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A New Scope of Practice for PAs and APRNs in Michigan State Bar of - - PowerPoint PPT Presentation
A New Scope of Practice for PAs and APRNs in Michigan State Bar of - - PowerPoint PPT Presentation
Exceptional service. Dykema delivers. A New Scope of Practice for PAs and APRNs in Michigan State Bar of Michigan Health Care Law Section Annual Meeting, September 12, 2017 Kathleen A. Reed California | Illinois | Michigan | Minnesota | Texas
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Physician’s Assistant
❖ New definition of “practice as a physician’s assistant” ➢ “Practice of medicine with a participating physician under a practice agreement” MCL 333.17001(1)(i) ➢ Move from a delegation/supervision model to practicing medicine pursuant to a “practice agreement”
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Physician’s Assistant
❖ Changing the paradigm - What was removed? ➢ References to “delegation” and “supervision” ➢ Monitoring and evaluation requirements associated with definition of “supervision” ✓But not really gone, because they are incorporated into the practice agreement
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Physician’s Assistant
❖ Changing the paradigm - What was removed? ➢ Restriction that PA only treat patients who are under the physician’s “case management responsibility” ➢ Prohibition against delegating ultimate responsibility for the quality of medical care services ➢ Written log of PAs practicing with a physician and strict maximum on number of PAs supervised
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Physician’s Assistant
❖ Changing the paradigm - What was added? ➢ PA must practice pursuant to a written practice agreement with a participating physician MCL
333.17001(1)(i) and 333.17047(1)
➢ Participating physician - independent or designated by a group practice or health facility or agency MCL
333.17001(1)(d), 333.20174
➢ Failure to comply with terms of a practice agreement is professional misconduct for the PA and the participating physician MCL 333.16221(u)
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Physician’s Assistant
❖ Changing the paradigm - What was added? (cont’d) ➢ PA may now independently prescribe controlled substances under own MI CS license and DEA registration ✓PA now included in definition of “prescriber” MCL
333.17708(2)
✓PA no longer needs to record name, DEA numbers of the physician on the prescription or starter dose order
- r receipt
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Physician’s Assistant
❖ Practice Agreement - required content MCL 333.17047 ➢ Collaboration Process. Describe process between PA and physician for communication, availability and decision making when providing medical treatment to a patient ✓ The process must utilize the knowledge and skills of the PA and participating physician based on their education, training and experience .
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Physician’s Assistant
❖ Practice Agreement - required content (cont’d): ➢ Designate Alternate Physician. Protocol for designating an alternative physician for consultation in situations when participating physician is not available. ➢
- Signatures. PA and the participating physician must sign
the practice agreement.
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Physician’s Assistant
❖ Practice Agreement - required content (cont’d): ➢ Specify the duties and responsibilities of the PA and participating physician. May not include as a duty or responsibility any act, task or function: ✓ that the PA or the physician is not qualified to perform by education, training, or experience; or ✓ is outside the scope of the PA’s or physician’s license
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Physician’s Assistant
❖ Practice Agreement - required content (cont’d): ➢
- Credentialing. Provision requiring the participating
physician to verify the PA’s credentials ➢
- Termination. Provision permitting termination by PA or
participating physician on 30 days’ prior written notice
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Physician’s Assistant
❖ Practice Agreement – Reporting to LARA ➢
- Generally. No general requirement to report/submit a
practice agreement to LARA ➢ PA practices in a PC or PLLC. License renewal form asks if PA is a shareholder/member of a PC/PLLC. If yes, PA must identify his/her participating physician, and whether physician is a shareholder/member of same PC/PLLC as PA. MCL 333.17048(4)
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Physician’s Assistant
❖ PA organizes as a legal entity with physicians/podiatrists ➢ If a PA organizes with physicians or podiatrists in a PC or PLLC, then the PA’s practice agreement must be with the physicians or podiatrists who are also shareholders or members of the same PC or PLLC as the PA. MCL
333.17048(3)
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Physician’s Assistant
Model Practice Agreement available from Michigan Academy of Physician Assistants at: http://www.michiganpa.org/page/practiceagreement
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Physician’s Assistant
❖ Professional misconduct under Section 16221: ➢ Failure to practice within a lawful practice agreement is professional misconduct MCL 333.16221(u) ➢ The number of PAs in a practice agreement with a physician is subject to professional discipline under Section 16221 MCL 333.17047(3) ➢ Board may deny PA or physician ability to enter into a practice agreement based on professional misconduct
MCL 333.17050
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Physician’s Assistant
❖ PA 379 gives Board of Medicine authority to promulgate rules that further restrict PA collaborative practice ➢ Medical Care Services. Board may prohibit inclusion of a particular medical care service in a practice agreement if the service requires extensive training, education or ability, or poses a threat to patient health or safety. MCL
333.17048(1)
➢ Prescribing Drugs. Board may define certain drugs or classes of drugs which a PA may not prescribe. MCL
333.17048(2)
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Physician’s Assistant – Practical Implications
❖ PA may evaluate and treat “new” patients. PA 379 removed requirement that PA may only treat a patient who is already under the “case management responsibility” of the physician ➢ Important implications for telemedicine, rural practice, urgent care settings ➢ Does not eliminate reimbursement or accreditation requirements
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Physician’s Assistant – Practical Implications
❖ PA credentialing and privileging ➢ Participating physician must take responsibility for verifying credentials MCL 333.17047(2)(f) ✓Assume this permits delegation to facility/agency so long as physician retains oversight responsibility ❖Must PA and participating physician both possess the training, skill expertise necessary to perform the medical tasks the PA may perform under the practice agreement?
MCL 333.17047(2)(e)
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Advanced Practice Registered Nurse - CNS
❖Clinical Nurse Specialist - Certified (“CNS”) ➢New category of RN specialty certification in Michigan
MCL 333.17210(1)(d)
✓Certification not available until effective date of rules detailing CNS qualifications/credentials ➢Expertise with certain patient populations/diseases ➢CNS academic credentials may be used until CNS specialty certification is available MCL 333.17211(2)(b)
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Advanced Practice Registered Nurse - CNS
❖ PA 499 adds CNS to the list of providers who may: ➢ Participate in debt repayment program MCL 333.2705(1) ➢ Provide notice of HIV+ test results & counseling MCL
333.5119(3)
➢ Make decisions affecting patient/resident rights, including:
MCL 333.20201
✓Withholding information on diagnosis from a patient ✓Right to share a room with a spouse ✓Withholding mail / social activities ✓Ordering restraints
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Advanced Practice Registered Nurse
Advanced Practice Registered Nurse (“APRN”) ❖ New category of specialty-certified RNs that includes: ➢ Certified Nurse Practitioners ➢ Certified Nurse Midwives ➢ Clinical Nurse Specialists – Certified
MCL 333.17201(1)(a)
❖ APRN does not include CRNAs
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Advanced Practice Registered Nurse Licensed Registered Nurses – RNs
Specialty Certified RNs
s APRNs
- CNM
- NP
- CNS
- CRNA
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Advanced Practice Registered Nurse
New Prescriptive Authority for APRNs: ❖ APRN is now included in definition of “prescriber” MCL
333.17708(2)
➢ Definition contemplates: ➢independent prescribing for non-controlled substances ➢physician delegation for controlled substances ❖ New prescriptive authority for APRNs does not require new or additional third party reimbursement or mandated worker’s compensation benefits for prescriptions written by APRNs
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Advanced Practice Registered Nurse
New Prescriptive Authority for APRNs: Non-Controlled Drugs – Independent Authority ❖ APRN may prescribe non-controlled substances independently, without need for delegation from physician
MCL 333.17211a(1)(a)
❖ APRN may order, receive or dispense complimentary starter doses of non-controlled substances independently, without need for delegation from physician
MCL 333.17212(2)
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Advanced Practice Registered Nurse
Prescriptive Authority for APRNs: Controlled Substances – Delegated Authority ❖ APRN may prescribe controlled substances (“CS”) as a delegated act of a physician MCL 333.17211a(1)(b) ❖ APRN may order, receive and dispense complimentary starter doses of CS as a delegated act of a physician MCL
333.17212(3)
❖ APRN not required to obtain MI CS license
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Advanced Practice Registered Nurse
Prescriptive Authority for APRNs: Controlled Substances – Delegated Authority ❖ Board of Medicine rules require a written authorization of delegation for CS prescriptive authority R338.2411(1) ➢ See sample form of written authorization, attached ❖ Federal CS rules require midlevel practitioners to make CS authorizing documents available for DEA inspection and copying 21 CFR 1304.03(e)
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Advanced Practice Registered Nurse
Prescriptive Authority for APRNs: Controlled Substances ❖ CS prescription must give both APRN’s and physician’s name and DEA registration numbers MCL 333.17211a(2) ➢ Issue: APRNs who use institutional DEA numbers ❖ 2016 rule change permits APRN to prescribe CS under delegation without restriction on setting/circumstance, but limits to 30 day supply for schedule 2 CS MAC R338.2411
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Advanced Practice Registered Nurse
New Prescriptive Authority for APRNs: SLP and PT – Independent Authority ❖ APRN may refer to a speech-language pathologist for treatment/assessment of swallowing disorders and medically- related communication disorders MCL 333.17607(3) ❖ APRN may prescribe physical therapy MCL 333.17820(1) ❖ No physician countersignature required
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Advanced Practice Registered Nurse
APRN Practice Locations ❖ APRN may make calls or go on rounds in private homes, public institutions, emergency vehicles, ambulatory clinics, hospitals, ICFs, SNFs, or other health care facilities MCL
333.17214
❖ APRN may undertake these activities without restrictions on the time or frequency of visits by a physician or the APRN
MCL 333.17214
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Advanced Practice Registered Nurse
❖ Caution: Statutory authority for specified independent tasks does not extend authority for all medical tasks or eliminate payer or accreditation requirements ➢ Delegation/supervision still required for some tasks ➢ Consider written collaboration agreement to satisfy payer and accreditation requirements, standard of care ➢ Helpful Medicare publication on midlevel providers: https://www.cms.gov/Outreach-and-Education/Medicare- Learning-Network-LN/MLNProducts/Downloads/Medicare- Information-for-APRNs-AAs-PAs-Booklet-ICN-901623.pdf
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