BILL ANALYSIS �
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;
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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.
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
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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
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
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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.
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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.
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
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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 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
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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
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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;
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;
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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
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.
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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
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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 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
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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 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
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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)
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Radiology Practitioner Assistant Society (sponsor)
American Registry of Radiologic Technologists
California Radiological Society
California Society of Radiologic Technologists
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