Radiologists fear scope creep, pressing societies to oppose MARCA bill granting rad assistants more sway
Radiologists are pressing two top medical societies representing the specialty to take a stance against proposed legislation that could spur wider use of rad assistants.
The American College of Radiology just recently announced it will remain neutral (at least for now) on the Medicare Access to Radiology Care Act, introduced in the U.S. Senate in August. MARCA, as it’s called for short, would ensure reimbursement to practices or departments for registered radiologist assistants’ services (not pay RRAs directly) in all healthcare settings and free physicians to focus on complex or urgent interpretation needs, supporters argue.
The college said it has heard “widely diverse” opinions from members on the bill. But a group of physicians are voicing disdain for the decision and urging both ACR, along with the Society of Interventional Radiology, to come out strongly against MARCA. Agnieszka Solberg, MD—a North Dakota-based interventional radiologist and chair of the peer review committee at CHI St. Alexius Health—questions the diversity of opinion among her peers on this issue. She recently administered an informal Survey Monkey poll to providers, targeting specialty Facebook groups, and found 93% of respondents oppose the legislation.
“I am disappointed in ACR and SIR leadership recently as their actions seem not to represent the opinions of the majority of radiologists,” Solberg told Radiology Business by email, adding that she understands the “complex history” between the two groups and the American Society of Radiologic Technologists, but believes they must represent “physicians first." “I do feel that ACR and SIR overall support radiologists well, but recent decisions, like not opposing MARCA, are surprising and disappointing.”
About the bill
U.S. Rep. Mike Doyle, D-Penn., and now-former Rep. Pete Olson, R-Texas, introduced versions of the Medicare Access to Radiology Care Act in 2017 and 2019 before Doyle proposed the 2021 iteration this past June. House Resolution 3657 would amend the Social Security Act to align federal payment policies with state licensure laws for radiologist assistants.
Back in 2018, the Centers for Medicare & Medicaid Services changed its rules so RRAs could perform certain services under the direct supervision of radiologists. Those include needle placements, biopsies and injections that accompany imaging studies. Such certified radiographers are rigorously trained and can safely perform certain assessments and functions (excluding image interpretation). However, radiology providers are unable to submit claims to Medicare for this work when performed in a hospital (where most RRA work occurs) or office setting.
“By not separating radiologist assistant reimbursement policies into different payment categories by service location, the adoption of MARCA would enable radiologists to devote more focused time to reviewing and interpreting complex medical images or urgent cases, thus increasing patients’ access to care,” the American Society of Radiologic Technologists said on its website. “RAs will be able to work more efficiently, and Medicare patients will receive care from qualified RAs regardless of the facility in which their procedure takes place.”
Doyle’s bill now has three cosponsors in the House. Meanwhile, Sen. John Boozman, R-Ark., introduced MARCA in the Senate Aug. 5, since garnering two cosponsors. Along with ASRT, the legislation is endorsed by the American Registry of Radiologic Technologists and the Society for Radiology Physician Extenders. ACR previously voiced support for the Medicare Access to Radiology Care Act of 2019 while highlighting rising demand for imaging services and the increased complexity of studies. The college at the time also underlined that RRAs do not perform final interpretation of images, nor do they prescribe medications or therapies.
“This commonsense, bipartisan bill will provide America’s seniors with more efficient healthcare, while saving jobs and money,” former Rep. Pete Olson said in April 2019. “This bill fills critical gaps in doctor shortages by utilizing radiologist assistants. This measure will improve the quality of care and ensure timely access to diagnostic and interventional imaging procedures.”
But this time around, the college announced Aug. 25 that it will remain neutral on MARCA 2021, with no plans to lobby for or against it. ACR’s board of chancellors will hold listening sessions and gather further feedback on the rule, including surveying stakeholders. Following receipt of a report, the American College of Radiology said it will consider lifting its neutral stance and issuing an official policy.
“ACR is a member-driven organization and members on both sides of this issue have readily shared their opinions,” CEO William Thorwarth, MD, told Radiology Business Thursday. “We have encouraged and gotten a great deal of feedback about MARCA, both pro and con. We continue to seek input from members and share information with the membership regarding this issue.”
Opposition forms
Members of the ACR such as Agnieszka Solberg, however, want the college to exit the middle and take a side. She emphasized her “great respect” for both technologists and registered radiologist assistants but is concerned that passing MARCA would propel many techs to work, instead, as RAs. This could drain the supply of such professionals, which are already scarce in rural areas like North Dakota, where she practices.
Solberg also worries that the bill leads registered radiologist assistants down a path toward independence. She believes in the importance of physician-led care and sees advanced practitioner encroachment as “a larger threat than AI.”
“While I believe that the RRAs of today are being sincere, we cannot control the RRA of tomorrow. Leadership and agenda changes,” she said. “Independence is not a decision by the ACR—it is a legislative decision. Our legislators sometimes look whether our societies support these endeavors. Bills can be amended with a stroke of a pen. I do not believe that RRAs should be able to work independently without physician supervision (which the proposed bill would not permit). I think RRA work should continue to be captured under the physician who is supervising the work.”
Others have taken to Twitter to voice their opposition, using hashtags #StopMARCA and #MARCAgate. Ben White, MD—a Texas neuroradiologist and blogger—echoed concerns about encroachment following an August ACR town hall on the topic.
“You can be anti-MARCA because of the likely long-term impact on radiology or you can be pro-MARCA because you think that it’ll buy us a few years of more control with RAs instead of NP/PAs. You can think it’s ultimately inevitable,” he tweeted Aug. 23. “What’s not tenable is acting as though scope creep won’t happen just because it’s not permitted in the initial expansion law. Paper is cheap. People on the slippery slope never believe it until they slip further than intended. Predicting consequences is a hard business.”
Some such as the user @ExitACR have chosen to remain anonymous, claiming they fear retribution.
“Many of us who have raised concerns about MARCA have been told in no uncertain [terms] to stand down by ACR insiders and academic big wigs,” the person shared on Twitter while declining to be identified or interviewed. “MARCA will hurt my career, but speaking out will hurt it quicker.”
Solberg said some shared similar sentiments through her survey, denoting alleged “fear of retribution” from the American College of Radiology and Society of Interventional Radiology. She, however, has not been asked to stop commenting publicly on the bill and plans to remain a member for the foreseeable future.
“I appreciate ACR leadership engaging with its members but remind leadership that it’s time not only to listen, but also to act in a way which represents the majority of the organizations’ members,” Solberg said.
Keith Hume, executive director of the interventional radiology society, acknowledged physicians' concerns while emphasizing that his top priority is addressing “detrimental” doc pay cuts outlined in the 2022 Medicare Physician Fee Schedule. If approved, he believes, they “could cripple practices and rob patients of the care they need.” SIR’s advocacy team and physician leaders are still analyzing MARCA to determine its impact on interventional radiologists while monitoring the bill’s progress closely.
“It has very few cosponsors and has not been scheduled for a hearing. There is no indication that action in imminent,” Hume told Radiology Business. “Should the bill advance, the advocacy team and physician volunteers will consider what position, if any, is necessary to take.”
Editor's note: This story has been updated to correct Agnieszka Solberg's position at CHI and further clarify SIR's response.
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.