTs in 15 disciplines. A number of state licensing laws,
including those in California, rely on ARRT examination scores for the issuance of state licenses.
In addition to certifying 300,000 technologists nationwide, ARRT certifies more than 31,200
RTs in California.
ARRT started certifying RAs after a consensus document was produced in 2002 detailing
educational preparation, roles and responsibilities, levels of supervision, regulatory issues and
certification standards. Currently, there are 12 RA educational programs in the country that have
received ARRT certification, including one in California at Loma Linda University. According
to the author's office, RAs are licensed in 29 other states.
The RA license category established by this bill is intended to act as a physician extender much
like a physician assistant, providing relief for radiologists and a professional path for RTs who
wish to advance their skills and practice. In addition to other provisions, this bill differs from
prior legislation that attempted to develop a certification program for RAs by placing the
regulatory authority with the MBC rather than DPH. It also creates an advisory committee of the
MBC to assist with implementation, including scope of practice recommendations; specifies
requirements for licensure, educational programs, and continuing education; and, provides
AB 352
Page 9
guidelines for license fees, penalties and disciplinary action, including due process provisions.
Licensed RAs would be required to practice under the direct supervision of a physician and
surgeon, and would be allowed to supervise RTs in the performance of medical imaging
procedures using fluoroscopy.
Support. According to the California Radiological Society, "Our members, who are beginning to
bring radiologist assistants in to their practices, often in the hospital setting, have encountered
issues since the category is not now recognized in state law. This interferes with the ability of
R.A.s to be recognized in the hospital credentialing process. It has also raised issues with some
malpractice liability carriers who will not provide coverage for the broader scope of duties for an
R.A. since they are not so recognized in statute or regulation as having broader training then (sic)
a radiologic technologist."
The California Society of Radiologic Technologists writes, "With the workload in diagnostic
imaging departments rapidly increasing over the past few years, the addition of radiology
extenders would increase productivity and efficiency, while enabling patients to receive timely
diagnosis and care. To have radiology extenders incorporated into the California workplace
keeps California up to date with current standards of care and practice in our imaging
departments."
Opposition. The California Nurses Association states, "CNA questions the necessity of creating
a new licensure category for RAs, and is concerned that the introduction of a new type of
practitioner will lead to a more fragmented system of care for radiology patients.
"As an organization, we advocate for the highest standards of care for patients, and have strong
concerns with any measure that aims to establish new licensure categories for healing arts
practitioners. By establishing licensure for RAs, including a new scope of practice, and a
supervisory role for over radiological technicians (RTs), this bill would introduce an additional
practitioner to provide care to the patient, thereby further fragmenting the continuum of care.
Further, some have asserted that this bill may provide a career-ladder for RTs. However,
because the bill would require an RA to also be an RT, this bill would potentially undermine the
employability of RTs who do not wish to go on to become an RA, because there would be little
incentive to employ both at the same time."
AB 623 (Lieu) of 2007 requires DPH to develop a certification process for RAs. This bill was
held in Assembly Appropriations Committee.
SB 700 (Aanestad) of 2005 provides for the certification of RAs by DPH. This bill was held in
Senate Business, Professions and Economic Development Committee.
REGISTERED SUPPORT / OPPOSITION:
Support
American Society of Radiologic Technologists (sponsor)
Radiology Practitioner Assistant Society (sponsor)
American Registry of Radiologic Technologists
California Radiological Society
California Society of Radiologic Technologists
AB 352
Page 10
Newport Harbor Radiology Associates Medical Group, Inc.
Society of Radiology Physician Extenders, Inc. (SRPE)
Numerous individuals
Opposition
American Nurses Association of California (ANA/C)
California Nurses Association (CNA)
Analysis Prepared by:
Angela Mapp / B.,P. & C.P. / (916) 319-3301