HB 2749

                                SECOND REGULAR SESSION
                   HOUSE BILL NO. 2749
                          103RD GENERAL ASSEMBLY
                         INTRODUCED BY REPRESENTATIVE DAVIDSON.
5346H.01I  JOSEPH ENGLER, Chief Clerk
                                           AN ACT
To repeal section 334.735, RSMo, and to enact in lieu thereof one new section relating to
       collaborative practice arrangements between physicians and physician assistants.
Be it enacted by the General Assembly of the state of Missouri, as follows:
        Section A. Section 334.735, RSMo, is repealed and one new section enacted in lieu
2 thereof, to be known as section 334.735, to read as follows:
        334.735. 1. As used in sections 334.735 to 334.749, the following terms mean:
2(1) "Applicant", any individual who seeks to become licensed as a physician
3 assistant;
4(2) "Certification" or "registration", a process by a certifying entity that grants
5 recognition to applicants meeting predetermined qualifications specified by such certifying
6 entity;
7(3) "Certifying entity", the nongovernmental agency or association which certifies or
8 registers individuals who have completed academic and training requirements;
9(4) "Collaborative practice arrangement", written agreements, jointly agreed upon
10 protocols, or standing orders, all of which shall be in writing, for the delivery of health care
11 services;
12(5) "Department", the department of commerce and insurance or a designated agency
13 thereof;
14(6) "License", a document issued to an applicant by the board acknowledging that the
15 applicant is entitled to practice as a physician assistant;
16(7) "Physician assistant", a person who has graduated from a physician assistant
17 program accredited by the Accreditation Review Commission on Education for the Physician
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.
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18 Assistant or its successor agency, prior to 2001, or the Committee on Allied Health Education
19 and Accreditation or the Commission on Accreditation of Allied Health Education Programs,
20 who has passed the certifying examination administered by the National Commission on
21 Certification of Physician Assistants and has active certification by the National Commission
22 on Certification of Physician Assistants, and who provides health care services delegated by a
23 licensed physician. A person who has been employed as a physician assistant for three years
24 prior to August 28, 1989, who has passed the National Commission on Certification of
25 Physician Assistants examination, and has active certification of the National Commission on
26 Certification of Physician Assistants;
27(8) "Recognition", the formal process of becoming a certifying entity as required by
28 the provisions of sections 334.735 to 334.749.
292. The scope of practice of a physician assistant shall consist only of the following
30 services and procedures:
31(1) Taking patient histories;
32(2) Performing physical examinations of a patient;
33(3) Performing or assisting in the performance of routine office laboratory and patient
34 screening procedures;
35(4) Performing routine therapeutic procedures;
36(5) Recording diagnostic impressions and evaluating situations calling for attention of
37 a physician to institute treatment procedures;
38(6) Instructing and counseling patients regarding mental and physical health using
39 procedures reviewed and approved by a collaborating physician;
40(7) Assisting the supervising physician in institutional settings, including reviewing
41 of treatment plans, ordering of tests and diagnostic laboratory and radiological services, and
42 ordering of therapies, using procedures reviewed and approved by a licensed physician;
43(8) Assisting in surgery; and
44(9) Performing such other tasks not prohibited by law under the collaborative practice
45 arrangement with a licensed physician as the physician assistant has been trained and is
46 proficient to perform.
473. Physician assistants shall not perform or prescribe abortions.
484. Physician assistants shall not prescribe any drug, medicine, device or therapy
49 unless pursuant to a collaborative practice arrangement in accordance with the law, nor
50 prescribe lenses, prisms or contact lenses for the aid, relief or correction of vision or the
51 measurement of visual power or visual efficiency of the human eye, nor administer or monitor
52 general or regional block anesthesia during diagnostic tests, surgery or obstetric procedures.
53 Prescribing of drugs, medications, devices or therapies by a physician assistant shall be
54 pursuant to a collaborative practice arrangement which is specific to the clinical conditions
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55 treated by the supervising physician and the physician assistant shall be subject to the
56 following:
57(1) A physician assistant shall only prescribe controlled substances in accordance
58 with section 334.747;
59(2) The types of drugs, medications, devices or therapies prescribed by a physician
60 assistant shall be consistent with the scopes of practice of the physician assistant and the
61 collaborating physician;
62(3) All prescriptions shall conform with state and federal laws and regulations and
63 shall include the name, address and telephone number of the physician assistant;
64(4) A physician assistant, or advanced practice registered nurse as defined in section
65 335.016 may request, receive and sign for noncontrolled professional samples and may
66 distribute professional samples to patients; and
67(5) A physician assistant shall not prescribe any drugs, medicines, devices or
68 therapies the collaborating physician is not qualified or authorized to prescribe.
695. A physician assistant shall clearly identify himself or herself as a physician
70 assistant and shall not use or permit to be used in the physician assistant's behalf the terms
71 "doctor", "Dr." or "doc" nor hold himself or herself out in any way to be a physician or
72 surgeon. No physician assistant shall practice or attempt to practice without physician
73 collaboration or in any location where the collaborating physician is not immediately
74 available for consultation, assistance and intervention, except as otherwise provided in this
75 section, and in an emergency situation, nor shall any physician assistant bill a patient
76 independently or directly for any services or procedure by the physician assistant; except that,
77 nothing in this subsection shall be construed to prohibit a physician assistant from enrolling
78 with a third-party plan or the department of social services as a MO HealthNet or Medicaid
79 provider while acting under a collaborative practice arrangement between the physician and
80 physician assistant.
816. The licensing of physician assistants shall take place within processes established
82 by the state board of registration for the healing arts through rule and regulation. The board
83 of healing arts is authorized to establish rules pursuant to chapter 536 establishing licensing
84 and renewal procedures, collaboration, collaborative practice arrangements, fees, and
85 addressing such other matters as are necessary to protect the public and discipline the
86 profession. An application for licensing may be denied or the license of a physician assistant
87 may be suspended or revoked by the board in the same manner and for violation of the
88 standards as set forth by section 334.100, or such other standards of conduct set by the board
89 by rule or regulation. Persons licensed pursuant to the provisions of chapter 335 shall not be
90 required to be licensed as physician assistants. All applicants for physician assistant licensure
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91 who complete a physician assistant training program after January 1, 2008, shall have a
92 master's degree from a physician assistant program.
937. At all times the physician is responsible for the oversight of the activities of, and
94 accepts responsibility for, health care services rendered by the physician assistant.
958. (1) A physician may enter into collaborative practice arrangements with physician
96 assistants. A licensed hospital, as defined in section 197.020, may perform the
97 administrative duties associated with any collaborative practice arrangement between a
98 physician or physicians and a physician assistant or physician assistants for services
99 delivered in that hospital as long as the hospital has identified in the collaborative
100 practice arrangement one or more physicians affiliated with the hospital who will serve
101 as the collaborating physician or physicians and established practice parameters for the
102 physician assistant or physician assistants listed in the collaborative practice
103 arrangement. A single collaborative practice arrangement may be between multiple
104 physicians and physician assistants if a hospital has agreed to perform the
105 administrative duties associated with the collaborative practice arrangement.
106(2) Collaborative practice arrangements, which shall be in writing, may delegate to a
107 physician assistant the authority to prescribe, administer, or dispense drugs and provide
108 treatment which is within the skill, training, and competence of the physician assistant.
109 Collaborative practice arrangements may delegate to a physician assistant[, as defined in
110 section 334.735,] the authority to administer, dispense, or prescribe controlled substances
111 listed in Schedules III, IV, and V of section 195.017, and Schedule II - hydrocodone.
112 Schedule III narcotic controlled substances and Schedule II - hydrocodone prescriptions shall
113 be limited to a one hundred twenty-hour supply without refill. Such collaborative practice
114 arrangements shall be in the form of a written arrangement, jointly agreed-upon protocols, or
115 standing orders for the delivery of health care services.
116[(2)] (3) Notwithstanding any other provision of this section to the contrary, a
117 collaborative practice arrangement may delegate to a physician assistant the authority to
118 administer, dispense, or prescribe Schedule II controlled substances for hospice patients;
119 provided, that the physician assistant is employed by a hospice provider certified pursuant to
120 chapter 197 and the physician assistant is providing care to hospice patients pursuant to a
121 collaborative practice arrangement that designates the certified hospice as a location where
122 the physician assistant is authorized to practice and prescribe.
1239. The written collaborative practice arrangement with a physician, including any
124 collaborative practice arrangement with a physician or physicians for services delivered
125 in a hospital as described in subsection 8 of this section, shall contain at least the following
126 provisions:
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127(1) Complete names, home and business addresses, zip codes, and telephone numbers
128 of the collaborating physician and the physician assistant;
129(2) A list of all other offices or locations, other than those listed in subdivision (1) of
130 this subsection, where the collaborating physician has authorized the physician assistant to
131 prescribe;
132(3) A requirement that there shall be posted at every office where the physician
133 assistant is authorized to prescribe, in collaboration with a physician, a prominently displayed
134 disclosure statement informing patients that they may be seen by a physician assistant and
135 have the right to see the collaborating physician;
136(4) All specialty or board certifications of the collaborating physician and all
137 certifications of the physician assistant;
138(5) The manner of collaboration between the collaborating physician and the
139 physician assistant, including how the collaborating physician and the physician assistant
140 will:
141(a) Engage in collaborative practice consistent with each professional's skill, training,
142 education, and competence;
143(b) Maintain geographic proximity, as determined by the board of registration for the
144 healing arts; and
145(c) Provide coverage during absence, incapacity, infirmity, or emergency of the
146 collaborating physician;
147(6) A list of all other written collaborative practice arrangements of the collaborating
148 physician and the physician assistant;
149(7) The duration of the written practice arrangement between the collaborating
150 physician and the physician assistant;
151(8) A description of the time and manner of the collaborating physician's review of
152 the physician assistant's delivery of health care services. The description shall include
153 provisions that the physician assistant shall submit a minimum of ten percent of the charts
154 documenting the physician assistant's delivery of health care services to the collaborating
155 physician for review by the collaborating physician, or any other physician designated in the
156 collaborative practice arrangement, every fourteen days. Reviews may be conducted
157 electronically;
158(9) The collaborating physician, or any other physician designated in the
159 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
160 percent of the charts in which the physician assistant prescribes controlled substances. The
161 charts reviewed under this subdivision may be counted in the number of charts required to be
162 reviewed under subdivision (8) of this subsection;
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163(10) A statement that no collaboration requirements in addition to the federal law
164 shall be required for a physician-physician assistant team working in a certified community
165 behavioral health clinic as defined by Pub.L. 113-93, or a rural health clinic under the federal
166 Rural Health Services Act, Pub.L. 95-210, as amended, or a federally qualified health center
167 as defined in 42 U.S.C. Section 1395x, as amended; and
168(11) If a collaborative practice arrangement is used in clinical situations where a
169 collaborating physician assistant provides health care services that include the diagnosis and
170 initiation of treatment for acutely or chronically ill or injured persons, then the collaborating
171 physician or any other physician designated in the collaborative practice arrangement shall be
172 present for sufficient periods of time, at least once every two weeks, except in extraordinary
173 circumstances that shall be documented, to participate in a chart review and to provide
174 necessary medical direction, medical services, consultations, and supervision of the health
175 care staff.
17610. The state board of registration for the healing arts under section 334.125 may
177 promulgate rules regulating the use of collaborative practice arrangements.
17811. The state board of registration for the healing arts shall not deny, revoke, suspend,
179 or otherwise take disciplinary action against a collaborating physician for health care services
180 delegated to a physician assistant, provided that the provisions of this section and the rules
181 promulgated thereunder are satisfied.
18212. Within thirty days of any change and on each renewal, the state board of
183 registration for the healing arts shall require every physician to identify whether the physician
184 is engaged in any collaborative practice arrangement, including collaborative practice
185 arrangements delegating the authority to prescribe controlled substances, and also report to
186 the board the name of each physician assistant with whom the physician has entered into such
187 arrangement. If a hospital is performing the administrative duties associated with a
188 collaborative practice arrangement as described in subsection 8 of this section, the
189 hospital, rather than the physician, shall report to the board the information required
190 under this subsection. The board may make such information available to the public. The
191 board shall track the reported information and may routinely conduct random reviews of such
192 arrangements to ensure that the arrangements are carried out in compliance with this chapter.
19313. The collaborating physician shall determine and document the completion of a
194 period of time during which the physician assistant shall practice with the collaborating
195 physician continuously present before practicing in a setting where the collaborating
196 physician is not continuously present. This limitation shall not apply to collaborative
197 arrangements of providers of population-based public health services as defined by 20 CSR
198 2150-5.100 as of April 30, 2009.
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19914. No contract or other arrangement shall require a physician to act as a
200 collaborating physician for a physician assistant against the physician's will. A physician
201 shall have the right to refuse to act as a supervising physician, without penalty, for a particular
202 physician assistant. No contract or other agreement shall limit the collaborating physician's
203 ultimate authority over any protocols or standing orders or in the delegation of the physician's
204 authority to any physician assistant. No contract or other arrangement shall require any
205 physician assistant to collaborate with any physician against the physician assistant's will. A
206 physician assistant shall have the right to refuse to collaborate, without penalty, with a
207 particular physician.
20815. Physician assistants shall file with the board a copy of their collaborating
209 physician form.
21016. No physician shall be designated to serve as a collaborating physician for more
211 than six full-time equivalent licensed physician assistants, full-time equivalent advanced
212 practice registered nurses, or full-time equivalent assistant physicians, or any combination
213 thereof. This limitation shall not apply to physician assistant collaborative practice
214 arrangements of hospital employees providing inpatient care service in hospitals as defined in
215 chapter 197, or to a certified registered nurse anesthetist providing anesthesia services under
216 the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is
217 immediately available if needed as set out in subsection 7 of section 334.104.
21817. No arrangement made under this section shall supercede current hospital licensing
219 regulations governing hospital medication orders under protocols or standing orders for the
220 purpose of delivering inpatient or emergency care within a hospital, as defined in section
221 197.020, if such protocols or standing orders have been approved by the hospital's medical
222 staff and pharmaceutical therapeutics committee.
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