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
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
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
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
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
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
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
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
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
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
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
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
Physician s Assistant Model Practice Agreement available from Michigan Academy of Physician Assistants at: http://www.michiganpa.org/page/practiceagreement 13
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
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
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
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
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
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
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
Advanced Practice Registered Nurse Licensed Registered Nurses RNs Specialty Certified RNs APRNs CNM NP CNS CRNA s 21
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
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) 23
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 24
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) 25
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 26
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 medicallyrelated communication disorders MCL 333.17607(3) APRN may prescribe physical therapy MCL 333.17820(1) No physician countersignature required 27
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 28
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 29
THANK YOU Kathleen A. Reed Dykema Gossett PLLC kreed@dykema.com Phone: 231.348.8134 Fax: 231.348.8135 30