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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