Bill Text: MO HB1842 | 2014 | Regular Session | Introduced
Bill Title: Establishes licensure and practice requirements for assistant physicians
Spectrum: Partisan Bill (Republican 1-0)
Status: (Introduced - Dead) 2014-04-14 - Rules - Reported Do Pass (H) [HB1842 Detail]
Download: Missouri-2014-HB1842-Introduced.html
SECOND REGULAR SESSION
97TH GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE FREDERICK.
5997L.01I D. ADAM CRUMBLISS, Chief Clerk
AN ACT
To repeal sections 334.035, 334.104, and 334.735, RSMo, and to enact in lieu thereof four new sections relating to assistant physicians.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 334.035, 334.104, and 334.735, RSMo, are repealed and four new sections enacted in lieu thereof, to be known as sections 334.035, 334.036, 334.104, and 334.735, to read as follows:
334.035. Except as otherwise provided in section 334.036, every applicant for a permanent license as a physician and surgeon shall provide the board with satisfactory evidence of having successfully completed such postgraduate training in hospitals or medical or osteopathic colleges as the board may prescribe by rule.
334.036. 1. For purposes of this section, the following terms shall mean:
(1) "Assistant physician", any medical school graduate who:
(a) Is a resident and citizen of the United States or is a legal resident alien;
(b) Has successfully completed Step 1 and Step 2 of the United States Medical Licensing Examination or the equivalent of such steps of any other board-approved medical licensing examination within the eighteen-month period immediately preceding application for licensure as an assistant physician; and
(c) Has not entered into postgraduate residency training prescribed by rule of the board under section 334.035;
(d) Has proficiency in the English language;
(2) "Assistant physician collaborative practice arrangement", an agreement between a physician and an assistant physician which meets the requirements of this section and section 334.104;
(3) "Medical school graduate", any person who has graduated from a medical college or osteopathic medical college described in section 334.031.
2. (1) An assistant physician collaborative practice arrangement shall limit the assistant physician to providing only primary care services and only in medically underserved rural or urban areas of this state.
(2) For a physician-assistant physician team working in a rural health clinic under the federal Rural Health Clinic Services Act, P.L. 95-210, as amended:
(a) An assistant physician shall be considered a physician assistant for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS); and
(b) No supervision requirements in addition to the minimum federal law shall be required.
3. (1) For purposes of this section, the licensure of assistant physicians shall take place within processes established by rules of the state board of registration for the healing arts. The board of healing arts is authorized to establish rules under chapter 536 establishing licensure and renewal procedures, supervision, collaborative practice arrangements, fees, and addressing such other matters as are necessary to protect the public and discipline the profession. An application for licensure may be denied or the licensure of an assistant physician may be suspended or revoked by the board in the same manner and for violation of the standards as set forth by section 334.100, or such other standards of conduct set by the board by rule.
(2) Any rule or portion of a rule, as that term is defined in section 536.010, that is created under the authority delegated in this section shall become effective only if it complies with and is subject to all of the provisions of chapter 536 and, if applicable, section 536.028. This section and chapter 536 are nonseverable and if any of the powers vested with the general assembly pursuant to chapter 536 to review, to delay the effective date, or to disapprove and annul a rule are subsequently held unconstitutional, then the grant of rulemaking authority and any rule proposed or adopted after August 28, 2014, shall be invalid and void.
4. An assistant physician shall clearly identify himself or herself as an assistant physician and shall be permitted to use the terms "doctor", "Dr." or "doc". No assistant physician shall practice or attempt to practice without an assistant physician collaborative practice arrangement, except as otherwise provided in this section and in an emergency situation.
5. The collaborating physician is responsible at all times for the oversight of the activities of, and accepts responsibility for, primary care services rendered by the assistant physician.
6. The provisions of section 334.104 shall apply to all assistant physician collaborative practice arrangements. To be eligible to practice as an assistant physician, a licensed assistant physician shall enter into an assistant physician collaborative practice arrangement within six months of his or her initial licensure and shall not have more than a six-month time period between collaborative practice arrangements during his or her licensure period. Any renewal of licensure under this section shall include verification of actual practice under a collaborative practice arrangement in accordance with this subsection during the immediately preceding licensure period.
334.104. 1. A physician may enter into collaborative practice arrangements with assistant physicians, physician assistants, or registered professional nurses. Collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care services. Collaborative practice arrangements, which shall be in writing, may delegate to [a] an assistant physician, physician assistant, or registered professional nurse the authority to administer or dispense drugs and provide treatment as long as the delivery of such health care services is within the scope of practice of the assistant physician, physician assistant, or registered professional nurse and is consistent with that assistant physician's, physician assistant's or nurse's skill, training and competence and the skill and training of the collaborating physician.
2. Collaborative practice arrangements, which shall be in writing, may delegate to:
(1) An assistant physician or physician assistant the authority to dispense or prescribe drugs and provide treatment to the extent permitted within the assistant physician's or physician assistant's scope of practice and licensure;
(2) A registered professional nurse the authority to administer, dispense or prescribe drugs and provide treatment if the registered professional nurse is an advanced practice registered nurse as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may delegate to an advanced practice registered nurse, as defined in section 335.016, the authority to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of section 195.017; except that, the collaborative practice arrangement shall not delegate the authority to administer any controlled substances listed in Schedules III, IV, and V of section 195.017 for the purpose of inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. Schedule III narcotic controlled substance prescriptions shall be limited to a one hundred twenty-hour supply without refill.
Such collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols or standing orders for the delivery of health care services.
3. The written collaborative practice arrangement shall contain at least the following provisions:
(1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse;
(2) A list of all other offices or locations besides those listed in subdivision (1) of this subsection where the collaborating physician authorized the assistant physician, physician assistant, or advanced practice registered nurse to prescribe;
(3) A requirement that there shall be posted at every office where the assistant physician, physician assistant, or advanced practice registered nurse is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by an assistant physician, physician assistant, or advanced practice registered nurse and have the right to see the collaborating physician;
(4) All specialty or board certifications of the collaborating physician and all certifications of the assistant physician, physician assistant, or advanced practice registered nurse;
(5) The manner of collaboration between the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse, including how the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse will:
(a) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;
(b) Maintain geographic proximity, except the collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of twenty-eight days per calendar year for rural health clinics as defined by P.L. 95-210, as long as the collaborative practice arrangement includes alternative plans as required in paragraph (c) of this subdivision. This exception to geographic proximity shall apply only to independent rural health clinics, provider-based rural health clinics where the provider is a critical access hospital as provided in 42 U.S.C. 1395i-4, and provider-based rural health clinics where the main location of the hospital sponsor is greater than fifty miles from the clinic. The collaborating physician is required to maintain documentation related to this requirement and to present it to the state board of registration for the healing arts when requested; and
(c) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;
(6) A description of the assistant physician's, physician assistant's, or advanced practice registered nurse's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the assistant physician, physician assistant, or nurse to prescribe and documentation that it is consistent with each professional's education, knowledge, skill, and competence;
(7) A list of all other written practice agreements of the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse;
(8) The duration of the written practice agreement between the collaborating physician and the assistant physician, physician assistant, or advanced practice registered nurse;
(9) A description of the time and manner of the collaborating physician's review of the assistant physician's, physician assistant's, or advanced practice registered nurse's delivery of health care services. The description shall include provisions that the assistant physician, physician assistant, or advanced practice registered nurse shall submit a minimum of ten percent of the charts documenting the assistant physician's, physician assistant's, or advanced practice registered nurse's delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every fourteen days; and
(10) The collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review every fourteen days a minimum of twenty percent of the charts in which the assistant physician, physician assistant, or advanced practice registered nurse prescribes controlled substances. The charts reviewed under this subdivision may be counted in the number of charts required to be reviewed under subdivision (9) of this subsection. 4. The state board of registration for the healing arts pursuant to section 334.125 [and] , in consultation with the board of nursing [pursuant to section 335.036 may jointly] shall promulgate rules regulating the use of collaborative practice arrangements for assistant physicians, physician assistants, and nurses. Such rules shall [be limited to specifying] specify geographic areas to be covered, the methods of treatment that may be covered by collaborative practice arrangements, the development and implementation of proficiency benchmarks and periodic skills assessment, and the requirements for review of services provided pursuant to collaborative practice arrangements, including delegating authority to prescribe controlled substances. Any rules relating to dispensing or distribution of medications or devices by prescription or prescription drug orders under this section shall be subject to the approval of the state board of pharmacy. Any rules relating to dispensing or distribution of controlled substances by prescription or prescription drug orders under this section shall be subject to the approval of the department of health and senior services and the state board of pharmacy. [In order to take effect, such rules shall be approved by a majority vote of a quorum of each board. Neither the state board of registration for the healing arts nor the board of nursing may separately promulgate rules relating to collaborative practice arrangements. Such jointly promulgated rules shall be consistent with guidelines for federally funded clinics] The state board of registration for the healing arts shall promulgate one set of rules applicable to all three licensure categories, and shall not promulgate separate rules applicable to only one licensure category. Such promulgated rules shall be consistent with guidelines for federally funded clinics.
The rulemaking authority granted in this subsection shall not extend to collaborative practice arrangements of hospital employees providing inpatient care within hospitals as defined pursuant to chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
5. The state board of registration for the healing arts shall not deny, revoke, suspend or otherwise take disciplinary action against a physician for health care services delegated to [a] an assistant physician, physician assistant, or registered professional nurse provided the provisions of this section and the rules promulgated thereunder are satisfied. Upon the written request of a physician subject to a disciplinary action imposed as a result of an agreement between a physician and [a] an assistant physician, physician assistant, or registered professional nurse [or registered physician assistant], whether written or not, prior to August 28, 1993, all records of such disciplinary licensure action and all records pertaining to the filing, investigation or review of an alleged violation of this chapter incurred as a result of such an agreement shall be removed from the records of the state board of registration for the healing arts and the division of professional registration and shall not be disclosed to any public or private entity seeking such information from the board or the division. The state board of registration for the healing arts shall take action to correct reports of alleged violations and disciplinary actions as described in this section which have been submitted to the National Practitioner Data Bank. In subsequent applications or representations relating to his or her medical practice, a physician completing forms or documents shall not be required to report any actions of the state board of registration for the healing arts for which the records are subject to removal under this section.
6. Within thirty days of any change and on each renewal, the state board of registration for the healing arts shall require every physician to identify whether the physician is engaged in any collaborative practice agreement, including collaborative practice agreements delegating the authority to prescribe controlled substances, [or physician assistant agreement] and also report to the board the name of each licensed professional with whom the physician has entered into such agreement. The board may make this information available to the public. The board shall track the reported information and may routinely conduct random reviews of such agreements to ensure that agreements are carried out for compliance under this chapter.
7. Notwithstanding any law to the contrary, a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services without a collaborative practice arrangement provided that he or she is under the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if needed. Nothing in this subsection shall be construed to prohibit or prevent a certified registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into a collaborative practice arrangement under this section, except that the collaborative practice arrangement [may] shall not delegate the authority to prescribe any controlled substances listed in Schedules III, IV, and V of section 195.017.
8. A collaborating physician shall not enter into a collaborative practice arrangement with more than three full-time equivalent assistant physicians, physician assistants, or advanced practice registered nurses. Such limitation may include any three full-time equivalent combination of assistant physician, physician assistant, and advanced practice registered nurse, but shall not exceed a total of three full-time equivalents for all three categories combined. This limitation shall not apply to collaborative arrangements of hospital employees providing inpatient care service in hospitals as defined in chapter 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008. 9. It is the responsibility of the collaborating physician to determine and document the completion of at least a one-month period of time during which the assistant physician, physician assistant, or advanced practice registered nurse shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present. This limitation shall not apply to collaborative arrangements of providers of population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
10. No agreement made under this section shall supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within a hospital as defined in section 197.020 if such protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.
11. No contract or other agreement shall require a physician to act as a collaborating physician for an assistant physician, physician assistant, or advanced practice registered nurse against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular assistant physician, physician assistant, or advanced practice registered nurse. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any assistant physician, physician assistant, or advanced practice registered nurse, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by hospital's medical staff.
12. No contract or other agreement shall require any assistant physician, physician assistant, or advanced practice registered nurse to serve as a collaborating advanced practice registered nurse for any collaborating physician against the assistant physician's, physician assistant's, or advanced practice registered nurse's will. An assistant physician, physician assistant, or advanced practice registered nurse shall have the right to refuse to collaborate, without penalty, with a particular physician.
13. All assistant physicians, physician assistants, and advanced practice registered nurses in collaborative practice arrangements shall wear identification badges while acting within the scope of their collaborative practice agreement. The identification badges shall prominently display the licensure status of such assistant physicians, physician assistants, and advanced practice registered nurses.
334.735. 1. As used in sections 334.735 to 334.749, the following terms mean:
(1) "Applicant", any individual who seeks to become licensed as a physician assistant;
(2) "Certification" or "registration", a process by a certifying entity that grants recognition to applicants meeting predetermined qualifications specified by such certifying entity;
(3) "Certifying entity", the nongovernmental agency or association which certifies or registers individuals who have completed academic and training requirements;
(4) "Department", the department of insurance, financial institutions and professional registration or a designated agency thereof;
(5) "License", a document issued to an applicant by the board acknowledging that the applicant is entitled to practice as a physician assistant;
(6) "Physician assistant", a person who has graduated from a physician assistant program accredited by the American Medical Association's Committee on Allied Health Education and Accreditation or by its successor agency, who has passed the certifying examination administered by the National Commission on Certification of Physician Assistants and has active certification by the National Commission on Certification of Physician Assistants who provides health care services delegated by a licensed physician. A person who has been employed as a physician assistant for three years prior to August 28, 1989, who has passed the National Commission on Certification of Physician Assistants examination, and has active certification of the National Commission on Certification of Physician Assistants;
(7) "Physician assistant collaborative practice arrangement", an agreement between a physician and a physician assistant which meets the requirements of this section and section 334.104;
(8) "Recognition", the formal process of becoming a certifying entity as required by the provisions of sections 334.735 to 334.749[;
(8) "Supervision", control exercised over a physician assistant working with a supervising physician and oversight of the activities of and accepting responsibility for the physician assistant's delivery of care. The physician assistant shall only practice at a location where the physician routinely provides patient care, except existing patients of the supervising physician in the patient's home and correctional facilities. The supervising physician must be immediately available in person or via telecommunication during the time the physician assistant is providing patient care. Prior to commencing practice, the supervising physician and physician assistant shall attest on a form provided by the board that the physician shall provide supervision appropriate to the physician assistant's training and that the physician assistant shall not practice beyond the physician assistant's training and experience. Appropriate supervision shall require the supervising physician to be working within the same facility as the physician assistant for at least four hours within one calendar day for every fourteen days on which the physician assistant provides patient care as described in subsection 3 of this section. Only days in which the physician assistant provides patient care as described in subsection 3 of this section shall be counted toward the fourteen-day period. The requirement of appropriate supervision shall be applied so that no more than thirteen calendar days in which a physician assistant provides patient care shall pass between the physician's four hours working within the same facility. The board shall promulgate rules pursuant to chapter 536 for documentation of joint review of the physician assistant activity by the supervising physician and the physician assistant].
2. (1) A supervision agreement shall limit the physician assistant to practice only [at locations described in subdivision (8) of subsection 1 of this section, where the supervising physician is no further than fifty miles by road using the most direct route available and where the location is not so situated as to create an impediment to effective intervention and supervision of patient care or adequate review of services] in accordance with this section and section 334.104.
(2) For a physician-physician assistant team working in a rural health clinic under the federal Rural Health Clinic Services Act, P.L. 95-210, as amended, no supervision requirements in addition to the minimum federal law shall be required.
3. The scope of practice of a physician assistant shall consist only of the following services and procedures:
(1) Taking patient histories;
(2) Performing physical examinations of a patient;
(3) Performing or assisting in the performance of routine office laboratory and patient screening procedures;
(4) Performing routine therapeutic procedures;
(5) Recording diagnostic impressions and evaluating situations calling for attention of a physician to institute treatment procedures;
(6) Instructing and counseling patients regarding mental and physical health using procedures reviewed and approved by a licensed physician;
(7) Assisting the [supervising] collaborating physician in institutional settings, including reviewing of treatment plans, ordering of tests and diagnostic laboratory and radiological services, and ordering of therapies, using procedures reviewed and approved by a licensed physician;
(8) Assisting in surgery; and
(9) Performing such other tasks not prohibited by law under the supervision of a licensed physician as the physician's assistant has been trained and is proficient to perform[; and
(10)] .
Physician assistants shall not perform or prescribe abortions.
4. Physician assistants shall not prescribe nor dispense any drug, medicine, device or therapy unless pursuant to a physician [supervision agreement] collaborative practice arrangement in accordance with the law, nor prescribe lenses, prisms or contact lenses for the aid, relief or correction of vision or the measurement of visual power or visual efficiency of the human eye, nor administer or monitor general or regional block anesthesia during diagnostic tests, surgery or obstetric procedures. Prescribing and dispensing of drugs, medications, devices or therapies by a physician assistant shall be pursuant to a physician assistant [supervision agreement] collaborative practice arrangement which is specific to the clinical conditions treated by the [supervising] collaborating physician and the physician assistant shall be subject to the following:
(1) A physician assistant shall only prescribe controlled substances in accordance with section 334.747;
(2) The types of drugs, medications, devices or therapies prescribed or dispensed by a physician assistant shall be consistent with the scopes of practice of the physician assistant and the [supervising] collaborating physician;
(3) All prescriptions shall conform with state and federal laws and regulations and shall include the name, address and telephone number of the physician assistant and the [supervising] collaborating physician;
(4) A physician assistant, or advanced practice registered nurse as defined in section 335.016 may request, receive and sign for noncontrolled professional samples and may distribute professional samples to patients;
(5) A physician assistant shall not prescribe any drugs, medicines, devices or therapies the supervising physician is not qualified or authorized to prescribe; and
(6) A physician assistant may only dispense starter doses of medication to cover a period of time for seventy-two hours or less.
5. A physician assistant shall clearly identify himself or herself as a physician assistant and shall not use or permit to be used in the physician assistant's behalf the terms "doctor", "Dr." or "doc" nor hold himself or herself out in any way to be a physician or surgeon. No physician assistant shall practice or attempt to practice without physician supervision or in any location where the [supervising] collaborating physician is not immediately available for consultation, assistance and intervention, except as otherwise provided in this section, and in an emergency situation, nor shall any physician assistant bill a patient independently or directly for any services or procedure by the physician assistant.
6. For purposes of this section, the licensing of physician assistants shall take place within processes established by the state board of registration for the healing arts through rule and regulation. The board of healing arts is authorized to establish rules pursuant to chapter 536 establishing licensing and renewal procedures, supervision, [supervision agreements] collaborative practice arrangements, fees, and addressing such other matters as are necessary to protect the public and discipline the profession. An application for licensing may be denied or the license of a physician assistant may be suspended or revoked by the board in the same manner and for violation of the standards as set forth by section 334.100, or such other standards of conduct set by the board by rule or regulation. Persons licensed pursuant to the provisions of chapter 335 shall not be required to be licensed as physician assistants. All applicants for physician assistant licensure who complete a physician assistant training program after January 1, 2008, shall have a master's degree from a physician assistant program.
7. ["Physician assistant supervision agreement" means a written agreement, jointly agreed-upon protocols or standing order between a supervising physician and a physician assistant, which provides for the delegation of health care services from a supervising physician to a physician assistant and the review of such services. The agreement shall contain at least the following provisions:
(1) Complete names, home and business addresses, zip codes, telephone numbers, and state license numbers of the supervising physician and the physician assistant;
(2) A list of all offices or locations where the physician routinely provides patient care, and in which of such offices or locations the supervising physician has authorized the physician assistant to practice;
(3) All specialty or board certifications of the supervising physician;
(4) The manner of supervision between the supervising physician and the physician assistant, including how the supervising physician and the physician assistant shall:
(a) Attest on a form provided by the board that the physician shall provide supervision appropriate to the physician assistant's training and experience and that the physician assistant shall not practice beyond the scope of the physician assistant's training and experience nor the supervising physician's capabilities and training; and
(b) Provide coverage during absence, incapacity, infirmity, or emergency by the supervising physician;
(5) The duration of the supervision agreement between the supervising physician and physician assistant; and
(6) A description of the time and manner of the supervising physician's review of the physician assistant's delivery of health care services. Such description shall include provisions that the supervising physician, or a designated supervising physician listed in the supervision agreement review a minimum of ten percent of the charts of the physician assistant's delivery of health care services every fourteen days] The provisions of section 334.104 shall apply to all physician assistant collaborative practice arrangements.
8. When a physician assistant supervision agreement is utilized to provide health care services for conditions other than acute self-limited or well-defined problems, the supervising physician or other physician designated in the supervision agreement shall see the patient for evaluation and approve or formulate the plan of treatment for new or significantly changed conditions as soon as practical, but in no case more than two weeks after the patient has been seen by the physician assistant.
9. At all times the physician is responsible for the oversight of the activities of, and accepts responsibility for, health care services rendered by the physician assistant.
10. It is the responsibility of the [supervising] collaborating physician to determine and document the completion of at least a one-month period of time during which the licensed physician assistant shall practice with a [supervising] collaborating physician continuously present before practicing in a setting where a [supervising] collaborating physician is not continuously present.
[11. No contract or other agreement shall require a physician to act as a supervising physician for a physician assistant against the physician's will. A physician shall have the right to refuse to act as a supervising physician, without penalty, for a particular physician assistant. No contract or other agreement shall limit the supervising physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any physician assistant, but this requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by the hospital's medical staff.
12. Physician assistants shall file with the board a copy of their supervising physician form.
13. No physician shall be designated to serve as supervising physician for more than three full-time equivalent licensed physician assistants. This limitation shall not apply to physician assistant agreements of hospital employees providing inpatient care service in hospitals as defined in chapter 197.]
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