Existing law, the Physician Assistant Practice Act, provides for regulation of physician assistants and authorizes a physician assistant to perform medical services as set forth by regulations when those services are rendered under the supervision of a licensed physician and surgeon, as specified. The act requires the supervising physician and surgeon to review, countersign, and date a sample consisting of, at a minimum, 5% of the medical records of patients treated by the physician assistant functioning under adopted protocols within 30 days of the date of treatment by the physician assistant. The act requires the supervising physician and surgeon to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient. A violation of those supervision requirements is a misdemeanor.

This bill would require that the medical record for each episode of care for a patient identify the physician and surgeon who is responsible for the supervision of the physician assistant. The bill would delete those medical record review provisions, and, instead, require the supervising physician and surgeon to use one or more of described review mechanisms. By adding these new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program by changing the definition of a crime.

The act authorizes a physician assistant, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patients record or in a drug order, an order to a person who may lawfully furnish the medication or medical device. The act prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. The act requires that the medical record of any patient cared for by a physician assistant for whom a physician assistants Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within 7 days.

This bill would establish an alternative medical records review mechanism, and would authorize the supervising physician and surgeon to use the alternative mechanism, or a sample review mechanism using a combination of the 2 described mechanisms, as specified, to ensure adequate supervision of the administration, provision, or issuance by a physician assistant of a drug order to a patient for Schedule II controlled substances.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Physician Assistant Practice Act, provides for regulation of physician assistants and authorizes a physician assistant to perform medical services as set forth by regulations when those services are rendered under the supervision of a licensed physician and surgeon, as specified. The act requires the supervising physician and surgeon to review, countersign, and date a sample consisting of, at a minimum, 5% of the medical records of patients treated by the physician assistant functioning under adopted protocols within 30 days of the date of treatment by the physician assistant. The act requires the supervising physician and surgeon to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient. A violation of those supervision requirements is a misdemeanor.

This bill would require that the medical record for each episode of care for a patient identify the physician and surgeon who is responsible for the supervision of the physician assistant. The bill would delete those medical record review provisions, and, instead, require the supervising physician and surgeon to use one or more of described review mechanisms. By adding these new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program by changing the definition of a crime.

The act authorizes a physician assistant, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patients record or in a drug order, an order to a person who may lawfully furnish the medication or medical device. The act prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. The act requires that the medical record of any patient cared for by a physician assistant for whom a physician assistants Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within 7 days.

This bill would establish an alternative medical records review mechanism, and would authorize the supervising physician and surgeon to use the alternative mechanism, or a sample review mechanism using a combination of the 2 described mechanisms, as specified, to ensure adequate supervision of the administration, provision, or issuance by a physician assistant of a drug order to a patient for Schedule II controlled substances.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Physician Assistant Practice Act, provides for regulation of physician assistants and authorizes a physician assistant to perform medical services as set forth by regulations when those services are rendered under the supervision of a licensed physician and surgeon, as specified. The act requires the supervising physician and surgeon to review, countersign, and date a sample consisting of, at a minimum, 5% of the medical records of patients treated by the physician assistant functioning under adopted protocols within 30 days of the date of treatment by the physician assistant. The act requires the supervising physician and surgeon to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient. A violation of those supervision requirements is a misdemeanor.

This bill would require that the medical record for each episode of care for a patient identify the physician and surgeon who is responsible for the supervision of the physician assistant. The bill would delete those medical record review provisions, and, instead, require the supervising physician and surgeon to use one or more of described review mechanisms. By adding these new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program by changing the definition of a crime.

The act authorizes a physician assistant, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patients record or in a drug order, an order to a person who may lawfully furnish the medication or medical device. The act prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. The act requires that the medical record of any patient cared for by a physician assistant for whom a physician assistants Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within 7 days.

This bill would delete that review and countersignature requirement for a physician assistants Schedule II drug order, and, instead, require that establish an alternative medical records review mechanism, and would authorize the supervising physician and surgeon use one to use the alternative mechanism, or a sample review mechanism using a combination of the 2 described mechanisms mechanisms, as specified, to ensure adequate supervision of the administration, provision, or issuance by a physician assistant of a drug order to a patient for Schedule II controlled substances.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Physician Assistant Practice Act, provides for regulation of physician assistants and authorizes a physician assistant to perform medical services as set forth by regulations when those services are rendered under the supervision of a licensed physician and surgeon, as specified. The act requires the supervising physician and surgeon to review, countersign, and date a sample consisting of, at a minimum, 5% of the medical records of patients treated by the physician assistant functioning under adopted protocols within 30 days of the date of treatment by the physician assistant. The act requires the supervising physician and surgeon to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient. A violation of those supervision requirements is a misdemeanor.

This bill would require that the medical record for each episode of care for a patient identify the physician and surgeon who is responsible for the supervision of the physician assistant. The bill would require a physician assistant who transmits an oral order to identify the name of the supervising physician and surgeon responsible for the patient. The bill would delete those medical record review provisions, and, instead, require the supervising physician and surgeon to use one or more of described review mechanisms. By adding these new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program by changing the definition of a crime.

The act authorizes a physician assistant, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patients record or in a drug order, an order to a person who may lawfully furnish the medication or medical device. The act prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. The act requires that the medical record of any patient cared for by a physician assistant for whom a physician assistants Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within 7 days.

This bill would delete that review and countersignature requirement for a physician assistants Schedule II drug order, and, instead, require that the supervising physician and surgeon use one of 2 described mechanisms to ensure adequate supervision of the administration, provision, or issuance by a physician assistant of a drug order to a patient for Schedule II controlled substances.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Physician Assistant Practice Act, provides for regulation of physician assistants and authorizes a physician assistant to perform medical services as set forth by regulations when those services are rendered under the supervision of a licensed physician and surgeon, as specified. The act requires the supervising physician and surgeon to review, countersign, and date a sample consisting of, at a minimum, 5 percent 5% of the medical records of patients treated by the physician assistant functioning under adopted protocols within 30 days of the date of treatment by the physician assistant. The act requires the supervising physician and surgeon to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient. A violation of those supervision requirements is a misdemeanor.

This bill would require that the medical record for each episode of care for a patient, patient identify the physician and surgeon who is responsible for the supervision of the physician assistant. The bill would require a physician assistant who transmits an oral order to identify the name of the supervising physician and surgeon responsible for the patient. The bill would delete those medical record review provisions, and, instead, require the supervising physician and surgeon to use one or more of described review mechanisms. By adding these new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program by changing the definition of a crime.

The act authorizes a physician assistant, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patients record or in a drug order, an order to a person who may lawfully furnish the medication or medical device. The act prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. The act requires that the medical record of any patient cared for by a physician assistant for whom a physician assistants Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within 7 days.

This bill would delete that review and countersignature requirement for a physician assistants Schedule II drug order, and, instead, require that the supervising physician and surgeon use one of 2 described mechanisms to ensure adequate supervision of the administration, provision, or issuance by a physician assistant of a drug order to a patient for Schedule II controlled substances.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

Existing law, the Physician Assistant Practice Act, provides for regulation of physician assistants and authorizes a physician assistant to perform medical services as set forth by regulations when those services are rendered under the supervision of a licensed physician and surgeon, as specified. The act requires the supervising physician and surgeon to review, countersign, and date a sample consisting of, at a minimum, 5 percent of the medical records of patients treated by the physician assistant functioning under adopted protocols within 30 days of the date of treatment by the physician assistant. The act requires the supervising physician and surgeon to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgment, the most significant risk to the patient. A violation of those supervision requirements is a misdemeanor.

This bill would require that the medical record for each episode of care for a patient, identify the physician and surgeon who is responsible for the supervision of the physician assistant. The bill would require a physician assistant who transmits an oral order to identify the name of the supervising physician and surgeon responsible for the patient. The bill would delete those medical record review provisions, and, instead, require the supervising physician and surgeon to use one or more of described review mechanisms. By adding these new requirements, the violation of which would be a crime, this bill would impose a state-mandated local program by changing the definition of a crime.

The act authorizes a physician assistant, while under prescribed supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patients record or in a drug order, an order to a person who may lawfully furnish the medication or medical device. The act prohibits a physician assistant from administering, providing, or issuing a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient unless the physician assistant has completed an education course that covers controlled substances and that meets approved standards. The act requires that the medical record of any patient cared for by a physician assistant for whom a physician assistants Schedule II drug order has been issued or carried out to be reviewed, countersigned, and dated by a supervising physician and surgeon within 7 days.

This bill would delete that review and countersignature requirement for a physician assistants Schedule II drug order, and, instead, require that the supervising physician and surgeon use one of 2 described mechanisms to ensure adequate supervision of the administration, provision, or issuance by a physician assistant of a drug order to a patient for Schedule II controlled substances.

The California Constitution requires the state to reimburse local agencies and school districts for certain costs mandated by the state. Statutory provisions establish procedures for making that reimbursement.

This bill would provide that no reimbursement is required by this act for a specified reason.

 UNFINISHED BUSINESS  

Bill No: SB 337

Author: Pavley (D)

Amended: 9/1/15

Vote: 21

SENATE BUS, PROF. & ECON. DEV. COMMITTEE: 9-0, 4/20/15

AYES: Hill, Bates, Berryhill, Block, Galgiani, Hernandez, Jackson, Mendoza, Wieckowski

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SENATE FLOOR: 38-0, 5/26/15

AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner, Stone, Vidak, Wieckowski, Wolk

NO VOTE RECORDED: Hall

ASSEMBLY FLOOR: 80-0, 9/3/15 - See last page for vote

SUBJECT: Physician assistants

SOURCE: California Academy of Physician Assistants

DIGEST: This bill provides two additional mechanisms for a supervising physician and surgeon to ensure adequate supervision of a physician assistant (PA) functioning under the protocols.

Assembly Amendments clarify that medical review meetings may occur in person or by electronic communication and specify how often a medical records review meeting must occur and in what manner.

ANALYSIS:

Existing law:

1. Establishes the Physician Assistant Board within the jurisdiction of the Medical Board of California (MBC) to administer and enforce the Medical Practice Act. (Business and Professions Code (BPC) § 3504)

2. Requires a PA and his or her supervising physician to establish written guidelines for the adequate supervision of the PA, and the requirement may be satisfied by the supervising physician adopting protocols for some or all of the tasks performed by the PA. (BPC § 3502 (c)(1))

3. Requires a supervising physician to review, countersign, and date a sample consisting of, at a minimum, five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. Requires the supervising physician to select for review those cases that by diagnosis, problem, treatment, or procedure represent the most significant risk to the patient. (BPC § 3502 (c)(2))

4. Requires a supervising physician who delegates the authority to issue a drug order to a PA to prepare and adopt a formulary and protocols that specify all criteria for the use of a particular drug of device, and any contraindications for the selection. Protocols for Schedule II controlled substances shall address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued. (BPC § 3502.1(a)(2))

5. Requires a supervising physician to review and countersign within seven days the record of any patient cared for by a PA for whom the PA’s Schedule II drug order has been issued or carried out. (BPC § 3502.1 (e))

This bill:

1. Defines “medical records review meeting” as a meeting between the supervising physician and surgeon and the PA during which medical records are reviewed to ensure adequate supervision of the PA functioning under protocols. Medical records review meetings may occur in person or by electronic communication.

2. Requires that the medical record identify the physician and surgeon who is responsible for the supervision of the PA for each episode of patient care.

3. Authorizes a supervising physician and surgeon to conduct a medical records review meeting at least once a month during at least 10 months of the year. During any month in which a medical records review meeting occurs, the supervising physician and surgeon and PA shall review an aggregate of at least 10 medical records of patients treated by the PA functioning under protocols. Documentation of medical records reviewed during the month shall be jointly signed and dated by the supervising physician and surgeon and the PA.

4. Authorizes a supervising physician and surgeon to conduct a medical records review by reviewing a sample of at least 10 medical records per month, at least 10 months during the year, using a combination of the countersignature mechanism and the medical records review meeting mechanism, as specified.

5. Authorizes a supervising physician and surgeon to review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the PA for whom the PA’s Schedule II drug order has been issued or carried out, if the PA has documentation evidencing the successful completion of an education course that covers controlled substances, and that controlled substance education course meets specified standards.

6. Makes technical changes.

Background

According to the author, “This bill is also needed to address an issue related to co-signatures on Schedule II medications. In August of 2014 the DEA published a final rule, effective October 6, 2014, following recommendations from the U.S. Food and Drug Administration (FDA) to up-schedule or reclassify hydrocodone combination products (HCP) from a Schedule III controlled substance to a Schedule II. The rescheduling of HCPs has had a significant impact, and unintended consequence, on some practices throughout California as existing law requires a 100% physician co-signature requirement on these medications within
7 days. This can be particularly challenging for practices that employ PAs to practice medicine in areas such as pain management, orthopedics, general surgery and several other practice types. The new ruling restricts the ability of a practice to fully utilize the PAs they employ as there is no other profession with prescribing privileges that has that level of mandate for documentation. Further, a co-signature mandate of 100% is overly burdensome for physicians in various practice types.

“Existing law requires a supervising physician to be available in-person or through electronic communication at all times when a PA is providing care for a patient. Given the many models of team-based care supervising physicians and PA often practice at different locations and lead PA run clinics as well as assume significant administrative responsibilities. In this context, a 100% mandate on co-signatures creates a barrier to efficient team-based care and stands to jeopardize access to appropriate treatment of pain for those patients with legitimate need.”

A PA performs many of the same diagnostic, preventative and health maintenance services as a physician, but PAs are limited in practice to those duties delegated by a supervising physician. These services may include, but are not limited to, the following:

• Taking health histories.

• Performing physical examinations.

• Ordering X-rays and laboratory tests.

• Ordering respiratory, occupational, or physical therapy treatments.

• Performing routine diagnostic tests.

• Establishing diagnoses.

• Treating and managing patient health problems.

• Administering immunizations and injections.

• Instructing and counseling patients.

• Providing continuing care to patients in the home, hospital, or extended care facility.

• Providing referrals within the health care system.

• Performing minor surgery.

• Providing preventative health care services.

• Acting as first or second assistants during surgery.

• Responding to life-threatening emergencies.

A PA must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. An academic degree and/or certificate is awarded upon graduation. Many PAs already have two- or four-year academic degrees before entering a PA training program. Most PA training programs require prior health care experience. As of June 2013, there were 9,101 active California PA licensees.

Supervision. Existing law has very specific requirements for a supervising physician to delegate practice authority to a PA, and the supervising physician must be physically or electronically available to his or her PA at the time of treatment. In addition to this, a supervising physician must review, countersign, and date a sample of at least five percent of a PA’s cases within 30 days of treatment.

The author argues that the five percent review requirement is outdated and unnecessary, given the close working relationship between PAs and physicians and existing delegation of service agreements and protocols. This bill provides two additional mechanisms for a supervising physician to ensure adequate PA supervision, and establishes an additional method to supervise a PA’s furnishing of Schedule II drugs.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Assembly Appropriations Committee, this bill will have minor and absorbable costs to the Physician Assistant Board within the MBC to conform to the new supervision options (Physician Assistant Fund).

SUPPORT: (Verified 9/3/15)

California Academy of Physician Assistants (source)

CAPG

Medical Board of California

Pacific Pain Medicine Consultants

Pacific Southwest Pain Center

Physician Assistant Board

Planned Parenthood Affiliates of California

OPPOSITION: (Verified 9/3/15)

None received

ARGUMENTS IN SUPPORT: The source of this bill, the California Academy of Physician Assistants, write, “With the implementation of the Patient Protection and Affordable Care Act, Covered California reported enrolling 3.4 million (1.4 through Covered CA plans and 1.9 in Medi-Cal) previously uninsured people in the first open enrollment year (2014). This bill recognizes the need to increase access to high quality, cost-effective and efficient team-based practice across all medical settings in order to meet the rising demand for health care services throughout the state.

“The physician/PA team is unique as PAs are licensed health professionals who practice medicine as members of a physician-led team, delivering a broad range of medical and surgical services at the direction of and under the supervision of his or her supervising physician. The supervising physician delegates to a PA specified medical tasks and procedures, consistent with his or her scope of practice, based on education, training and experience.

“Established over 30 years ago, existing law stipulates supervision criteria between a supervising physician and surgeon and the Physician Assistant (PA). It narrowly defines documentation of this required supervision in the form of the supervising physician co-signature on the medical record. SB 377 increases the options for documenting supervision between a supervising physician and PA would allow for flexibility at the practice level to reflect current models of team-based care.”

ASSEMBLY FLOOR: 80-0, 9/3/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins

Prepared by: Sarah Huchel / B., P. & E.D. / (916) 651-4104

9/4/15 10:42:46

**** END ****

 UNFINISHED BUSINESS  

Bill No: SB 337

Author: Pavley (D)

Amended: 9/1/15

Vote: 21

SENATE BUS, PROF. & ECON. DEV. COMMITTEE: 9-0, 4/20/15

AYES: Hill, Bates, Berryhill, Block, Galgiani, Hernandez, Jackson, Mendoza, Wieckowski

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SENATE FLOOR: 38-0, 5/26/15

AYES: Allen, Anderson, Bates, Beall, Berryhill, Block, Cannella, De León, Fuller, Gaines, Galgiani, Hancock, Hernandez, Hertzberg, Hill, Hueso, Huff, Jackson, Lara, Leno, Leyva, Liu, McGuire, Mendoza, Mitchell, Monning, Moorlach, Morrell, Nguyen, Nielsen, Pan, Pavley, Roth, Runner, Stone, Vidak, Wieckowski, Wolk

NO VOTE RECORDED: Hall

ASSEMBLY FLOOR: 80-0, 9/3/15 - See last page for vote

SUBJECT: Physician assistants

SOURCE: California Academy of Physician Assistants

DIGEST: This bill provides two additional mechanisms for a supervising physician and surgeon to ensure adequate supervision of a physician assistant (PA) functioning under the protocols.

Assembly Amendments clarify that medical review meetings may occur in person or by electronic communication and specify how often a medical records review meeting must occur and in what manner.

ANALYSIS:

Existing law:

1. Establishes the Physician Assistant Board within the jurisdiction of the Medical Board of California (MBC) to administer and enforce the Medical Practice Act. (Business and Professions Code (BPC) § 3504)

2. Requires a PA and his or her supervising physician to establish written guidelines for the adequate supervision of the PA, and the requirement may be satisfied by the supervising physician adopting protocols for some or all of the tasks performed by the PA. (BPC § 3502 (c)(1))

3. Requires a supervising physician to review, countersign, and date a sample consisting of, at a minimum, five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. Requires the supervising physician to select for review those cases that by diagnosis, problem, treatment, or procedure represent the most significant risk to the patient. (BPC § 3502 (c)(2))

4. Requires a supervising physician who delegates the authority to issue a drug order to a PA to prepare and adopt a formulary and protocols that specify all criteria for the use of a particular drug of device, and any contraindications for the selection. Protocols for Schedule II controlled substances shall address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued. (BPC § 3502.1(a)(2))

5. Requires a supervising physician to review and countersign within seven days the record of any patient cared for by a PA for whom the PA’s Schedule II drug order has been issued or carried out. (BPC § 3502.1 (e))

This bill:

1. Defines “medical records review meeting” as a meeting between the supervising physician and surgeon and the PA during which medical records are reviewed to ensure adequate supervision of the PA functioning under protocols. Medical records review meetings may occur in person or by electronic communication.

2. Requires that the medical record identify the physician and surgeon who is responsible for the supervision of the PA for each episode of patient care.

3. Authorizes a supervising physician and surgeon to conduct a medical records review meeting at least once a month during at least 10 months of the year. During any month in which a medical records review meeting occurs, the supervising physician and surgeon and PA shall review an aggregate of at least 10 medical records of patients treated by the PA functioning under protocols. Documentation of medical records reviewed during the month shall be jointly signed and dated by the supervising physician and surgeon and the PA.

4. Authorizes a supervising physician and surgeon to conduct a medical records review by reviewing a sample of at least 10 medical records per month, at least 10 months during the year, using a combination of the countersignature mechanism and the medical records review meeting mechanism, as specified.

5. Authorizes a supervising physician and surgeon to review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the PA for whom the PA’s Schedule II drug order has been issued or carried out, if the PA has documentation evidencing the successful completion of an education course that covers controlled substances, and that controlled substance education course meets specified standards.

6. Makes technical changes.

Background

According to the author, “This bill is also needed to address an issue related to co-signatures on Schedule II medications. In August of 2014 the DEA published a final rule, effective October 6, 2014, following recommendations from the U.S. Food and Drug Administration (FDA) to up-schedule or reclassify hydrocodone combination products (HCP) from a Schedule III controlled substance to a Schedule II. The rescheduling of HCPs has had a significant impact, and unintended consequence, on some practices throughout California as existing law requires a 100% physician co-signature requirement on these medications within
7 days. This can be particularly challenging for practices that employ PAs to practice medicine in areas such as pain management, orthopedics, general surgery and several other practice types. The new ruling restricts the ability of a practice to fully utilize the PAs they employ as there is no other profession with prescribing privileges that has that level of mandate for documentation. Further, a co-signature mandate of 100% is overly burdensome for physicians in various practice types.

“Existing law requires a supervising physician to be available in-person or through electronic communication at all times when a PA is providing care for a patient. Given the many models of team-based care supervising physicians and PA often practice at different locations and lead PA run clinics as well as assume significant administrative responsibilities. In this context, a 100% mandate on co-signatures creates a barrier to efficient team-based care and stands to jeopardize access to appropriate treatment of pain for those patients with legitimate need.”

A PA performs many of the same diagnostic, preventative and health maintenance services as a physician, but PAs are limited in practice to those duties delegated by a supervising physician. These services may include, but are not limited to, the following:

• Taking health histories.

• Performing physical examinations.

• Ordering X-rays and laboratory tests.

• Ordering respiratory, occupational, or physical therapy treatments.

• Performing routine diagnostic tests.

• Establishing diagnoses.

• Treating and managing patient health problems.

• Administering immunizations and injections.

• Instructing and counseling patients.

• Providing continuing care to patients in the home, hospital, or extended care facility.

• Providing referrals within the health care system.

• Performing minor surgery.

• Providing preventative health care services.

• Acting as first or second assistants during surgery.

• Responding to life-threatening emergencies.

A PA must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. An academic degree and/or certificate is awarded upon graduation. Many PAs already have two- or four-year academic degrees before entering a PA training program. Most PA training programs require prior health care experience. As of June 2013, there were 9,101 active California PA licensees.

Supervision. Existing law has very specific requirements for a supervising physician to delegate practice authority to a PA, and the supervising physician must be physically or electronically available to his or her PA at the time of treatment. In addition to this, a supervising physician must review, countersign, and date a sample of at least five percent of a PA’s cases within 30 days of treatment.

The author argues that the five percent review requirement is outdated and unnecessary, given the close working relationship between PAs and physicians and existing delegation of service agreements and protocols. This bill provides two additional mechanisms for a supervising physician to ensure adequate PA supervision, and establishes an additional method to supervise a PA’s furnishing of Schedule II drugs.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

According to the Assembly Appropriations Committee, this bill will have minor and absorbable costs to the Physician Assistant Board within the MBC to conform to the new supervision options (Physician Assistant Fund).

SUPPORT: (Verified 9/3/15)

California Academy of Physician Assistants (source)

California Academy of Family Physicians

CAPG

Medical Board of California

Pacific Pain Medicine Consultants

Pacific Southwest Pain Center

Physician Assistant Board

Planned Parenthood Affiliates of California

OPPOSITION: (Verified 9/3/15)

None received

ARGUMENTS IN SUPPORT: The source of this bill, the California Academy of Physician Assistants, write, “With the implementation of the Patient Protection and Affordable Care Act, Covered California reported enrolling 3.4 million (1.4 through Covered CA plans and 1.9 in Medi-Cal) previously uninsured people in the first open enrollment year (2014). This bill recognizes the need to increase access to high quality, cost-effective and efficient team-based practice across all medical settings in order to meet the rising demand for health care services throughout the state.

“The physician/PA team is unique as PAs are licensed health professionals who practice medicine as members of a physician-led team, delivering a broad range of medical and surgical services at the direction of and under the supervision of his or her supervising physician. The supervising physician delegates to a PA specified medical tasks and procedures, consistent with his or her scope of practice, based on education, training and experience.

“Established over 30 years ago, existing law stipulates supervision criteria between a supervising physician and surgeon and the Physician Assistant (PA). It narrowly defines documentation of this required supervision in the form of the supervising physician co-signature on the medical record. SB 377 increases the options for documenting supervision between a supervising physician and PA would allow for flexibility at the practice level to reflect current models of team-based care.”

ASSEMBLY FLOOR: 80-0, 9/3/15

AYES: Achadjian, Alejo, Travis Allen, Baker, Bigelow, Bloom, Bonilla, Bonta, Brough, Brown, Burke, Calderon, Campos, Chang, Chau, Chávez, Chiu, Chu, Cooley, Cooper, Dababneh, Dahle, Daly, Dodd, Eggman, Frazier, Beth Gaines, Gallagher, Cristina Garcia, Eduardo Garcia, Gatto, Gipson, Gomez, Gonzalez, Gordon, Gray, Grove, Hadley, Harper, Roger Hernández, Holden, Irwin, Jones, Jones-Sawyer, Kim, Lackey, Levine, Linder, Lopez, Low, Maienschein, Mathis, Mayes, McCarty, Medina, Melendez, Mullin, Nazarian, Obernolte, O'Donnell, Olsen, Patterson, Perea, Quirk, Rendon, Ridley-Thomas, Rodriguez, Salas, Santiago, Steinorth, Mark Stone, Thurmond, Ting, Wagner, Waldron, Weber, Wilk, Williams, Wood, Atkins

Prepared by: Sarah Huchel / B., P. & E.D. / (916) 651-4104

9/3/15 18:47:36

**** END ****

SENATE THIRD READING

STR Bill Id:SB 337

Author:(Pavley)

As Amended Ver:September 1, 2015

Majority vote

SENATE VOTE: 38-0

SUMMARY: Authorizes a physician supervising a physician assistant (PA) to use two additional mechanisms for the general supervision of a PA, authorizes a physician to use one additional mechanism for the supervision of a PA that administers a Schedule II controlled substance, and requires a PA's patient medical records to identify the PA’s supervising physician. Specifically, this bill:

1. Revises the definition of "medical records review meeting" to mean a meeting between the supervising physician and the PA during which medical records are reviewed to ensure adequate supervision of the PA functioning under protocols.

2. Authorizes the supervising physician and PA to hold medical records review meetings in person or by electronic communication.

3. Requires the medical record, for each episode of care for a patient, to identify the physician who is responsible for the supervision of the PA.

4. Authorizes a physician to choose from two additional mechanisms to supervise a PA, making a total of three mechanisms:

   1. Conduct a medical records review meeting at least once a month during at least 10 months of the year—any month in which a medical records review meeting occurs, the supervising physician and PA must review an aggregate of at least 10 medical records of patients treated by the PA. Documentation of medical records reviewed during the month must be jointly signed and dated by the supervising physician and the PA.

   2. Use a combination of the two other mechanisms – the existing 5% countersignature mechanism and the new medical records review mechanism. During each month for which a sample is reviewed, the physician must:

      1. Review at least one of the medical records in the sample using the existing five percent countersignature mechanism; and,

      2. Review at least one of the medical records in the sample using the new medical records review method.

5. States that, in complying with the supervision requirements 4) above, the physician must select for review those cases that by diagnosis, problem treatment, or procedure represent, in the physician's judgment, the most significant risk to the patient.

6. States that compliance with Business and Professions Code (BPC) Section 3502 (numbers 3), 4), and 5) above) will be also considered compliance with section 1399.546 of Title 16 of the California Code of Regulations.

7. Authorizes a physician to use an additional mechanism for the supervision of a PA that prescribes a Schedule II controlled substance. The physician may review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20% of the patients with the PA's Schedule II prescriptions if:

   1. The PA has:

      1. Completed a controlled substances education course that meets the standards established in the PAB's regulations and is provided either by an accredited continuing education provider or by an approved physician assistant training program; or,

      2. The PA has a certificate of completion of the course described BPC Section 3502.1(c)(2); and,

   2. The supervision is verified and documented in the manner established by the PAB's regulations.

8. Makes other minor technical and clarifying changes.

FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill will result in minor and absorbable costs to the Physician Assistant Board (PAB) within the Medical Board of California to conform to the new supervision options.

COMMENTS:

Purpose. This bill is sponsored by the California Academy of Physician Assistants. According to the author, "[This bill] increases options for the physician/PA team to document supervision. The options included in the bill will strengthen the team-based approach by encouraging more active discussion during the records review.

"The Patient Protection and Affordable Care Act has resulted in millions of additional people seeking health care services in California. This increase has created an even greater need for high quality, efficient team-based care across all medical settings.

"This is especially true for the practice of physician assistants, who are authorized to provide physician exams, diagnose and treat illness, and prescribe medication, under the supervision of a physician. [This bill] recognizes the growing changes in medical practice settings and the use of electronic medical records to update methods for documentation of the supervision of PAs and encourages more interactive review of patient cases."

Background. Existing law requires a PA's supervising physician to countersign a sample of at least five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. According to the author, the requirement does not accommodate many care delivery models. Therefore, this bill seeks to add two additional mechanisms which provide a supervising physician more options to adequately supervise a PA depending on the care delivery model.

Supervision of Controlled Substances. Under existing law, a physician must countersign the medical record of all the PA’s patients within seven days of prescribing the drug for Schedule II controlled substances. Because existing law allows a physician to provide supervision electronically, the author states that PA-lead clinics may be unable to provide Schedule II drugs (such as hydrocodone combination product drugs like Vicodin) if the physician must be physically available to countersign the medical records within seven days for every prescription. Therefore, this bill seeks to provide an additional supervision mechanism for Schedule II drugs.

For a full discussion of this bill, please see the policy committee analysis.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301 FN: 0001907

SENATE THIRD READING

STR Bill Id:SB 337

Author:(Pavley)

As Amended Ver:June 16, 2015

Majority vote

SENATE VOTE: 38-0

SUMMARY: Authorizes a physician supervising a physician assistant (PA) to use two additional mechanisms for the general supervision of a PA, authorizes a physician to use one additional mechanism for the supervision of a PA that administers a Schedule II controlled substance, and requires a PA's patient medical records to identify the PA’s supervising physician. Specifically, this bill:

1. Revises the definition of "medical records review meeting" to mean a meeting between the supervising physician and the PA during which medical records are reviewed to ensure adequate supervision of the PA functioning under protocols.

2. Authorizes the supervising physician and PA to hold medical records review meetings in person or by electronic communication.

3. Requires the medical record, for each episode of care for a patient, to identify the physician who is responsible for the supervision of the PA.

4. Authorizes a physician to choose from two additional mechanisms to supervise a PA, making a total of three mechanisms:

   1. Conduct a medical records review meeting at least once a month during at least 10 months of the year—any month in which a medical records review meeting occurs, the supervising physician and PA must review an aggregate of at least 10 medical records of patients treated by the PA. Documentation of medical records reviewed during the month must be jointly signed and dated by the supervising physician and the PA.

   2. Develop review methods for the review of cases involving treatment by the PA. The review methods must be identified in the delegation of services agreement and include at least an aggregate of 10 cases per month for at least 10 months of the year. Documentation of the cases reviewed during the month must be jointly signed and dated by the physician and PA.

5. States that, in complying with the supervision requirements 4) above, the physician must select for review those cases that by diagnosis, problem treatment, or procedure represent, in the physician's judgment, the most significant risk to the patient.

6. States that compliance with Business and Professions Code (BPC) Section 3502 (numbers 3), 4), and 5) above) will be also considered compliance with section 1399.546 of Title 16 of the California Code of Regulations.

7. Authorizes a physician to use an additional mechanism for the supervision of a PA that prescribes a Schedule II controlled substance. The physician may review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20% of the patients with the PA's Schedule II prescriptions if:

   1. The PA has:

      1. Completed a controlled substances education course that meets the standards established in the PAB's regulations and is provided either by an accredited continuing education provider or by an approved physician assistant training program; or,

      2. The PA has a certificate of completion of the course described BPC Section 3502.1(c)(2); and,

   2. The supervision is verified and documented in the manner established by the PAB's regulations.

8. Makes other minor technical and clarifying changes.

FISCAL EFFECT: According to the Assembly Appropriations Committee, this bill will result in minor and absorbable costs to the Physician Assistant Board (PAB) within the Medical Board of California to conform to the new supervision options.

COMMENTS:

Purpose. This bill is sponsored by the California Academy of Physician Assistants. According to the author, "[This bill] increases options for the physician/PA team to document supervision. The options included in the bill will strengthen the team-based approach by encouraging more active discussion during the records review.

"The Patient Protection and Affordable Care Act has resulted in millions of additional people seeking health care services in California. This increase has created an even greater need for high quality, efficient team-based care across all medical settings.

"This is especially true for the practice of physician assistants, who are authorized to provide physician exams, diagnose and treat illness, and prescribe medication, under the supervision of a physician. [This bill] recognizes the growing changes in medical practice settings and the use of electronic medical records to update methods for documentation of the supervision of PAs and encourages more interactive review of patient cases."

Background. Existing law requires a PA's supervising physician to countersign a sample of at least five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. According to the author, the requirement does not accommodate many care delivery models. Therefore, this bill seeks to add two additional mechanisms which provide a supervising physician more options to adequately supervise a PA depending on the care delivery model.

Supervision of Controlled Substances. Under existing law, a physician must countersign the medical record of all the PA’s patients within seven days of prescribing the drug for Schedule II controlled substances. Because existing law allows a physician to provide supervision electronically, the author states that PA-lead clinics may be unable to provide Schedule II drugs (such as hydrocodone combination product drugs like Vicodin) if the physician must be physically available to countersign the medical records within seven days for every prescription. Therefore, this bill seeks to provide an additional supervision mechanism for Schedule II drugs.

For a full discussion of this bill, please see the policy committee analysis.

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301 FN: 0001848

Date of Hearing: July 8, 2015

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Jimmy Gomez, Chair

SBPCA Bill Id:SB 337

Author:(Pavley) – As Amended Ver:June 16, 2015

Urgency: No State Mandated Local Program: Yes Reimbursable: No

SUMMARY:

This bill modifies the allowable methods a physician may use to supervise a physician assistant. Specifically, this bill:

1. Authorizes a physician supervising a physician assistant (PA) to use two additional mechanisms for the general supervision of a PA, in place of the current-law requirement to review 5% of patient charts, namely, medical review meetings or a physician-approved protocol with minimum standards.

2. Authorizes a physician to use one additional mechanism for the supervision of a PA that administers a Schedule II controlled substance in place of the current-law requirement to countersign each prescription, namely, review and countersignature of a 20% sample.

3. Requires a PA’s patient medical records to identify the PA’s supervising physician.

FISCAL EFFECT:

Minor and absorbable costs to the Physician Assistant Board (PAB) within the Medical Board of California to conform to the new supervision options (Physician Assistant Fund).

COMMENTS:

1. Purpose. This bill adds different supervision options in an attempt to streamline the physician/PA workflow while still ensuring patient protection. The new options recognize current care delivery models and electronic medical records review. In addition, the bill allows a sample of prescriptions for Schedule II drugs to be reviewed, instead of each prescription. The bill is sponsored by the California Academy of Physician Assistants.

2. Background. A PA may provide medical services pursuant to a delegation of services agreement with a physician. As of June 2013, there were about 9,000 active PA licenses in California. The recent reclassification of hydrocodone as a Schedule II drug has resulted in significant workload for physicians to review each prescription, and changing care delivery models have prompted a reconsideration of current supervision requirements.

3. Opposition. The Medical Board of California opposes the reduction in physician supervision of Schedule II drugs, which are prone to abuse.

Analysis Prepared by: Lisa Murawski / APPR. / (916) 319-2081

Date of Hearing: June 23, 2015

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Susan Bonilla, Chair

SBPCA Bill Id:SB 337

Author:(Pavley) – As Amended Ver:June 16, 2015

SENATE VOTE: 38-0

SUBJECT: Physician assistants.

SUMMARY: Authorizes a physician supervising a physician assistant (PA) to use two additional mechanisms for the general supervision of a PA, authorizes a physician to use one additional mechanism for the supervision of a PA that administers a Schedule II controlled substance, and requires a PA’s patient medical records to identify the PA’s supervising physician.

EXISTING LAW:

1. Establishes the Physician Assistant Board (PAB) within the jurisdiction of the Medical Board of California (MBC) to license and regulate PAs. (Business and Professions Code (BPC) § 3504)

2. Requires a PA and the supervising physician to establish written guidelines for the adequate supervision of the PA, and the requirement may be satisfied by the supervising physician adopting protocols for some or all of the tasks performed by the PA. (BPC § 3502 (c)(1))

3. Requires a supervising physician to be available in person or by electronic communication at all times when the PA is caring for patients. (Title 16, California Code of Regulations (CCR) § 1399.545 (a))

4. Requires a supervising physician to delegate to a PA only the tasks and procedures consistent with the supervising physician's specialty or usual and customary practice and with the patient's health and condition, and requires the supervising physician to observe or review evidence of the PA’s performance of all tasks and procedures to be delegated to the PA until the physician is assured of the PA’s competency. (16 CCR § 1399.545 (b)(c))

5. Requires a supervising physician to review, countersign, and date a sample consisting of, at a minimum, five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. Requires the supervising physician to select for review those cases that by diagnosis, problem, treatment, or procedure represent, in his or her judgement, the most significant risk to the patient. (BPC § 3502 (c)(2))

6. Authorizes the MBC or the PAB to establish other alternative mechanisms for the adequate supervision of the PA. (BPC § 3502 (c)(3))

7. Requires a supervising physician who delegates the authority to issue a drug order to a PA to first prepare and adopt a formulary and protocols that specify all criteria for the use of a particular drug or device, and any contraindications for the selection. Protocols for Schedule II controlled substances must address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued. (BPC § 3502.1(a)(2))

8. Requires a supervising physician to review and countersign within seven days the record of any patient cared for by a PA for whom the PA’s Schedule II drug order has been issued or carried out. (BPC § 3502.1 (e))

9. Allows a PA to administer Schedule II, III, IV and V drug orders without advance approval from a supervising physician if the PA has completed an education course that covers controlled substances and that meets standards, including pharmacological content, approved by the PAB. The education course must be provided either by an accredited continuing education provider or by an approved PA training program. For Schedule II controlled substances, the course must contain a minimum of three hours exclusively on Schedule II controlled substances. (BPC § 3502.1 (c)(2))

10. Requires PAs who are authorized by their supervising physician to issue drug orders for controlled substances to register with the United States Drug Enforcement Administration (DEA). (BPC § 3502.1 (f))

THIS BILL:

1. Revises the definition of “medical records review meeting” to mean a meeting between the supervising physician and the PA during which medical records are reviewed to ensure adequate supervision of the PA functioning under protocols.

2. Authorizes the supervising physician and PA to hold medical records review meetings in person or by electronic communication.

3. Requires the medical record, for each episode of care for a patient, to identify the physician who is responsible for the supervision of the PA.

4. Authorizes a physician to choose from two additional mechanisms to supervise a PA, making a total of three mechanisms:

   1. Conduct a medical records review meeting at least once a month during at least 10 months of the year—any month in which a medical records review meeting occurs, the supervising physician and PA must review an aggregate of at least 10 medical records of patients treated by the PA. Documentation of medical records reviewed during the month must be jointly signed and dated by the supervising physician and the PA.

   2. Develop review methods for the review of cases involving treatment by the PA. The review methods must be identified in the delegation of services agreement and include at least an aggregate of 10 cases per month for at least 10 months of the year. Documentation of the cases reviewed during the month must be jointly signed and dated by the physician and PA.

5. States that, in complying with the supervision requirements above (number 4), the physician must select for review those cases that by diagnosis, problem treatment, or procedure represent, in the physician’s judgment, the most significant risk to the patient.

6. States that compliance with BPC § 3502 (numbers 3-5 above) will be also considered compliance with § 1399.546 of Title 16 of the California Code of Regulations.

7. Authorizes a physician to use an additional mechanism for the supervision of a PA that prescribes a Schedule II controlled substance. The physician may review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients with the PA’s Schedule II prescriptions if:

   1. The PA has:

      1. Completed a controlled substances education course that meets the standards established in the PAB’s regulations and is provided either by an accredited continuing education provider or by an approved physician assistant training program; or,

      2. The PA has a certificate of completion of the course described BPC § 3502.1(c)(2); and,

   2. The supervision is verified and documented in the manner established by the PAB’s regulations.

8. Makes other minor technical and clarifying changes.

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, this bill will result in negligible state costs.

COMMENTS:

Purpose. This bill is sponsored by the California Academy of Physician Assistants. According to the author, “[This bill] increases options for the physician/PA team to document supervision. The options included in the bill will strengthen the team-based approach by encouraging more active discussion during the records review.

The Patient Protection and Affordable Care Act has resulted in millions of additional people seeking health care services in California. This increase has created an even greater need for high quality, efficient team-based care across all medical settings.

This is especially true for the practice of physician assistants, who are authorized to provide physician exams, diagnose and treat illness, and prescribe medication, under the supervision of a physician. [This bill] recognizes the growing changes in medical practice settings and the use of electronic medical records to update methods for documentation of the supervision of PAs and encourages more interactive review of patient cases.”

Background. According to the PAB, a PA is a licensed health care professional, trained to provide patient evaluation, education, and health care services. A PA works with a physician to provide medical care and guidance needed by a patient.

In order to become a PA, an applicant must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. Upon graduation from the program, an academic degree or certificate is awarded. Many PAs already have two or four year academic degrees before entering a PA training program. Most PA training programs require prior health care experience.

While a licensed PA is authorized to perform many of the same health care services as a physician, the services the PA may provide are limited to the services expressly authorized by the PA’s supervising physician. The physician’s written authorization is known as a delegation of services agreement. In the agreement, the physician is allowed to authorize only the services that the physician determines the PA competent to perform, consistent with the PA’s education, training, and experience.

As of June 2013, there were about 9,000 active PA licenses in California.

General Supervision Requirements. Existing law requires each PA to be supervised by at least one physician. The physician may supervise the PA either when both are at the same location or by telephone. Further, the physician must be physically or electronically available to the PA at the time of treatment.

The PA and the supervising physician must also establish written guidelines for the adequate supervision of the PA. The requirement may be satisfied by adopting protocols for some or all of the tasks performed by the PA.

In addition, the physician is responsible for following each patient’s progress and must review, countersign, and date a sample of at least five percent of a PA’s patient medical records within 30 days of treatment. The physician decides to review cases that represent the most significant risk to the patient.

According to the author, the current five percent requirement does not accommodate all care delivery models, which can lead to less access to care and supervision issues. This bill seeks to add two additional mechanisms to allow a supervising physician more options to adequately supervise a PA:

1. Allow the physician to conduct a medical records review meeting at least once a month during at least 10 months of the year. In the months in which a medical records review meeting occurs, the physician and PA must review at least 10 of the PA’s patient medical records. This option would allow a physician to spread the meetings out over the year rather than as the treatments occur.

2. Allow the physician to develop the method for reviewing cases. The review methods must be identified in the delegation of services agreement and include at least an aggregate of 10 cases per month for at least 10 months of the year. This option would allow the physician to combine several months of review, for instance if the physician wants to physically review the records but is only in the area six months out of the year.

Supervision of Controlled Substances. Under the United States Controlled Substances Act, the DEA classifies drugs into five categories (schedules), depending upon the drug’s acceptable medical use and the drug’s abuse or dependency potential. As the schedule number decreases, the higher the concern for potential abuse—Schedule V drugs present the least potential for abuse, while Schedule II drugs are considered to have a high potential. Schedule I drugs typically have no accepted medical purpose.

Existing law allows a supervising physician to authorize a PA to prescribe drugs classified as Schedule II, III, IV and V if:

1. The physician develops practice specific, written protocols and formularies. The protocols for Schedule II controlled substances must address diagnosis of illness, injury, or condition for which the drug is being prescribed;

2. The PA registers with the DEA; and,

3. The PA obtains advanced approval from the physician.

In addition, a PA may prescribe controlled substances without advanced approval by the supervising physician if the PA has completed a controlled substance education course that meets standards approved by the PAB. For Schedule II controlled substances, the course must spend at least three hours exclusively on Schedule II controlled substances.

There is also an additional supervision requirement for Schedule II controlled substances—the physician must reviews, countersign, and date the medical record of all the PA’s patients within seven days of prescribing the drug. Schedule III and IV drugs do not have a countersigning requirement, but the physician is still required to review the medical records of the PA’s patients overall. The PAB is also required to consult with the Medical Board of California and report during sunset review the impacts of the exemption. The PAB is up for sunset review in 2016.

According to the author, the 100% countersigning requirement is also prohibitive to many new care delivery models. Because existing law allows a physician to provide supervision electronically, PA-lead clinics may be unable to provide Schedule II drugs if the physician must be physically available to countersign the medical records within seven days for every prescription. Further, there are still the general supervision requirements, which may create a duplicative or overlapping signing requirement for Schedule II drugs.

The Reclassification of HCP to Schedule II. In August of 2014, the DEA published a final rule, effective October 6, 2014, following recommendations from the U.S. Food and Drug Administration (FDA) to reclassify hydrocodone combination products (HCP) from a Schedule III controlled substance to a Schedule II. HCP products, such as Vicodin, are popular alternatives to Oxycodone for pain management (due to risk of addiction and side effects). According to the author, “the new ruling restricts the ability of a practice to fully utilize the PAs they employee as there is no other profession with prescribing privileges that has that level of mandate for documentation.”

Other States. The Schedule II countersigning requirements vary from state-to-state. Some states have no countersigning requirement and others do not permit PAs to administer Schedule II drugs at all.

Prior Related Legislation. SB 1069 (Pavley), Chapter 512, Statutes of 2010, authorized a PA, pursuant to a delegation of services agreement, to order durable medical equipment, certify unemployment insurance disability, and for individuals receiving home health services or personal care services, after consultation with the supervising physician, approve, sign, modify, or add to a plan of treatment or plan of care. The bill also authorized PAs to conduct specified medical examinations and sign corresponding medical certificates for various individuals.

AB 3 (Bass), Chapter 376, Statutes of 2007, created the “California Team Practice Improvement Act” which deleted the prohibition on the authority of a PA to issue a drug order for specified classes of controlled substances if the PA has completed a specified education course, required a PA and his or her supervising physician to establish written supervisory guidelines and protocols, increased to four the number of PAs a physician may supervise, and specified that services provided by a PA are included as covered benefits under the Medi-Cal program.

AB 2626 (Plescia) Chapter 452, Statutes of 2004, removed the requirement for the supervising physician to review, co-sign and date each prescription written by a PA and limited the co-signature requirement to each Schedule II drug order written by a PA.

ARGUMENTS IN SUPPORT:

The California Academy of Physician Assistants (sponsor) writes in support, “Established over 30 years ago, existing law stipulates supervision criteria between a supervising physician and surgeon and the [PA]. It narrowly defines documentation of this required supervision in the form of the supervising physician co-signature on the medical record and prescriptions. [This bill] increases the options for documenting supervision between a supervising physician and PA would allow for flexibility at the practice level to reflect current models of team-based care. This bill will allow physicians and PA’s to spend more time with patients.”

ARGUMENTS IN OPPOSITION:

The Medical Board of California writes in opposition, “[the MBC] recognizes that the intent of this bill is to provide flexibility and allow for a more team-based approach in PA supervision, which the [MBC] believes is a laudable goal. The recent amendments addressed concerns raised by the [MBC]…. However, the [MBC] still has concerns related to the reduced physician review of Schedule II drug orders from 100 percent to 20 percent, as this is a significant reduction of supervising physician review for types of opioid medications that are prevalent for abuse.”

REGISTERED SUPPORT:

California Academy of Physician Assistance (sponsor)

CAPG, the Voice of Accountable Physician Groups

Pacific Pain Medicine Consultants

Planned Parenthood

253 PAs

56 M.D.s and D.O.s

REGISTERED OPPOSITION:

Medical Board of California

California Pharmacists Association

Analysis Prepared by: Vincent Chee / B. & P. / (916) 319-3301

 THIRD READING 

Bill No: SB 337

Author: Pavley (D)

Amended: 4/13/15

Vote: 21

SENATE BUS, PROF. & ECON. DEV. COMMITTEE: 9-0, 4/20/15

AYES: Hill, Bates, Berryhill, Block, Galgiani, Hernandez, Jackson, Mendoza, Wieckowski

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

SUBJECT: Physician assistants

SOURCE: California Academy of Physician Assistants

DIGEST: This bill establishes alternative means for a supervising physician to ensure adequate supervision of a physician assistant for routine care and the administration, provision, or issuance of a Schedule II drug.

ANALYSIS:

Existing law:

1. Declares that the Physician Assistant Practice Act (Act) is established to encourage the utilization of physician assistants (PAs) by physicians, and by physicians and podiatrists practicing in the same medical group, and to provide that existing legal constraints should not be an unnecessary hindrance to the more effective provision of health care services. It is also the purpose of the Act to allow for innovative development of programs for the education, training, and utilization of PAs. (Business and Professions Code (BPC) § 3500)

2. Establishes the Physician Assistant Board (Board) within the jurisdiction of the Medical Board of California (MBC) to administer and enforce the Act.
   (BPC § 3504)

3. Requires a supervising physician to be available in person or by electronic communication at all times when the PA is caring for patients.
   (Title 16, California Code of Regulations (CCR) § 1399.545 (a))

4. Requires a supervising physician to delegate to a PA only those tasks and procedures consistent with the supervising physician's specialty or usual and customary practice and with the patient's health and condition, and requires the supervising physician to observe or review evidence of the PA’s performance of all tasks and procedures to be delegated to the PA until assured of competency. (16 CCR § 1399.545 (b)(c))

5. Requires the PA and supervising physician to establish in writing transport and back-up procedures for the immediate care of patients who are in need of emergency care beyond the PA’s scope of practice for such times when a supervising physician is not on the premises. (16 CCR § 1399.545 (d))

6. Requires a supervising physician to review, countersign, and date a sample consisting of, at a minimum, five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. Requires the supervising physician to select for review those cases that by diagnosis, problem, treatment, or procedure represent the most significant risk to the patient. (BPC § 3502 (c)(2))

7. Authorizes the MBC or the Board to establish other alternative mechanisms for the adequate supervision of the PA. (BPC § 3502 (c)(3))

8. Requires a supervising physician who delegates the authority to issue a drug order to a PA to prepare and adopt a formulary and protocols that specify all criteria for the use of a particular drug of device, and any contraindications for the selection. Protocols for Schedule II controlled substances shall address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued. (BPC § 3502.1(a)(2))

9. Requires a supervising physician to review and countersign within seven days the record of any patient cared for by a PA for whom the PA’s Schedule II drug order has been issued or carried out. (BPC § 3502.1 (e))

10. Allows a PA to administer Schedule II – Schedule V drug orders without advance approval from a supervising physician if the PA has completed an education course that covers controlled substances and that meets standards, including pharmacological content, approved by the Board. The education course shall be provided either by an accredited continuing education provider or by an approved PA training program. If the PA will administer, provide, or issue a drug order for Schedule II controlled substances, the course shall contain a minimum of three hours exclusively on Schedule II controlled substances. (BPC § 3502.1 (c)(2))

11. Requires PAs who are authorized by their supervising physician to issue drug orders for controlled substances to register with the United States Drug Enforcement Administration (DEA). (BPC § 3502.1 (f))

This bill:

1. Defines “medical records review meeting” as a meeting between the supervising physician and the PA during which a sample of medical records is reviewed to ensure adequate supervision of the PA functioning under protocols. The number of medical records and the specific issues to be reviewed shall be established in the delegation of services agreement.

2. Requires the medical record to identify the physician who is responsible for the supervision of the PA for each episode of care for a patient. When a PA transmits an oral order, he or she shall also identify the name of the supervising physician responsible for the patient. 

3. Provides two additional mechanisms for the supervising physician to choose from to ensure adequate PA supervision:

1. The supervising physician and PA shall conduct and document a medical records review meeting at least 10 times annually which may occur in person or by electronic communication.

2. The supervising physician shall supervise the care provided by the PA through a review of those cases or patients deemed appropriate by the supervising physician. The review methods used shall be identified in the delegation of services agreement, and may occur in person or by electronic communication.

4. Deems that compliance by a PA and supervising physician with this bill shall also deem compliance with specified regulations.

5. Creates the following additional mechanism for a supervising physician to ensure adequate supervision of the administration, provision, or issuance by a PA of a Schedule II drug order. If the PA has documentation evidencing the successful completion of an education course that meets specified standards, the supervising physician shall review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the PA for whom the PA’s Schedule II drug order has been issued or carried out.

Background

According to the author, “This bill is … needed to address an issue related to co-signatures on Schedule II medications. In August of 2014, the DEA published a final rule, effective October 6, 2014, following recommendations from the U.S. Food and Drug Administration to up-schedule or reclassify hydrocodone combination products (HCP) from a Schedule III controlled substance to a Schedule II. The rescheduling of HCPs has had a significant impact, and unintended consequence, on some practices throughout California as existing law requires a 100% physician co-signature requirement on these medications within
7 days. This can be particularly challenging for practices that employ PAs to practice medicine in areas such as pain management, orthopedics, general surgery and several other practice types. The new ruling restricts the ability of a practice to fully utilize the PAs they employ as there is no other profession with prescribing privileges that has that level of mandate for documentation. Further, a co-signature mandate of 100% is overly burdensome for physicians in various practice types.”

A PA performs many of the same diagnostic, preventative and health maintenance services as a physician, but PAs are limited in practice to those duties delegated by a supervising physician.

A PA must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. An academic degree and/or certificate is awarded upon graduation. Many PAs already have two- or four-year academic degrees before entering a PA training program, and most PA training programs require prior health care experience. As of June 2013, there were 9,101 active California PA licensees.

Existing law requires a supervising physician to authorize specific practice authority to a PA through a delegation of service agreement and protocols, and current law mandates that the supervising physician be physically or electronically available to his or her PA at the time of treatment. In addition, a supervising physician must review, countersign, and date a sample of at least five percent of a PA’s cases within 30 days of treatment.

The author argues that the five percent review requirement is outdated and unnecessary, given the close working relationship between PAs and physicians and their detailed practice agreements. This bill provides two additional mechanisms for the supervising physician to choose from to ensure adequate PA supervision:

1. The supervising physician and PA shall conduct and document a medical records review meeting at least 10 times annually, which may occur in person or by electronic communication; or,

2. The supervising physician shall supervise the care provided by the PA through a review of those cases or patients deemed appropriate by the supervising physician. The review methods used shall be identified in the delegation of services agreement, and may occur in person or by electronic communication.

This bill also establishes an additional method to supervise a PA’s furnishing of Schedule II drugs. Current law requires a supervising physician to review and countersign a medical record within seven days of each PA’s issuance of a Schedule II drug order. According to the author, this practice is also unduly burdensome and proposes that, if a PA has documentation evidencing the successful completion of an education course that meets specified Board standards, the supervising physician may instead review, countersign, and date, within seven days, a sample of at least 20 percent of the medical records for patients cared for by the PA for whom the PA’s Schedule II drug order has been issued.

FISCAL EFFECT: Appropriation: No Fiscal Com.: Yes Local: Yes

SUPPORT: (Verified 5/13/15)

California Academy of Physician Assistants (source)

CAPG

Planned Parenthood Affiliates of California

Numerous individuals

OPPOSITION: (Verified 5/13/15)

California Pharmacists Association

ARGUMENTS IN SUPPORT: The source of this bill, the California Academy of Physician Assistants, write, “With the implementation of the Patient Protection and Affordable Care Act, Covered California reported enrolling 3.4 million (1.4 through Covered CA plans and 1.9 in Medi-Cal) previously uninsured people in the first open enrollment year (2014). This bill recognizes the need to increase access to high quality, cost-effective and efficient team-based practice across all medical settings in order to meet the rising demand for health care services throughout the state.

“The physician/PA team is unique as PAs are licensed health professionals who practice medicine as members of a physician-led team, delivering a broad range of medical and surgical services at the direction of and under the supervision of his or her supervising physician. The supervising physician delegates to a PA specified medical tasks and procedures, consistent with his or her scope of practice, based on education, training and experience.

“Established over 30 years ago, existing law stipulates supervision criteria between a supervising physician and surgeon and the Physician Assistant (PA). It narrowly defines documentation of this required supervision in the form of the supervising physician co-signature on the medical record. SB 337 increases the options for documenting supervision between a supervising physician and PA would allow for flexibility at the practice level to reflect current models of team-based care.”

ARGUMENTS IN OPPOSITION: The California Pharmacists Association writes, “It has been stated that a major driver for the changes proposed by this bill is the DEA’s reclassification of hydrocodone combination products (HCPs) from Schedule III of the federal Controlled Substances Act to Schedule II. We acknowledge that this action by the DEA has increased workload for physicians who supervise PAs. Indeed, the reclassification has significantly increased workload for pharmacists as well…. However, heightened scrutiny of the prescribing and dispensing of HCPs was the exact intent of the DEA when it reclassified them…. The DEA is attempting to curb overprescribing of HCPs to reduce abuse and ensure more judicious use of these drugs. This bill would counter the efforts of the DEA by reducing supervision of PAs relative to their prescribing of HCPs and all other Schedule II drugs.”

Prepared by: Sarah Huchel / B., P. & E.D. / (916) 651-4104

5/22/15 13:54:33

**** END ****

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Jerry Hill, Chair

2015 - 2016 Regular

Bill No: SB 337 Hearing Date: April 20, 2015

Subject: Physician assistants.

SUMMARY:

Establishes alternative means for a supervising physician to ensure adequate supervision of a physician assistant for routine care and the administration, provision, or issuance of a Schedule II drug.

Existing law:

1. Declares that the Physician Assistant Practice Act (Act) is established to encourage the utilization of physician assistants (PAs) by physicians, and by physicians and podiatrists practicing in the same medical group, and to provide that existing legal constraints should not be an unnecessary hindrance to the more effective provision of health care services. It is also the purpose of the Act to allow for innovative development of programs for the education, training, and utilization of PAs. (Business and Professions Code (BPC) Section 3500)

2. Establishes the Physician Assistant Board (Board) within the jurisdiction of the Medical Board of California (MBC) to administer and enforce the Act. (BPC § 3504)

3. Requires a PA and his or her supervising physician to establish written guidelines for the adequate supervision of the PA, and the requirement may be satisfied by the supervising physician adopting protocols for some or all of the tasks performed by the PA. (BPC § 3502 (c)(1))

4. Requires a supervising physician to be available in person or by electronic communication at all times when the PA is caring for patients. (Title 16, California Code of Regulations (CCR) Section 1399.545 (a))

5. Requires a supervising physician to delegate to a PA only those tasks and procedures consistent with the supervising physician's specialty or usual and customary practice and with the patient's health and condition, and requires the supervising physician to observe or review evidence of the PA’s performance of all tasks and procedures to be delegated to the PA until assured of competency.
   (16 CCR § 1399.545 (b)(c))

6. Requires the PA and supervising physician to establish in writing transport and back-up procedures for the immediate care of patients who are in need of emergency care beyond the PA’s scope of practice for such times when a supervising physician is not on the premises. (16 CCR § 1399.545 (d))

7. Requires a supervising physician to review, countersign, and date a sample consisting of, at a minimum, five percent of the medical records of patients treated by the PA within 30 days of the date of treatment. Requires the supervising physician to select for review those cases that by diagnosis, problem, treatment, or procedure represent the most significant risk to the patient. (BPC § 3502 (c)(2))

8. Authorizes the MBC or the Board to establish other alternative mechanisms for the adequate supervision of the PA. (BPC § 3502 (c)(3))

9. Requires a supervising physician who delegates the authority to issue a drug order to a PA to prepare and adopt a formulary and protocols that specify all criteria for the use of a particular drug of device, and any contraindications for the selection. Protocols for Schedule II controlled substances shall address the diagnosis of illness, injury, or condition for which the Schedule II controlled substance is being administered, provided, or issued. (BPC § 3502.1(a)(2))

10. Requires a supervising physician to review and countersign within seven days the record of any patient cared for by a PA for whom the PA’s Schedule II drug order has been issued or carried out. (BPC § 3502.1 (e))

11. Allows a PA to administer Schedule II – Schedule V drug orders without advance approval from a supervising physician if the PA has completed an education course that covers controlled substances and that meets standards, including pharmacological content, approved by the Board. The education course shall be provided either by an accredited continuing education provider or by an approved PA training program. If the PA will administer, provide, or issue a drug order for Schedule II controlled substances, the course shall contain a minimum of three hours exclusively on Schedule II controlled substances. (BPC § 3502.1 (c)(2))

12. Requires PAs who are authorized by their supervising physician to issue drug orders for controlled substances to register with the United States Drug Enforcement Administration. (BPC § 3502.1 (f))

This bill:

1. Defines “medical records review meeting” as a meeting between the supervising physician and the PA during which a sample of medical records is reviewed to ensure adequate supervision of the PA functioning under protocols. The number of medical records and the specific issues to be reviewed shall be established in the delegation of services agreement.

2. Requires the medical record to identify the physician who is responsible for the supervision of the PA for each episode of care for a patient. When a PA transmits an oral order, he or she shall also identify the name of the supervising physician responsible for the patient. 

3. Provides two additional mechanisms for the supervising physician to choose from to ensure adequate PA supervision:

1. The supervising physician and PA shall conduct and document a medical records review meeting at least 10 times annually which may occur in person or by electronic communication.

2. The supervising physician shall supervise the care provided by the PA through a review of those cases or patients deemed appropriate by the supervising physician. The review methods used shall be identified in the delegation of services agreement, and may occur in person or by electronic communication.

4. Deems that compliance by a PA and supervising physician with this bill shall also deem compliance with specified regulations.

5. Creates the following additional mechanism for a supervising physician to ensure adequate supervision of the administration, provision, or issuance by a PA of a Schedule II drug order. If the PA has documentation evidencing the successful completion of an education course that meets specified standards, the supervising physician shall review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the PA for whom the PA’s Schedule II drug order has been issued or carried out.

FISCAL EFFECT:

Unknown. This bill has been keyed “fiscal” by Legislative Counsel.

COMMENTS:

1. Purpose. This bill is sponsored by the California Academy of Physician Assistants. According to the Author, “Existing law, promulgated over 30 years ago, narrowly defines documentation of required supervision in the form of medical record
   co-signature, established for use with paper medical charts, by the supervising physician for adequate supervision of the PA to be recorded. Existing law also authorizes either in-person or electronic supervision of a PA. Given this authorization, PAs are well suited to expand the access of care for the care team and may serve as the lead clinician on-site for the delivery of care. While established criteria for documenting supervision works well is some settings, it does not reflect or allow for documentation of supervision in many current models of team-based care.

“This bill is also needed to address an issue related to co-signatures on Schedule II medications. In August of 2014 the DEA published a final rule, effective October 6, 2014, following recommendations from the U.S. Food and Drug Administration (FDA) to up-schedule or reclassify hydrocodone combination products (HCP) from a Schedule III controlled substance to a Schedule II. The rescheduling of HCPs has had a significant impact, and unintended consequence, on some practices throughout California as existing law requires a 100% physician co-signature requirement on these medications within 7 days. This can be particularly challenging for practices that employ PAs to practice medicine in areas such as pain management, orthopedics, general surgery and several other practice types. The new ruling restricts the ability of a practice to fully utilize the PAs they employ as there is no other profession with prescribing privileges that has that level of mandate for documentation. Further, a co-signature mandate of 100% is overly burdensome for physicians in various practice types.

“Existing law requires a supervising physician to be available in-person or through electronic communication at all times when a PA is providing care for a patient. Given the many models of team-based care supervising physicians and PA often practice at different locations and lead PA run clinics as well as assume significant administrative responsibilities. In this context, a 100% mandate on co-signatures creates a barrier to efficient team-based care and stands to jeopardize access to appropriate treatment of pain for those patients with legitimate need.”

2. Background. A PA performs many of the same diagnostic, preventative and health maintenance services as a physician, but PAs are limited in practice to those duties delegated by a supervising physician. These services may include, but are not limited to, the following:

• Taking health histories.

• Performing physical examinations.

• Ordering X-rays and laboratory tests.

• Ordering respiratory, occupational, or physical therapy treatments.

• Performing routine diagnostic tests.

• Establishing diagnoses.

• Treating and managing patient health problems.

• Administering immunizations and injections.

• Instructing and counseling patients.

• Providing continuing care to patients in the home, hospital, or extended care facility.

• Providing referrals within the health care system.

• Performing minor surgery.

• Providing preventative health care services.

• Acting as first or second assistants during surgery.

• Responding to life-threatening emergencies.

A PA must attend a specialized medical training program associated with a medical school that includes classroom studies and clinical experience. An academic degree and/or certificate is awarded upon graduation. Many PAs already have two- or four-year academic degrees before entering a PA training program. Most PA training programs require prior health care experience.

As of June 2013, there were 9,101 active California PA licensees.

3. Supervision. Existing law has very specific requirements for a supervising physician to delegate practice authority to a PA, and the supervising physician must be physically or electronically available to his or her PA at the time of treatment. In addition to this, a supervising physician must review, countersign, and date a sample of at least five percent of a PA’s cases within 30 days of treatment.

The Author argues that the five percent review requirement is outdated and unnecessary, given the close working relationship between PAs and physicians and existing delegation of service agreements and protocols. This bill provides two additional mechanisms for the supervising physician to choose from to ensure adequate PA supervision:

1. The supervising physician and PA shall conduct and document a medical records review meeting at least 10 times annually, which may occur in person or by electronic communication; or,

2. The supervising physician shall supervise the care provided by the PA through a review of those cases or patients deemed appropriate by the supervising physician. The review methods used shall be identified in the delegation of services agreement, and may occur in person or by electronic communication.

This bill also establishes an additional method to supervise a PA’s furnishing of Schedule II drugs. Current law requires a supervising physician to review and countersign a medical record within seven days of each PA’s issuance of a Schedule II drug order. According to the Author, this practice is also unduly burdensome and proposes that, if a PA has documentation evidencing the successful completion of an education course that meets specified Board standards, the supervising physician may instead review, countersign, and date, within seven days, a sample of at least 20 percent of the medical records for patients cared for by the PA for whom the PA’s Schedule II drug order has been issued.

4. Arguments in Support. The Sponsor of this bill, the California Academy of Physician Assistants, write, “With the implementation of the Patient Protection and Affordable Care Act, Covered California reported enrolling 3.4 million (1.4 through Covered CA plans and 1.9 in Medi-Cal) previously uninsured people in the first open enrollment year (2014). This bill recognizes the need to increase access to high quality, cost-effective and efficient team-based practice across all medical settings in order to meet the rising demand for health care services throughout the state.

“The physician/PA team is unique as PAs are licensed health professionals who practice medicine as members of a physician-led team, delivering a broad range of medical and surgical services at the direction of and under the supervision of his or her supervising physician. The supervising physician delegates to a PA specified medical tasks and procedures, consistent with his or her scope of practice, based on education, training and experience.

“Established over 30 years ago, existing law stipulates supervision criteria between a supervising physician and surgeon and the Physician Assistant (PA). It narrowly defines documentation of this required supervision in the form of the supervising physician co-signature on the medical record. SB 377 increases the options for documenting supervision between a supervising physician and PA would allow for flexibility at the practice level to reflect current models of team-based care.”

5. Prior Related Legislation. SB 1069 (Pavley, Chapter 512, Statutes of 2010) authorized a PA, pursuant to a delegation of services agreement, to order durable medical equipment, certify unemployment insurance disability, and for individuals receiving home health services or personal care services, after consultation with the supervising physician, approve, sign, modify, or add to a plan of treatment or plan of care. This bill also authorized PAs to conduct specified medical examinations and sign corresponding medical certificates for various individuals.

AB 3 (Bass, Chapter 376, Statutes of 2007) created the “California Team Practice Improvement Act” which deleted the prohibition on the authority of a PA to issue a drug order for specified classes of controlled substances if the PA has completed a specified education course, required a PA and his or her supervising physician to establish written supervisory guidelines and protocols, increased to four the number of PAs a physician may supervise, and specified that services provided by a PA are included as covered benefits under the Medi-Cal program.

AB 2626 (Plescia, Chapter 452, Statutes of 2004) removed the requirement for the supervising physician to review, co-sign and date each prescription written by a PA and limited the co-signature requirement to each Schedule II drug order written by a PA.

SUPPORT AND OPPOSITION:

Support:

California Academy of Physician Assistants (Sponsor)

Numerous individuals

Opposition:

None on file as of April 14, 2015.

-- END --