HOUSE BILL NO. 3217 103RD GENERAL ASSEMBLY
INTRODUCED BY REPRESENTATIVE OVERCAST.
7064H.01I JOSEPH ENGLER, Chief Clerk
AN ACT To repeal sections 334.037, 334.104, and 334.735, RSMo, and to enact in lieu thereof three new sections relating to collaborative practice arrangements.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 334.037, 334.104, and 334.735, RSMo, are repealed and three 2 new sections enacted in lieu thereof, to be known as sections 334.037, 334.104, and 334.735, 3 to read as follows: 334.037. 1. A physician may enter into collaborative practice arrangements with 2 assistant physicians. Collaborative practice arrangements shall be in the form of written 3 agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care 4 services. Collaborative practice arrangements, which shall be in writing, may delegate to an 5 assistant physician the authority to administer or dispense drugs and provide treatment as long 6 as the delivery of such health care services is within the scope of practice of the assistant 7 physician and is consistent with that assistant physician's skill, training, and competence and 8 the skill and training of the collaborating physician. 9 2. The written collaborative practice arrangement shall contain at least the following 10 provisions: 11 (1) Complete names, home and business addresses, zip codes, and telephone numbers 12 of the collaborating physician and the assistant physician; 13 (2) A list of all other offices or locations besides those listed in subdivision (1) of this 14 subsection where the collaborating physician authorized the assistant physician to prescribe; 15 (3) A requirement that there shall be posted at every office where the assistant 16 physician is authorized to prescribe, in collaboration with a physician, a prominently
EXPLANATION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is intended to be omitted from the law. Matter in bold-face type in the above bill is proposed language. HB 3217 2
17 displayed disclosure statement informing patients that they may be seen by an assistant 18 physician and have the right to see the collaborating physician; 19 (4) All specialty or board certifications of the collaborating physician and all 20 certifications of the assistant physician; 21 (5) The manner of collaboration between the collaborating physician and the assistant 22 physician, including how the collaborating physician and the assistant physician shall: 23 (a) Engage in collaborative practice consistent with each professional's skill, training, 24 education, and competence; 25 (b) Maintain geographic proximity; except, the collaborative practice arrangement 26 may allow for geographic proximity to be waived for a maximum of twenty-eight days per 27 calendar year for rural health clinics as defined by Pub. L. 95-210 (42 U.S.C. Section 1395x), 28 as amended, as long as the collaborative practice arrangement includes alternative plans as 29 required in paragraph (c) of this subdivision. Such exception to geographic proximity shall 30 apply only to independent rural health clinics, provider-based rural health clinics if the 31 provider is a critical access hospital as provided in 42 U.S.C. Section 1395i-4, and provider- 32 based rural health clinics if the main location of the hospital sponsor is greater than fifty miles 33 from the clinic. The collaborating physician shall maintain documentation related to such 34 requirement and present it to the state board of registration for the healing arts when 35 requested; and 36 (c) Provide coverage during absence, incapacity, infirmity, or emergency by the 37 collaborating physician; 38 (6) A description of the assistant physician's controlled substance prescriptive 39 authority in collaboration with the physician, including a list of the controlled substances the 40 physician authorizes the assistant physician to prescribe and documentation that it is 41 consistent with each professional's education, knowledge, skill, and competence; 42 (7) A list of all other written practice agreements of the collaborating physician and 43 the assistant physician; 44 (8) The duration of the written practice agreement between the collaborating 45 physician and the assistant physician; 46 (9) A description of the time and manner of the collaborating physician's review of 47 the assistant physician's delivery of health care services. The description shall include 48 provisions that the assistant physician shall submit a minimum of ten percent of the charts 49 documenting the assistant physician's delivery of health care services to the collaborating 50 physician for review by the collaborating physician, or any other physician designated in the 51 collaborative practice arrangement, every fourteen days; and 52 (10) The collaborating physician, or any other physician designated in the 53 collaborative practice arrangement, shall review every fourteen days a minimum of twenty HB 3217 3
54 percent of the charts in which the assistant physician prescribes controlled substances. The 55 charts reviewed under this subdivision may be counted in the number of charts required to be 56 reviewed under subdivision (9) of this subsection. 57 3. The state board of registration for the healing arts under section 334.125 shall 58 promulgate rules regulating the use of collaborative practice arrangements for assistant 59 physicians. Such rules shall specify: 60 (1) Geographic areas to be covered; 61 (2) The methods of treatment that may be covered by collaborative practice 62 arrangements; 63 (3) In conjunction with deans of medical schools and primary care residency program 64 directors in the state, the development and implementation of educational methods and 65 programs undertaken during the collaborative practice service which shall facilitate the 66 advancement of the assistant physician's medical knowledge and capabilities, and which may 67 lead to credit toward a future residency program for programs that deem such documented 68 educational achievements acceptable; and 69 (4) The requirements for review of services provided under collaborative practice 70 arrangements, including delegating authority to prescribe controlled substances. 71 72 Any rules relating to dispensing or distribution of medications or devices by prescription or 73 prescription drug orders under this section shall be subject to the approval of the state board 74 of pharmacy. Any rules relating to dispensing or distribution of controlled substances by 75 prescription or prescription drug orders under this section shall be subject to the approval of 76 the department of health and senior services and the state board of pharmacy. The state board 77 of registration for the healing arts shall promulgate rules applicable to assistant physicians 78 that shall be consistent with guidelines for federally funded clinics. The rulemaking authority 79 granted in this subsection shall not extend to collaborative practice arrangements of hospital 80 employees providing inpatient care within hospitals as defined in chapter 197 or population- 81 based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008. 82 4. The state board of registration for the healing arts shall not deny, revoke, suspend, 83 or otherwise take disciplinary action against a collaborating physician for health care services 84 delegated to an assistant physician provided the provisions of this section and the rules 85 promulgated thereunder are satisfied. 86 5. Within thirty days of any change and on each renewal, the state board of 87 registration for the healing arts shall require every physician to identify whether the physician 88 is engaged in any collaborative practice arrangement, including collaborative practice 89 arrangements delegating the authority to prescribe controlled substances, and also report to 90 the board the name of each assistant physician with whom the physician has entered into such HB 3217 4
91 arrangement. The board may make such information available to the public. The board shall 92 track the reported information and may routinely conduct random reviews of such 93 arrangements to ensure that arrangements are carried out for compliance under this chapter. 94 6. A collaborating physician shall not enter into a collaborative practice arrangement 95 with more than [six] ten full-time equivalent assistant physicians, full-time equivalent 96 physician assistants, or full-time equivalent advance practice registered nurses, or any 97 combination thereof. Such limitation shall not apply to collaborative arrangements of 98 hospital employees providing inpatient care service in hospitals as defined in chapter 197 or 99 population-based public health services as defined by 20 CSR 2150-5.100 as of April 30, 100 2008, or to a certified registered nurse anesthetist providing anesthesia services under the 101 supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately 102 available if needed as set out in subsection 7 of section 334.104. 103 7. The collaborating physician shall determine and document the completion of at 104 least a one-month period of time during which the assistant physician shall practice with the 105 collaborating physician continuously present before practicing in a setting where the 106 collaborating physician is not continuously present. No rule or regulation shall require the 107 collaborating physician to review more than ten percent of the assistant physician's patient 108 charts or records during such one-month period. Such limitation shall not apply to 109 collaborative arrangements of providers of population-based public health services as defined 110 by 20 CSR 2150-5.100 as of April 30, 2008. 111 8. No agreement made under this section shall supersede current hospital licensing 112 regulations governing hospital medication orders under protocols or standing orders for the 113 purpose of delivering inpatient or emergency care within a hospital as defined in section 114 197.020 if such protocols or standing orders have been approved by the hospital's medical 115 staff and pharmaceutical therapeutics committee. 116 9. No contract or other agreement shall require a physician to act as a collaborating 117 physician for an assistant physician against the physician's will. A physician shall have the 118 right to refuse to act as a collaborating physician, without penalty, for a particular assistant 119 physician. No contract or other agreement shall limit the collaborating physician's ultimate 120 authority over any protocols or standing orders or in the delegation of the physician's 121 authority to any assistant physician, but such requirement shall not authorize a physician in 122 implementing such protocols, standing orders, or delegation to violate applicable standards 123 for safe medical practice established by a hospital's medical staff. 124 10. No contract or other agreement shall require any assistant physician to serve as a 125 collaborating assistant physician for any collaborating physician against the assistant 126 physician's will. An assistant physician shall have the right to refuse to collaborate, without 127 penalty, with a particular physician. HB 3217 5
128 11. All collaborating physicians and assistant physicians in collaborative practice 129 arrangements shall wear identification badges while acting within the scope of their 130 collaborative practice arrangement. The identification badges shall prominently display the 131 licensure status of such collaborating physicians and assistant physicians. 132 12. (1) An assistant physician with a certificate of controlled substance prescriptive 133 authority as provided in this section may prescribe any controlled substance listed in Schedule 134 III, IV, or V of section 195.017, and may have restricted authority in Schedule II, when 135 delegated the authority to prescribe controlled substances in a collaborative practice 136 arrangement. Prescriptions for Schedule II medications prescribed by an assistant physician 137 who has a certificate of controlled substance prescriptive authority are restricted to only those 138 medications containing hydrocodone. Such authority shall be filed with the state board of 139 registration for the healing arts. The collaborating physician shall maintain the right to limit a 140 specific scheduled drug or scheduled drug category that the assistant physician is permitted to 141 prescribe. Any limitations shall be listed in the collaborative practice arrangement. Assistant 142 physicians shall not prescribe controlled substances for themselves or members of their 143 families. Schedule III controlled substances and Schedule II - hydrocodone prescriptions 144 shall be limited to a five-day supply without refill, except that buprenorphine may be 145 prescribed for up to a thirty-day supply without refill for patients receiving medication- 146 assisted treatment for substance use disorders under the direction of the collaborating 147 physician. Assistant physicians who are authorized to prescribe controlled substances under 148 this section shall register with the federal Drug Enforcement Administration and the state 149 bureau of narcotics and dangerous drugs, and shall include the Drug Enforcement 150 Administration registration number on prescriptions for controlled substances. 151 (2) The collaborating physician shall be responsible to determine and document the 152 completion of at least one hundred twenty hours in a four-month period by the assistant 153 physician during which the assistant physician shall practice with the collaborating physician 154 on-site prior to prescribing controlled substances when the collaborating physician is not on- 155 site. Such limitation shall not apply to assistant physicians of population-based public health 156 services as defined in 20 CSR 2150-5.100 as of April 30, 2009, or assistant physicians 157 providing opioid addiction treatment. 158 (3) An assistant physician shall receive a certificate of controlled substance 159 prescriptive authority from the state board of registration for the healing arts upon verification 160 of licensure under section 334.036. 161 13. Nothing in this section or section 334.036 shall be construed to limit the authority 162 of hospitals or hospital medical staff to make employment or medical staff credentialing or 163 privileging decisions. HB 3217 6
334.104. 1. A physician may enter into collaborative practice arrangements with 2 registered professional nurses. Collaborative practice arrangements shall be in the form of 3 written agreements, jointly agreed-upon protocols, or standing orders for the delivery of 4 health care services. Collaborative practice arrangements, which shall be in writing, may 5 delegate to a registered professional nurse the authority to administer or dispense drugs and 6 provide treatment as long as the delivery of such health care services is within the scope of 7 practice of the registered professional nurse and is consistent with that nurse's skill, training 8 and competence. 9 2. (1) Collaborative practice arrangements, which shall be in writing, may delegate to 10 a registered professional nurse the authority to administer, dispense or prescribe drugs and 11 provide treatment if the registered professional nurse is an advanced practice registered nurse 12 as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may 13 delegate to an advanced practice registered nurse, as defined in section 335.016, the authority 14 to administer, dispense, or prescribe controlled substances listed in Schedules III, IV, and V of 15 section 195.017, and Schedule II - hydrocodone; except that, the collaborative practice 16 arrangement shall not delegate the authority to administer any controlled substances listed in 17 Schedules III, IV, and V of section 195.017, or Schedule II - hydrocodone for the purpose of 18 inducing sedation or general anesthesia for therapeutic, diagnostic, or surgical procedures. 19 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall 20 be limited to a one hundred twenty-hour supply without refill. 21 (2) Notwithstanding any other provision of this section to the contrary, a collaborative 22 practice arrangement may delegate to an advanced practice registered nurse the authority to 23 administer, dispense, or prescribe Schedule II controlled substances for hospice patients; 24 provided, that the advanced practice registered nurse is employed by a hospice provider 25 certified pursuant to chapter 197 and the advanced practice registered nurse is providing care 26 to hospice patients pursuant to a collaborative practice arrangement that designates the 27 certified hospice as a location where the advanced practice registered nurse is authorized to 28 practice and prescribe. 29 (3) Such collaborative practice arrangements shall be in the form of written 30 agreements, jointly agreed-upon protocols or standing orders for the delivery of health care 31 services. 32 (4) An advanced practice registered nurse may prescribe buprenorphine for up to a 33 thirty-day supply without refill for patients receiving medication-assisted treatment for 34 substance use disorders under the direction of the collaborating physician. 35 3. The written collaborative practice arrangement shall contain at least the following 36 provisions: HB 3217 7
37 (1) Complete names, home and business addresses, zip codes, and telephone numbers 38 of the collaborating physician and the advanced practice registered nurse; 39 (2) A list of all other offices or locations besides those listed in subdivision (1) of this 40 subsection where the collaborating physician authorized the advanced practice registered 41 nurse to prescribe; 42 (3) A requirement that there shall be posted at every office where the advanced 43 practice registered nurse is authorized to prescribe, in collaboration with a physician, a 44 prominently displayed disclosure statement informing patients that they may be seen by an 45 advanced practice registered nurse and have the right to see the collaborating physician; 46 (4) All specialty or board certifications of the collaborating physician and all 47 certifications of the advanced practice registered nurse; 48 (5) The manner of collaboration between the collabora