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 | Washington, D.C. www.dykema.com
2016 – A Busy Year for Scope of Practice Legislation in Michigan ❖ Scope of Practice of Physician’s Assistants: House Bill 5533, PA 379 of 2016 ➢ Effective Date: March 22, 2017 ❖ Scope of Practice of Advanced Practice Registered Nurses: House Bill 5400, PA 499 of 2016 ➢ Effective Date: April 9, 2017 ❖ Other Legislation Affecting Scope of Practice ➢ Midwife, Behavior Analyst, Telemedicine, Pharmacy 1 Exceptional service. Dykema delivers.
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” 2 Exceptional service. Dykema delivers.
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 3 Exceptional service. Dykema delivers.
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 4 Exceptional service. Dykema delivers.
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) 5 Exceptional service. Dykema delivers.
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 or receipt 6 Exceptional service. Dykema delivers.
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 . 7 Exceptional service. Dykema delivers.
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. 8 Exceptional service. Dykema delivers.
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 9 Exceptional service. Dykema delivers.
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 10 Exceptional service. Dykema delivers.
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) 11 Exceptional service. Dykema delivers.
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) 12 Exceptional service. Dykema delivers.
Physician’s Assistant Model Practice Agreement available from Michigan Academy of Physician Assistants at: http://www.michiganpa.org/page/practiceagreement 13 Exceptional service. Dykema delivers.
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 14 Exceptional service. Dykema delivers.
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) 15 Exceptional service. Dykema delivers.
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 16 Exceptional service. Dykema delivers.
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) 17 Exceptional service. Dykema delivers.
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) 18 Exceptional service. Dykema delivers.
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 19 Exceptional service. Dykema delivers.
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 20 Exceptional service. Dykema delivers.
Advanced Practice Registered Nurse Licensed Registered Nurses – RNs Specialty Certified RNs APRNs ● CNM ● CRNA ● NP ● CNS s 21 Exceptional service. Dykema delivers.
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 22 Exceptional service. Dykema delivers.
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