If you think you’ve been seeing more non-physician practitioners (NPPs) reading medical imaging exams, you’re not alone. A new study in Current Problems in Diagnostic Radiology found that the rate of NPP interpretations went up almost 27% over four years.
US radiologists have zealously guarded their position as the primary readers of imaging exams, even as allied health professionals like nurses and physician assistants clamor to extend their scope of practice (SOP) into image interpretation. The struggle often plays out in state legislatures, with each side pushing laws benefiting their positions.
How has this dynamic affected NPP interpretation rates? In the current study, researchers looked at NPP interpretations of 110 million imaging claims from 2016 to 2020. They also examined how NPP rates changed by geographic location, and whether state laws on NPP practice authority affected rates. Findings included:
- The rate of NPP interpretation for imaging studies went from 2.6% to 3.3% in the study period – growth of 26.9%.
- Metropolitan areas saw the highest growth rate in NPP interpretation, with growth of 31.3%, compared to micropolitan areas (18.8%), while rates in rural areas did not grow at a statistically significant rate.
- Rates of NPP interpretation tended to grow more in states with less restrictive versus more restrictive practice-authority laws (45% vs. 16.6%).
- NPP interpretation was focused on radiography/fluoroscopy (53%), ultrasound (24%), and CT and MRI (21%).
The findings are particularly interesting because they run counter to one of the main arguments made by NPPs for expanding their scope of practice into imaging: to alleviate workforce shortages in rural areas. Instead, NPPs (like physicians themselves) tend to gravitate to urban areas – where their services may not be as needed.
The study also raises questions about whether the training that NPPs receive is adequate for a highly subspecialized area like medical imaging, particularly given the study’s findings that advanced imaging like CT and MRI make up one in five exams being read by NPPs.
The findings undermine one of the main arguments in favor of using non-physician practitioners – to address access-to-care issues. The question is whether the study has an impact on the ongoing turf battle between radiologists and NPPs over image interpretation playing out in state legislatures.
The American College of Radiology (ACR) rolled out a significant change to its imaging contrast guidelines, allowing non-radiologists and non-physician practitioners (NPPs) to supervise intravenous CT and MRI contrast administration at accredited imaging centers.
A range of NPPs (NPs, PAs, RNs) and qualifying non-radiologist physicians will be able to directly supervise contrast administration under the “general supervision” of on-site radiologists, as long as it’s supported by state scope of practice laws.
- Superving radiologists must be available for “assistance or direction” and trained to handle acute contrast reactions/situations, but they won’t have to be in the same room as the patient.
These guidelines mirror the ACR’s new practice parameters for contrast supervision (adopted in May), and follow CMS’ recent efforts to expand more diagnostic tasks to non-physicians.
- CMS granted radiology assistants the ability perform a range of imaging tasks in 2020 and permitted NPPs to directly supervise Level 2 tests in 2021 (like contrast-enhanced CT and MRI), in both cases requiring “general” radiologist supervision (on-site, but not in room… and virtual during the pandemic).
Although NPPs’ radiology expansion has historically sparked heated debates, the new ACR contrast supervision guidelines hasn’t faced many public objections so far.
- That’s potentially because some (busy) radiologists don’t view directly supervising contrast administration as a practical or efficient use of their time (even if they still have to drive to the imaging center), especially considering that technologists often spot adverse reactions before anyone else.
- However, there’s surely plenty of radiologists who are concerned about whether these new guidelines might exacerbate scope creep, cut their earning potential (especially trainees), reduce radiologists’ patient-facing opportunities, and undermine patient care.
The ACR’s decision to grant NPPs greater contrast supervision rights and loosen radiologists’ contrast supervision requirements might not be surprising to folks paying attention to recent ACR and CMS policies. That said, it’s still a notable step (and potential contributor) in the NPPs’ expanding role within radiology – and opinions might differ regarding whether that’s a good thing.
A new Harvey L. Neiman study showed that the recent expansion of nonphysician practitioners (NPPs) across US radiology practices coincided with similar increases in NPP-billed services — services that have traditionally been performed and billed by radiologists.
The Study – Researchers reviewed 2017-2019 data for Medicare claims-submitting nurse practitioners and physician assistants (together “NPPs”) who were employed by US radiology practices, finding that:
- The number of radiology-employed NPPs who submitted claims increased by 16.3% between 2017 and 2019 (523 to 608 NPPs), while the number of US radiology practices that employed claims-submitting NPPs jumped by 14.3% (196 to 224 practices)
- This NPP service expansion was driven by clinical evaluation and management services (E&M; +7.6% to 354), invasive procedures (+18.3% to 458), and image interpretation services (+31.8% to 112).
- Meanwhile, total NPP wRVUs increased by 17.3%, similarly driven by E&M services (+40% to 111k wRVUs), invasive procedures (+5.6% to 189k), and image interpretation (+74% to 8,850 wRVUs)
- Some radiologists might be concerned that image interpretation saw the greatest NPP headcount and wRVU growth (see +31.8% & +74% stats above), although imaging only represented a small share of overall NPP wRVUs (2.9% in 2019), and 86.7% of NPP-submitted imaging services were for either DEXA scans or swallowing studies.
Although roughly 87% of radiology practices still don’t employ NPPs who submit Medicare claims (as of 2019 anyway), this study reveals a clear trend towards NPPs performing more billable procedures — including image interpretation.
Given previous evidence of NPPs’ growing employment in radiology practices and the major role NPPs play within other specialties, this trend is very likely to continue, leading to more blended radiology teams and more radiologist concerns about the NPP ‘slippery slope.’
A new JACR study detailed nonphysician practitioners’ (NPPs) expansion across US radiology practices, mirroring a trend already seen in other parts of healthcare and raising questions about how much further radiology NPPs might expand.
The Study – The study reviewed 2017-2019 Medicare data for nurse practitioners and physician assistants (together “NPPs”) employed by US radiology practices, finding that:
- Radiology practices employing NPPs increased by 10.5% (228 to 252 practices), while the number of overall radiology practices declined by 36.5% (2,643 to 1,679)
- As a result, the share of radiology practices with NPPs on staff nearly doubled (8.6% to 15% of US practices)
- NPP-employing practices expanded their NPP workforce at a much faster rate (+17.5%, 588 to 691) than they added radiologists (+10.4%, 6,596 to 7,282)
- The growth of urban practices employing NPPs (10% to 17% share) significantly outpaced rural practices (5% to 7% share), despite a greater need for radiology coverage in rural areas
- Radiology practices were also more likely to employ NPPs if they were larger, staffed more interventional radiologists, or had a high number of early-career radiologists
The study was limited to radiology-only practices, which employ two-thirds of U.S. radiologists, but excludes many academic, hospital-employed, and multi-specialty groups. That said, it’s possible that radiology NPP growth would be even greater if these groups were included.
Although 85% of practices didn’t employ NPPs and radiologists still outnumbered NPPs by a 32:1 ratio (as of 2019 anyway), this study reveals a clear trend towards more practices employing NPPs and rising overall radiology NPP headcounts. That’s probably not surprising given the historical growth of NPPs within other specialties, and radiology’s continued shift towards national and PE-owned practices, but it’s still interesting to see how it’s taking place.
It’s also interesting that this study wasn’t met with the level of radiologist uproar that we saw the last few times radiology NPPs made it into the industry news cycle. Even though NPPs’ expansion across radiology practices doesn’t mean that they will start encroaching into radiologists’ clinical territory (as some rads fear), it does suggest that we’ll see a lot more blended rad/NPP workforces going forward.