AUTHORIZED SERVICES OF PHYSICIAN ASSISTANTS
Present law authorizes a physician assistant to perform selected medical services only in collaboration with a licensed physician. The range of services that may be provided by a physician assistant must be set forth in a written protocol, jointly developed by the collaborating physician and the physician assistant.
Under present law, rules that purport to regulate the collaboration of physician assistants with physicians must be jointly adopted by the board of medical examiners and the board of physician assistants.
This bill both expands upon and replaces the present law described above with the provisions under this heading and the next two headings:
This bill authorizes a physician assistant to do the following:
(1) Perform medical diagnosis and treatment as a physician assistant pursuant either to a protocol or collaborative agreement, as applicable, for which the physician assistant has been prepared by education, training, and experience, and that the physician assistant is competent to perform only if licensed by the board of physician assistants and only within the usual scope of practice of the collaborating physician;
(2) Perform minor procedures, including, but not limited to: (i) simple laceration repair; (ii) excision of skin lesions, moles, warts, cysts, or lipomas; (iii) incision and draining of superficial abscesses; (iv) skin biopsies; (v) arthrocentesis; (vi) thoracentesis; (vii) paracentesis; (viii) endometrial biopsies; (ix) IUD insertion; and (x) colposcopy;
(3) Assist a physician who performs procedures considered Level II office-based surgery or Level III office-based surgery, as those are defined under state law, or a more complex procedure, if: (i) the physician assistant is credentialed or receives privileges from the medical staff of the facility to assist a physician with enumerated procedures; (ii) the physician performing the procedure is credentialed or privileged to perform the procedure by the medical staff of the facility; and (iii) the physician is present or immediately available for consultation with the physician assistant during and after the procedure;
(4) Issue drugs authorized by law pursuant to protocols or collaborative agreement, and as applicable:
(A) Prescribe, dispense, order, administer, and procure appropriate medical devices, legend drugs, and controlled substances that are within the physician assistant's scope of practice if the physician assistant has registered and complied with all applicable requirements of state law and rule and the FDA;
(B) A physician assistant may only prescribe or issue a Schedule II or Schedule III opioid for a maximum of a nonrefillable, 30-day course of treatment. However, this (4) does not apply to a prescription issued in a hospital, a nursing home licensed state law, or an inpatient facility licensed under state law;
(5) Unless a physician assistant's protocols or collaborative agreement indicate otherwise, plan and initiate a therapeutic regimen that includes ordering and prescribing non-pharmacological interventions, including (i) durable medical equipment; (ii) nutrition; (iii) blood and blood products; and (iv) diagnostic support services that include, but are not limited to, home health care, hospice, and physical and occupational therapy; and
(6) Complete, sign, and file medical certifications of death, if authorized to do so in the physician assistant's protocol or collaborative agreement.
PHYSICIAN ASSISTANTS NOT ENDORSED BY THE BOARD OF PHYSICIAN ASSISTANTS
This bill requires a physician assistant who has not been endorsed by the board of physician assistants to practice under protocols jointly developed by the collaborating physician and the physician assistant. The physician assistant must maintain a copy of the protocols either on paper or electronically at each of the physician assistant's practice locations and must make the protocols available upon request by the board of physician assistants, the licensing board of the collaborating physician, or an authorized agent thereof. The protocols must set forth the range of services that may be provided by the physician assistant and must also contain a discussion of the problems and conditions likely to be encountered by the physician assistant and the appropriate treatment for such problems and conditions.
Physician assistant practice under protocols requires active and continuous overview of the physician assistant's activities to ensure that the physician's directions and advice are implemented, but does not require the continuous and constant physical presence of the collaborating physician.
This bill prohibits a physician assistant from performing tasks that are not within the physician assistant's range of skills and competence, that are not within the usual scope of practice of the collaborating physician, and that are not consistent with the protection of the health and well-being of the patients.
This bill requires that the protocols include, at a minimum, the following:
(1) The physician assistant's name, license number, and primary practice location;
(2) The collaborating physician's name, license number, medical specialty, and primary practice location;
(3) A general description of the oversight of the physician assistant by the collaborating physician;
(4) A general description of the physician assistant's process for collaboration with physicians and other members of the healthcare team;
(5) A process by which 100 percent of patient charts are reviewed by the collaborating physician within 10 days when a controlled drug is issued by the physician assistant;
(6) A process by which at least 20 percent of the physician assistant's patient charts are reviewed by the collaborating physician every 30 days;
(7) That, if the physician assistant changes practice settings to practice in a new medical specialty, a description of a process by which the patient medical charts prepared by the physician assistant are reviewed by the collaborating physician for a minimum of six months or until the physician assistant becomes eligible for endorsement, whichever period is longer;
(8) That if the physician assistant practices in a remote location site from the collaborating physician's practice site, the collaborating physician must conduct a remote site visit at least every 30 days;
(9) That the physician assistant collaborates with, consults with, or refers to, the collaborating physician or appropriate healthcare professional as indicated by the patient's condition and the applicable standard of care: (i) when a patient presents with a condition outside of the competence, scope, or experience of the physician assistant or collaborating physician; or (ii) when a patient's condition fails to adhere to the treatment plan or fails to respond to the treatment plan within a timeframe that is not within the expected disease progression; and
(10) Designation of one or more alternative physicians for consultation in situations in which the collaborating physician is not available for consultation.
PHYSICIAN ASSISTANTS THAT HAVE BEEN ENDORSED BY THE BOARD
This bill requires a physician assistant who has been endorsed by the board of physician assistants to have a collaborative agreement with a physician. The physician assistant must maintain a copy of the collaborative agreement either on paper or electronically at each of the physician assistant's practice locations and make the collaborative agreement available upon request by the board of physician, the licensing board of the collaborating physician, or an authorized agent of such boards.
This bill requires that in order to receive endorsement from the board of physician assistants, a physician assistant must have, at a minimum, 6,000 hours of documented postgraduate clinical experience, have a physician willing to enter into a collaborative agreement with the physician assistant, and meet such other requirements as set forth in rules promulgated by the board of physician assistants. This bill prohibits a physician assistant with 6,000 hours or more of documented postgraduate clinical experience from practicing without first receiving endorsement by the board of physician assistants.
This bill requires that collaborative agreements governing physician assistants who have 6,000 hours or more of documented postgraduate clinical experience and are endorsed by the board of physician assistants include, at a minimum, the following information:
(1) The physician assistant's name, license number, and primary practice location;
(2) The collaborating physician's name, license number, medical specialty, and primary practice location;
(3) That the physician assistant performs only those services that are within the physician assistant's competence, knowledge, and skills that are within the usual scope of practice of the collaborating physician, and that are consistent with the protection of the health and well-being of patients;
(4) A process by which 100 percent of patient charts are reviewed by the collaborating physician within 30 days when a controlled drug is issued by the physician assistant;
(5) That if the physician assistant changes practice settings to practice in a new medical specialty, a description of a process by which a sample of patient medical charts prepared by the physician assistant are reviewed by the collaborating physician, or a physician designated by the collaborating physician, for a minimum of six months;
(6) That the physician assistant collaborates with, consults with, or refers to the collaborating physician or appropriate healthcare professional as indicated by the patient's condition and the applicable standard of care;
(7) Methods of communication between the physician assistant and collaborating physician; and
(8) Requirements of patient chart review and remote site visits, if any, established at the practice level and commensurate with the level of training, experience, and competence of the physician assistant within the expected scope of practice of the physician assistant.
STANDARD OF CARE
This bill clarifies that the standard of care for a physician assistant is the same standard of care as applicable to a physician who performs the same service.
SPECIALIST BOARDS MUST ADOPT RULES FOR COLLABORATION
This bill requires rules that purport to regulate the collaboration of physician assistants with licensed osteopathic physicians to be jointly adopted by the board of osteopathic medical examination and the board of physician assistants. Rules that purport to regulate the collaboration of physician assistants with licensed podiatrists must be jointly adopted by the board of podiatric medical examiners and the board of physician assistants.
PRACTICES FOR COLLABORATION WITH PHYSICIAN ASSISTANTS
Present law establishes that more than one physician may collaborate with the same physician assistant if each physician assistant has a primary collaborating physician and may have additional alternate collaborating physicians who collaborate with the physician assistant in the absence or unavailability of the primary collaborating physician. Each physician assistant must notify the board of physician assistants of the name, address, and license number of the physician assistant's primary collaborating physician and must notify the board of physician assistants of a change in the primary collaborating physician within 15 days of the change. This bill adds to present law by requiring a physician assistant to notify the board of physician assistants of the name and address of the physician assistant's primary practice location and to notify the board of physician assistants within 15 days of a practice location change.
Under present law, the prescriptive practices of physician assistants and the collaborating physicians with whom the physician assistants are rendering services must be monitored by the board of medical examiners and the board of physician assistants. As used in this provision, "monitor" does not include the regulation of the practice of medicine or the regulation of the practice of a physician assistant, but may include site visits by members of the board of medical examiners and the board of physician assistants.
This bill authorizes the board of physician assistants to monitor the prescriptive practices of the physician assistant through site visits by authorized agents of the board of physician assistants.
Under present law, complaints against physician assistants or collaborating physicians must be reported to the director of the division of health-related boards, board of medical examiners, and the board of physician assistants, as appropriate. This bill revises this provision to, instead, require complaints against physician assistants to be reported to the office of investigations of the division of health-related boards.
Present law requires that every prescription order issued by a physician assistant be entered in the medical records of the patient and must be written on a preprinted prescription pad bearing the name, address, and telephone number of the collaborating physician and of the physician assistant, and the physician assistant must sign each prescription order so written. This bill removes the requirement that every prescription order issued by a physician assistant be written on a preprinted prescription pad. However, prescriptions that are handwritten must be written on a preprinted prescription pad bearing the name, address, telephone number, and signature of the physician assistant.
Present law authorizes a physician assistant to prescribe drugs under state law, who provides services in a community mental health center or federally qualified health center, or solely via telehealth, may arrange for the required personal review of the physician assistant's charts by a collaborating physician, with the same authority to render prescriptive services that the physician assistant is authorized to render, in the office or practice site of the physician, or the required visit by a collaborating physician to any remote site, or both, via HIPAA-compliant electronic means rather than at the site of the clinic. This bill removes telehealth as an option in this provision.
Present law requires (i) a patient of a physician who is receiving services from a physician assistant to be fully informed that the service provider is a physician assistant, or (ii) a sign to be conspicuously placed within the office of the physician indicating that certain services may be rendered by a physician assistant.
This bill requires both that the patient be fully informed that the individual is a physician assistant and that a sign be conspicuously placed.
GROUNDS FOR DENIAL, SUSPENSION, OR REVOCATION OF LICENSES OF PHYSICIAN ASSISTANTS
Under present law, the grounds on which the board of physician assistants may exercise its power to deny, suspend, or revoke a physician assistant license are (i) the conviction of a crime; (ii) fraud in procuring or attempting to procure a license to practice medicine as a physician assistant; (3) the commission of unprofessional or unethical conduct; (iv) an addiction to the use of alcohol, narcotics, or other drugs; (v) engaging in the inappropriate prescribing, dispensing, or otherwise distributing a controlled substance or other drug in the course of professional practice; (vi) suspension or revocation of a license in another state for disciplinary reasons; or (vii) failure to comply with the lawful order or duly promulgated rules of the board of physician assistants.
This bill adds to the list in the above provision holding oneself out as board-certified in a medical specialty, or utilizing a medical specialty designation with (i) a title or title reference; (ii) an advertisement; (iii) the name of any healthcare setting that is majority owned by physician assistants, unless services are provided by a physician actively practicing such medical specialty to more than 50 percent of patients at the site; (iv) credentialing with any licensed healthcare facility or health insurance entity; or (v) an application for healthcare liability insurance coverage.
DEATH REGISTRATION
Under present law, a funeral director who first assumes custody of a dead body, medical examiner, or attending or pronouncing physician in a hospital may file the death certificate. The funeral director, medical examiner, or attending or pronouncing physician in a hospital shall obtain the personal data from the next of kin or the best qualified person or source available, and shall obtain the medical certification from the person responsible for medical certification. This bill authorizes the following to file the death certificate: (i) a physician assistant authorized by protocol or collaborative agreement; or (ii) an advance practice registered nurse authorized by protocol or collaborative agreement.
Under present law, the medical certification must be completed, signed and returned to the funeral director by the physician in charge of the patient's care for the illness or condition that resulted in death within 48 hours after death, except when inquiry is required by the county medical examiner or to obtain a veteran's medical records. In the absence of the physician, the certificate may be completed and signed by another physician designated by the physician or by the chief medical officer of the institution in which the death occurred. In cases of deaths that occur outside of a medical institution and are either unattended by a physician or not under hospice care, the county medical examiner must investigate and certify the death certificate when one of the following conditions exists:
(1) There is no physician who had attended the deceased during the four months preceding death, except that any physician who had attended the patient more than four months preceding death may elect to certify the death certificate if the physician can make a good faith determination as to cause of death and if the county medical examiner has not assumed jurisdiction; or
(2) The physician who had attended the deceased during the four months preceding death communicates, orally or in writing, to the county medical examiner that, in the physician's best medical judgment, the patient's death did not result from the illness or condition for which the physician was attending the patient.
This bill requires a physician assistant or advance practice registered nurse in charge of the patient's care for the illness or conditions that resulted in death to complete, sign, and return the medical certification to the funeral director. A physician assistant authorized by protocol or collaborative agreement, or advance practice registered nurse authorized by protocol or collaborative agreement, who attended the patient more than four months preceding death may (i) certify the death certification if the physician assistant or advance practice nurse can make a good faith determination as to cause of death and if the county medical examiner has not assumed jurisdiction; and (ii) communicate, orally or in writing, that in the physician assistant's or advance practice registered nurse's best medical judgment, the patient's dea