Existing law, the Physician Assistant Practice Act, establishes the Physician Assistant Board within the jurisdiction of the Medical Board of California for the licensure and regulation of physician assistants. The act authorizes physician assistants to perform medical services as set forth by regulations and the act when those services are rendered pursuant to a practice agreement and under the supervision of a licensed physician and surgeon. Existing law prohibits a physician and surgeon from supervising more than 4 physician assistants at any one time.

This bill would also authorize a physician and surgeon to supervise up to 8 physician assistants at one time if all of the physician assistants are focused solely on performing in-home health evaluations to gather patient information and perform annual wellness visits or health evaluations that do not involve direct patient treatment or prescribing medication.

Existing law, the Physician Assistant Practice Act, establishes the Physician Assistant Board within the jurisdiction of the Medical Board of California for the licensure and regulation of physician assistants. The act authorizes physician assistants to perform medical services as set forth by regulations and the act when those services are rendered pursuant to a practice agreement and under the supervision of a licensed physician and surgeon. Existing law prohibits a physician and surgeon from supervising more than 4 physician assistants at any one time.

This bill would also authorize a physician and surgeon to supervise up to 8 physician assistants at one time if all of the physician assistants are focused solely on performing in-home health evaluations to gather patient information and perform annual wellness visits or health evaluations that do not involve direct patient treatment or prescribing medication.

Existing law, the Physician Assistant Practice Act, establishes the Physician Assistant Board within the jurisdiction of the Medical Board of California for the licensure and regulation of physician assistants. The act authorizes physician assistants to perform medical services as set forth by regulations and the act when those services are rendered pursuant to a practice agreement and under the supervision of a licensed physician and surgeon. Existing law prohibits a physician and surgeon from supervising more than 4 physician assistants at any one time.

This bill would except from that prohibition the supervision of physician assistants performing home health evaluations to gather patient information and perform annual wellness visits, advanced assessments, or health evaluations, as specified. also authorize a physician and surgeon to supervise up to 8 physician assistants at one time if all of the physician assistants are focused solely on performing in home health evaluations to gather patient information and perform annual wellness visits or health evaluations that do not involve direct patient treatment or prescribing medication.

Existing law, the Physician Assistant Practice Act, establishes the Physician Assistant Board within the jurisdiction of the Medical Board of California for the licensure and regulation of physician assistants. The act authorizes physician assistants to perform medical services as set forth by regulations and the act when those services are rendered pursuant to a practice agreement and under the supervision of a licensed physician and surgeon. Existing law authorizes a physician assistant to perform medical services without the supervision of the physician assistants approved supervising physician and surgeon under certain emergency conditions if a licensed physician and surgeon is available to provide supervision. prohibits a physician and surgeon from supervising more than 4 physician assistants at any one time.

This bill would authorize except from that prohibition the supervision of physician assistants performing home health evaluations to gather patient information and perform health evaluations, as specified, without physician and surgeon supervision. annual wellness visits, advanced assessments, or health evaluations, as specified.

Under existing law, the Department of Consumer Affairs is comprised of various boards, bureaus, commissions, committees, and similarly constituted agencies that license and regulate the practice of various professions and vocations. Existing law requires the Director of the Department of Consumer Affairs to administer and enforce those provisions. Existing law requires the director to notify the appropriate policy committees of the Legislature within 60 days after the position of chief or executive officer of any board, as defined, within the department becomes vacant, as specified.

This bill would make a nonsubstantive change to the vacancy notification requirement provision.

CONCURRENCE IN SENATE AMENDMENTS

CSA2 Bill Id:AB 1070

Author:(Low)

As Amended Ver:June 28, 2023

Majority vote

SUMMARY

Original Committee of Reference: Business and Professions

Authorizes a physician and surgeon to supervise more than four physician assistants (PAs) if the PAs are only performing home health evaluations.

Senate Amendments

Current Committee Recommendation: Concur

1. Establish a separate supervision category for the home health PAs.
2. Limit the number of home health PAs that can be supervised to eight.
3. Require all of the home health PAs to be solely focused on home health evaluations.
4. Clarify that the supervision of home health PAs is the same as the supervision of PAs generally.
5. Clarify that the home health PAs must provide the home health evaluation information to the supervising physician.
6. Delete the reference to "advance assessment."
7. Define "in home health evaluation" to mean a comprehensive physical exam, assessment of current and prior health conditions, a complete medication review, screening tests, health education, and assessment of social determination of health needs to be used for diagnosing individual medical conditions.
8. Define "annual wellness visit" to mean a preventive visit with correlating current procedural terminology codes performed annually to a patient, to be used for the purposes of diagnosing patient conditions during the annual wellness visit, which may include a nonphysical examination for patients covered by Medicare Part B for more than 12 months.

COMMENTS

Background. PAs are healthcare providers that can provide a wide range of medical services under the supervision of a physician, including prescribing, when authorized by a supervising physician under a document known as a practice agreement. The practice agreement outlines what a PA may or may not do based on the PA's competence and the level of physician supervision required. A physician may also supervise more than one PA, but no more than four at a time.

Due to the high level of medical care that PAs are capable of providing, the supervision ratio limit was put in place to prevent physicians from becoming overextended. This bill would lift the supervision requirement, and therefore the ratio, for evaluation and triage services that do not involve direct patient treatment or prescribing medication.

Precedent for Lifting Ratios. On March 4, 2020, the governor proclaimed a state of emergency as a result of the impacts of COVID-19 to help the state prepare to respond to medical care and hospitalization needs. During the emergency, the governor issued Executive Order N-39-20, authorizing the California Department of Consumer Affairs (DCA) to waive professional licensing or scope of practice requirements for licensed healthcare professionals, including PAs.

On April 14, 2020, the DCA issued a waiver titled DCA-20-04 Physician Assistant Supervision Requirements that waived the four PA to one physician ratio requirement and lifted the supervision requirement in practice sites or organized health care systems when a supervising physician was not available. The waiver was extended until March 31, 2022.

According to the Author

"In-home health evaluations are an incredibly valuable service provided by clinicians throughout the state. The in-home evaluation allows physician assistants an unparalleled line of sign into the member's clinical, social, functional, behavioral and environmental condition. The COVID-19 pandemic not only exposed the lack of access to health care for many Californians, it had a profound impact on workforce availability that remains a challenge today. Many patients have not seen a physician in over a year. Highly trained and credentialed PA's are well qualified to perform in-home assessments and provide the limited scope of services rendered without supervision. By eliminating the need for physician involvement when licensed PA's are merely gathering patient information and performing a health evaluation that does not involve treating or prescribing, the system is made more efficient for both the physician and the PA by reducing unnecessary paperwork and by removing any potential obstacles for PA's to perform these limited in scope evaluations."

Arguments in Support

Signify Health writes that this bill is "the right approach and ensures that nothing shall prohibit a physician assistant from gathering patient information and/or performing a health evaluation including diagnostic screenings that does not involve rendering treatment or prescribing medications…. Our Physician Assistants are required to be certified by a national accreditation body to be considered for hire. They are trained and coached to ensure the highest standards of clinical accuracy and patient/member satisfaction throughout their tenures."

The California Academy of Physician Assistants writes that this bill is "a common sense measure aimed at bringing the most basic kind of health care to hard-to-reach populations.”

Arguments in Opposition

The Medical Board of California writes in opposition, "The Board appreciates the recent amendments and the desire to expand services to meet the needs of patients. In the Board's view, however, the bill still does not sufficiently clarify what may happen during these home health evaluations or how these visits will be documented and managed by the supervising physician. Further, without a limit on the number of patients that a physician assistant may see each day under this new authority, the supervising physician may not be able to adequately oversee their work. Finally, the Board was not assured that patients who may be fragile, homebound, and receiving care under the provisions of [this bill] will have their multiple needs met adequately."

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, no significant state costs anticipated.

VOTES

ASM BUSINESS AND PROFESSIONS: 18-0-0

YES: Berman, Flora, Alanis, Alvarez, Bonta, Chen, Dixon, Gipson, Grayson, Irwin, Jackson, Lee, Lowenthal, McCarty, McKinnor, Stephanie Nguyen, Joe Patterson, Ting

ASM APPROPRIATIONS: 16-0-0

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Robert Rivas, Sanchez, Weber, Wilson

ASSEMBLY FLOOR: 75-0-5

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Ward, Weber, Wilson, Wood, Zbur, Rendon

ABS, ABST OR NV: Flora, McKinnor, Muratsuchi, Wallis, Wicks

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

ASM BUSINESS AND PROFESSIONS: 19-0-0

YES: Berman, Flora, Alanis, Alvarez, Bains, Bonta, Chen, Dixon, Gipson, Grayson, Irwin, Jackson, Lee, Lowenthal, McCarty, McKinnor, Stephanie Nguyen, Joe Patterson, Ting

UPDATED

VERSION: June 28, 2023

CONSULTANT: Vincent Chee / B. & P. / (916) 319-3301 FN: 0001833

Date of Hearing: September 13, 2023

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Marc Berman, Chair

ABPCA Bill Id:AB 1070

Author:(Low) – As Amended Ver:June 28, 2023

NOTE: This bill is being heard pursuant to Assembly Rule 77.2 for concurrence in Senate amendments only.

SUBJECT: Physician assistants: physician supervision: exceptions.

SUMMARY: Authorizes a physician and surgeon to supervise up to eight physician assistants (PAs) if the PAs are only performing home health evaluations.

EXISTING LAW:

1. Regulates and licenses PAs under the Physician Assistant Practice Act and establishes the Physician Assistant Board (PAB) to administer and enforce the act. (Business and Professions Code (BPC) §§ 3500-3545)
2. Defines “supervising physician” or “supervising physician and surgeon” as a physician and surgeon who supervises one or more physician assistants and who is not currently on disciplinary probation prohibiting the employment or supervision of a physician assistant. (BPC § 3501(e))
3. “Supervision” means that a physician and surgeon oversees the activities of, and accepts responsibility for, the medical services rendered by a PA. (BPC § 3501(f)(1))
4. Specifies that supervision does not require the physical presence of the physician and surgeon, but does require the following:
   1. Adherence to adequate supervision as agreed to in the practice agreement. (BPC § 3501(f)(1)(A))
   2. The physician and surgeon is available by telephone or other electronic communication methods at the time the PA examines the patient. (BPC § 3501(f)(1)(B))
5. Specifies that the PAB may require the physical presence of a physician and surgeon as a term or condition of a PA’s reinstatement, probation, or imposing discipline. (BPC § 3501(f)(2))
6. Defines “practice agreement” as the writing, developed through collaboration among one or more physicians and surgeons and one or more PAs, that defines the medical services the PA is authorized to perform and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more PAs in the organized health care system. (BPC § 3501(k))
7. Authorizes a PA to perform medical services if the following requirements are met:
   1. The PA renders the services under the supervision of a physician and surgeon who is not subject to a disciplinary condition prohibiting that supervision or prohibiting the employment of a PA. (BPC § 3502(a)(1))
   2. The PA renders the services under a practice agreement. (BPC § 3502(a)(2))
   3. The PA is competent to perform the services. (BPC § 3502(a)(3))
   4. The PA’s education, training, and experience have prepared the PA to render the services. (BPC § 3502(a)(4))
8. Requires a practice agreement to include provisions that address the following:
   1. The types of medical services a PA is authorized to perform. (BPC § 3502.3(a)(1)(A))
   2. Policies and procedures to ensure adequate supervision of the PA, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the PA in the provision of medical services. (BPC § 3502.3(a)(1)(B))
   3. The methods for the continuing evaluation of the competency and qualifications of the PA. (BPC § 3502.3(a)(1)(C))
   4. The furnishing or ordering of drugs or devices by a PA. (BPC § 3502.3(a)(1)(D))
   5. Any additional provisions agreed to by the PA and physician and surgeon. (BPC § 3502.3(a)(1)(E))
9. Prohibits a physician and surgeon from supervising more than four PAs at any one time except in declared emergencies. (BPC §§ 3516(b), 3502.5)

THIS BILL:

1. Defines “in home health evaluation” as a comprehensive physical exam, assessment of current and prior health conditions, a complete medication review, screening tests, health education, and assessment of social determination of health needs to be used for diagnosing individual medical conditions.
2. Defines “annual wellness visit” as a preventive visit with correlating current procedural terminology codes performed annually to a patient, to be used for the purposes of diagnosing patient conditions during the annual wellness visit, which may include a nonphysical examination for patients covered by Medicare Part B for more than 12 months.
3. Authorizes a physician and surgeon to supervise up to eight PAs at one time if the following conditions are satisfied by all supervised PAs:
   1. The PAs are focused solely on performing in home health evaluations.
   2. The PAs are performing in home health evaluations solely for the following purposes:
      1. Gathering patient information.
      2. Performing an annual wellness visit or health evaluation, if it does not involve direct patient treatment or prescribing medication.
      3. A physician assistant who performs an in home health evaluation for the purposes specified in subparagraph (B) of paragraph (2) remains subject to all supervisory and scope requirements pursuant to this chapter and shall provide the supervising physician and surgeon with all information related to their evaluation under subparagraphs (A) and (B) of paragraph (2).

FISCAL EFFECT: According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, no significant state costs anticipated.

COMMENTS:

Purpose. This bill is sponsored by the author. According to the author, “In-home health evaluations are an incredibly valuable service provided by clinicians throughout the state. The in-home evaluation allows physician assistants an unparalleled line of sign into the member’s clinical, social, functional, behavioral and environmental condition. The COVID-19 pandemic not only exposed the lack of access to health care for many Californians, it had a profound impact on workforce availability that remains a challenge today. Many patients have not seen a physician in over a year. Highly trained and credentialed PA’s are well qualified to perform in-home assessments and provide the limited scope of services rendered without supervision. By eliminating the need for physician involvement when licensed PA’s are merely gathering patient information and performing a health evaluation that does not involve treating or prescribing, the system is made more efficient for both the physician and the PA by reducing unnecessary paperwork and by removing any potential obstacles for PA’s to perform these limited in scope evaluations.”

Background. PAs are healthcare providers that can provide a wide range of medical services under the supervision of a physician, including prescribing, when authorized by a supervising physician under a document known as a practice agreement. The practice agreement outlines what a PA may or may not do based on the PA’s competence and the level of physician supervision required. A physician may also supervise more than one PA, but no more than four at a time.

Due to the high level of medical care that PAs are capable of providing, the supervision ratio limit was put in place to prevent physicians from becoming overextended. After the amendments taken in the Senate, this bill would create a narrow exemption to the ratio requirement, allowing a physician to supervise up to eight PAs who only provide home health care.

Precedent for Lifting Ratios. On March 4, 2020, the governor proclaimed a state of emergency as a result of the impacts of COVID-19 to help the state prepare to respond to medical care and hospitalization needs. During the emergency, the governor issued Executive Order N-39-20, authorizing the California Department of Consumer Affairs (DCA) to waive professional licensing or scope of practice requirements for licensed healthcare professionals, including PAs.

On April 14, 2020, the DCA issued a waiver titled DCA-20-04 Physician Assistant Supervision Requirements that waived the four PA to one physician ratio requirement and lifted the supervision requirement in practice sites or organized health care systems when a supervising physician was not available. The waiver was extended until March 31, 2022.

ARGUMENTS IN SUPPORT:

The California Academy of Physician Assistants writes in support, "This is a common sense measure aimed at bringing the most basic kind of health care to hard-to-reach populations and we respectfully ask for an aye vote."

Signify Health writes in support, "Currently California allows a physician to oversee 4 physician assistants that provide in-home evaluations. With the current need for these important home evaluations, we believe [this bill] is the right approach and ensures that nothing shall prohibit a physician assistant from gathering patient information and/or performing a health evaluation including diagnostic screenings that does not involve rendering treatment or prescribing medications.

The United Nurses Associations of California/Union of Health Care Professionals writes in support, “The tasks contemplated by [this bill] are routine and basic duties at the lower end of the skillsets of PAs, which involve primarily consulting with patients and filling out medical forms. These very basic tasks will not unduly strain the supervisory capabilities of physicians and surgeons. Neither will this endanger patient safety. Quite the contrary, by removing an artificial cap on the number of PAs that can be supervised, this allows the health care system to expand its reach and provide services to patients who may not otherwise have any access to these services.

ARGUMENTS IN OPPOSITION:

The Medical Board of California writes in opposition: “The Board appreciates the recent amendments and the desire to expand services to meet the needs of patients. In the Board’s view, however, the bill still does not sufficiently clarify what may happen during these home health evaluations or how these visits will be documented and managed by the supervising physician. Further, without a limit on the number of patients that a physician assistant may see each day under this new authority, the supervising physician may not be able to adequately oversee their work. Finally, the Board was not assured that patients who may be fragile, homebound, and receiving care under the provisions of [this bill] will have their multiple needs met adequately.

REGISTERED SUPPORT:

California Academy of Physician Assistants

Signify Health

United Nurses Associations of California/Union of Health Care Professionals

REGISTERED OPPOSITION:

Medical Board of California

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

CONCURRENCE IN SENATE AMENDMENTS

CSA1 Bill Id:AB 1070

Author:(Low)

As Amended Ver:June 28, 2023

Majority vote

SUMMARY

Authorizes a physician and surgeon to supervise more than four physician assistants (PAs) if the PAs are only performing home health evaluations.

Senate Amendments

1. Establish a separate supervision category for the home health PAs.
2. Limit the number of home health PAs that can be supervised to eight.
3. Require all of the home health PAs to be solely focused on home health evaluations.
4. Clarify that the supervision of home health PAs is the same as the supervision of PAs generally.
5. Clarify that the home health PAs must provide the home health evaluation information to the supervising physician.
6. Delete the reference to "advance assessment."
7. Define "in home health evaluation" to mean a comprehensive physical exam, assessment of current and prior health conditions, a complete medication review, screening tests, health education, and assessment of social determination of health needs to be used for diagnosing individual medical conditions.
8. Define "annual wellness visit" to mean a preventive visit with correlating current procedural terminology codes performed annually to a patient, to be used for the purposes of diagnosing patient conditions during the annual wellness visit, which may include a nonphysical examination for patients covered by Medicare Part B for more than 12 months.

COMMENTS

Background. PAs are healthcare providers that can provide a wide range of medical services under the supervision of a physician, including prescribing, when authorized by a supervising physician under a document known as a practice agreement. The practice agreement outlines what a PA may or may not do based on the PA's competence and the level of physician supervision required. A physician may also supervise more than one PA, but no more than four at a time.

Due to the high level of medical care that PAs are capable of providing, the supervision ratio limit was put in place to prevent physicians from becoming overextended. This bill would lift the supervision requirement, and therefore the ratio, for evaluation and triage services that do not involve direct patient treatment or prescribing medication.

Precedent for Lifting Ratios. On March 4, 2020, the governor proclaimed a state of emergency as a result of the impacts of COVID-19 to help the state prepare to respond to medical care and hospitalization needs. During the emergency, the governor issued Executive Order N-39-20, authorizing the California Department of Consumer Affairs (DCA) to waive professional licensing or scope of practice requirements for licensed healthcare professionals, including PAs.

On April 14, 2020, the DCA issued a waiver titled DCA-20-04 Physician Assistant Supervision Requirements that waived the four PA to one physician ratio requirement and lifted the supervision requirement in practice sites or organized health care systems when a supervising physician was not available. The waiver was extended until March 31, 2022.

According to the Author

"In-home health evaluations are an incredibly valuable service provided by clinicians throughout the state. The in-home evaluation allows physician assistants an unparalleled line of sign into the member's clinical, social, functional, behavioral and environmental condition. The COVID-19 pandemic not only exposed the lack of access to health care for many Californians, it had a profound impact on workforce availability that remains a challenge today. Many patients have not seen a physician in over a year. Highly trained and credentialed PA's are well qualified to perform in-home assessments and provide the limited scope of services rendered without supervision. By eliminating the need for physician involvement when licensed PA's are merely gathering patient information and performing a health evaluation that does not involve treating or prescribing, the system is made more efficient for both the physician and the PA by reducing unnecessary paperwork and by removing any potential obstacles for PA's to perform these limited in scope evaluations."

Arguments in Support

Signify Health writes that this bill is "the right approach and ensures that nothing shall prohibit a physician assistant from gathering patient information and/or performing a health evaluation including diagnostic screenings that does not involve rendering treatment or prescribing medications…. Our Physician Assistants are required to be certified by a national accreditation body to be considered for hire. They are trained and coached to ensure the highest standards of clinical accuracy and patient/member satisfaction throughout their tenures."

The California Academy of Physician Assistants writes that this bill is "a common sense measure aimed at bringing the most basic kind of health care to hard-to-reach populations."

Arguments in Opposition

The Medical Board of California writes that it "is concerned that the language of the bill that defines the work to be performed in a home health evaluation is vague and may be difficult for consumers to understand, clinicians to follow, and regulators to uphold. Although PAs are a key and valued allied health provider, the Board was also concerned that the bill would lead to ineffective oversight of PAs engaged in the work proposed by the bill."

FISCAL COMMENTS

According to the Senate Appropriations Committee, pursuant to Senate Rule 28.8, no significant state costs anticipated.

VOTES:

ASM BUSINESS AND PROFESSIONS: 18-0-0

YES: Berman, Flora, Alanis, Alvarez, Bonta, Chen, Dixon, Gipson, Grayson, Irwin, Jackson, Lee, Lowenthal, McCarty, McKinnor, Stephanie Nguyen, Joe Patterson, Ting

ASM APPROPRIATIONS: 16-0-0

YES: Holden, Megan Dahle, Bryan, Calderon, Wendy Carrillo, Dixon, Mike Fong, Hart, Lowenthal, Mathis, Papan, Pellerin, Robert Rivas, Sanchez, Weber, Wilson

ASSEMBLY FLOOR: 75-0-5

YES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Ward, Weber, Wilson, Wood, Zbur, Rendon

ABS, ABST OR NV: Flora, McKinnor, Muratsuchi, Wallis, Wicks

SENATE FLOOR: 40-0-0

YES: Allen, Alvarado-Gil, Archuleta, Ashby, Atkins, Becker, Blakespear, Bradford, Caballero, Cortese, Dahle, Dodd, Durazo, Eggman, Glazer, Gonzalez, Grove, Hurtado, Jones, Laird, Limón, McGuire, Menjivar, Min, Newman, Nguyen, Niello, Ochoa Bogh, Padilla, Portantino, Roth, Rubio, Seyarto, Skinner, Smallwood-Cuevas, Stern, Umberg, Wahab, Wiener, Wilk

UPDATED

VERSION: June 28, 2023

CONSULTANT: Vincent Chee / B. & P. / (916) 319-3301 FN: 0001833

 THIRD READING  

Bill No: AB 1070

Author: Low (D)

Amended: 6/28/23 in Senate

Vote: 21

SENATE BUS., PROF. & ECON. DEV. COMMITTEE: 10-0, 6/5/23

AYES: Roth, Alvarado-Gil, Archuleta, Ashby, Becker, Dodd, Eggman, Niello, Smallwood-Cuevas, Wahab

NO VOTE RECORDED: Nguyen, Glazer, Wilk

SENATE APPROPRIATIONS COMMITTEE: Senate Rule 28.8

ASSEMBLY FLOOR: 75-0, 5/4/23 (Consent) - See last page for vote

SUBJECT: Physician assistants: physician supervision: exceptions

SOURCE: Author

DIGEST:

This bill authorizes a physician and surgeon to supervise more than four physician assistants (PAs) if the PA is doing specified activities in a home health evaluation.

ANALYSIS:

Existing law:

1. Establishes the PA Act, administered by the Physician Assistant Board (PAB), which provides for the licensing and regulation of PAs and authorizes a PA to perform medical services under the Act if they do so under the supervision of a licensed physician and surgeon who is not subject to discipline; if the PA renders services pursuant to a practice agreement that meets specified requirements; if they PA is competent to perform the services and; if the PA’s education, training, and experience have prepared the PA to render the services. (Business and Professions Code (BPC) § 3500 et seq., § 3502)
2. Defines “supervising physician” or “supervising physician and surgeon” as a physician and surgeon licensed by the Medical Board of California (MBC) or by the Osteopathic Medical Board of California who supervises one or more physician assistants, who possesses a current valid license to practice medicine, and who is not currently on disciplinary probation prohibiting the employment or supervision of a physician assistant. Specifies that “supervision” means that a licensed physician and surgeon oversees the activities of, and accepts responsibility for, the medical services rendered by a PA and shall not be construed to require the physical presence of the physician and surgeon, but does require adherence to adequate supervision as agreed to in the practice agreement and the physician and surgeon being available by telephone or other electronic communication method at the time the PA examines the patient. (BPC § 3501(f))
3. Defines “practice agreement” as the writing, developed through collaboration among one or more physicians and surgeons and one or more PAs, that defines the medical services the PA is authorized to perform and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more PAs in the organized health care system. (BPC § 3501(k))
4. Authorizes a PA to perform medical services if the following requirements are met:
   1. The PA renders the services under the supervision of a physician and surgeon who is not subject to a disciplinary condition prohibiting that supervision or prohibiting the employment of a PA. (BPC § 3502(a)(1))
   2. The PA renders the services under a practice agreement. (BPC § 3502(a)(2))
   3. The PA is competent to perform the services. (BPC § 3502(a)(3))
   4. The PA’s education, training, and experience have prepared the PA to render the services. (BPC § 3502(a)(4))
5. Requires a practice agreement to include provisions that address the following:
   1. The types of medical services a PA is authorized to perform. (BPC § 3502.3(a)(1)(A))
   2. Policies and procedures to ensure adequate supervision of the PA, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the PA in the provision of medical services. (BPC § 3502.3(a)(1)(B))
   3. The methods for the continuing evaluation of the competency and qualifications of the PA. (BPC § 3502.3(a)(1)(C))
   4. The furnishing or ordering of drugs or devices by a PA. (BPC § 3502.3(a)(1)(D))
   5. Any additional provisions agreed to by the PA and physician and surgeon. (BPC § 3502.3(a)(1)(E))
6. Prohibits a physician and surgeon from supervising more than four PAs at any one time except in declared emergencies. (BPC §§ 3516(b), 3502.5)

This bill:

1. Authorizes a physician and surgeon to supervise up to eight PAs if the PAs are focused solely on performing in home health evaluations to gather patient information and perform an annual wellness visit or health evaluation, if it does not involve direct patient treatment or prescribing medication.
2. States that a PA who performs an in home health evaluation remains subject to all supervisory and scope requirements and must provide the supervising physician and surgeon with all information related to their evaluation.
3. Defines “In home health evaluation” as a comprehensive physical exam, assessment of current and prior health conditions, a complete medication review, screening tests, health education, and assessment of social determination of health needs to be used for diagnosing individual medical conditions.
4. Defines “annual wellness visit” as a preventive visit with correlating current procedural terminology codes performed annually to a patient, to be used for the purposes of diagnosing patient conditions during the annual wellness visit, which may include a nonphysical examination for patients covered by Medicare Part B for more than 12 months.

Background

PAs and PAB. The concept of a PA originated in a 1961 article in the Journal of the American Medical Association calling for “an advanced medical assistant with special training, intermediate between that of the technician and that of the doctor, who could not only handle any technical procedures but could also take some degree of medical responsibility.” The first PA training program began in 1965 at Duke University with the admission of four ex-military corpsmen into a two-year program. California began regulating the profession in 1970 “to redress the growing shortage and geographic misdistribution of health care services in California.” The PA practice act permitted the supervised delegation of certain medical services to PAs, thus freeing physicians to focus their skills on other procedures.

Today, PAB licenses and regulates approximately 13,000 PAs who provide health care services with the direction and responsible supervision of a doctor of medicine or osteopathy. Within the physician-PA relationship, PAs make clinical decisions and provide a broad range of diagnostic, therapeutic, preventive, and health maintenance services including, but not limited to:

• 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 and graduate from an accredited PA program associated with a medical school that includes classroom studies and clinical experience. The professional curriculum for PA education includes basic medical, behavioral, and social sciences; introduction to clinical medicine and patient assessment; supervised clinical practice; and health policy and professional practice issues.

PAs predominantly practice in primary care service settings such as private practice physician offices and hospitals; however, PAs also provide services in community health clinics and rural health clinics. As reported by the Bureau of Labor Statistics, nationally, the majority of PAs work in physicians’ offices (55%) and in hospital settings (26%).

The PA Act has been updated several times over the decades to reflect changing realities in supervisory requirements and healthcare practices. The PA Act was updated in 2019 through SB 697 (Caballero, Chapter 707, Statutes of 2019) which changed the way PAs and physician and surgeons arrange and handle supervision. Among numerous other provisions, the bill allowed multiple physicians and surgeons to supervise a PA and redefined the supervision agreement. What was once referred to as a delegation of services agreement, is now referred to as a practice agreement. A practice agreement is written between a supervising physician and surgeon and a PA (which could be one or more supervisors/supervisees). The agreement defines the medical services that a PA is authorized to perform, along with policies and procedures to ensure adequate supervision, methods for evaluating competency, the specific authorizations for furnishing or ordering drugs or devices, and any other provisions agreed to by the supervising physician and surgeon and the PA.

Effective, January 1, 2020, a physician and surgeon who supervises a PA does not need to be physically present when a PA is treating a patient, but must have the specifications of the supervision agreed to in the practice agreement and the physician and surgeon must be available by telephone or other electronic communication methods at the time the PA is examining a patient.

This bill does not change any existing requirements for practice agreements and does not provide additional practice authority to PAs. A PA providing services during a home health evaluation will still be subject to PAB oversight and the current pathways for recourse.

Ratio and Access to Care. The PA Act currently allows one physician and surgeon to only supervise up to four PAs. According to a 2018 report from the California Healthcare Foundation and Healthforce Center at the University of California San Francisco, “The American Academy of Physician Assistants and both the American College of Physicians and the American Osteopathic Association have adopted a formal policy position stating that physician-to-PA ratios should not be standardized, but rather determined at the practice level and be reflective of practice and community needs.” The report noted that “The statutory limit on the number of PAs a single physician may collaborate with can negatively affect access to care. Such a cap limits the ability of health care organizations to expand to meet demand for services, particularly as community health centers are increasingly reliant on PAs to provide care within tight budget constraints. In addition, PAs are more likely than physicians to provide care in rural areas and to low-income and underserved populations; supervision regulations can impede PA workforce growth in these settings.”

COVID-19 Experience. On March 30, 2020, the Governor issued Executive Order N-39-20 authorizing the Director of the Department of Consumer Affairs to waive any statutory or regulatory professional licensing relating to healing arts during the duration of the COVID-19 pandemic – including rules relating to examination, education, experience, and training.

DCA-20-67 waived BPC Section 3516, subdivision (b), which prohibits a physician and surgeon from supervising more than four physician assistants at any one time, and waived statutory and regulatory requirements that a practice agreement or written delegation of services agreement exist for a physician assistant to perform medical services, as specified.

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

SUPPORT: (Verified 8/23/23)

California Academy of Physician Assistants

Signify Health

OPPOSITION: (Verified 7/11/23)

Medical Board of California

ARGUMENTS IN SUPPORT: Signify Health believes that this bill is “the right approach and ensures that nothing shall prohibit a physician assistant from gathering patient information and/or performing a health evaluation including diagnostic screenings that does not involve rendering treatment or prescribing medications.” According to the organization, “Our Physician Assistants are required to be certified by a national accreditation body to be considered for hire. They are trained and coached to ensure the highest standards of clinical accuracy and patient/member satisfaction throughout their tenures.”

The California Academy of Physician Assistants notes that the bill is “a common sense measure aimed at bringing the most basic kind of health care to hard-to-reach populations.”

ARGUMENTS IN OPPOSITION: The Medical Board of California “is concerned that the language of the bill that defines the work to be performed in a home health evaluation is vague and may be difficult for consumers to understand, clinicians to follow, and regulators to uphold. Although PAs are a key and valued allied health provider, the Board was also concerned that the bill would lead to ineffective oversight of PAs engaged in the work proposed by the bill.”

ASSEMBLY FLOOR: 75-0, 5/4/23

AYES: Addis, Aguiar-Curry, Alanis, Alvarez, Arambula, Bains, Bauer-Kahan, Bennett, Berman, Boerner, Bonta, Bryan, Calderon, Juan Carrillo, Wendy Carrillo, Cervantes, Chen, Connolly, Megan Dahle, Davies, Dixon, Essayli, Mike Fong, Vince Fong, Friedman, Gabriel, Gallagher, Garcia, Gipson, Grayson, Haney, Hart, Holden, Hoover, Irwin, Jackson, Jones-Sawyer, Kalra, Lackey, Lee, Low, Lowenthal, Maienschein, Mathis, McCarty, Stephanie Nguyen, Ortega, Pacheco, Papan, Jim Patterson, Joe Patterson, Pellerin, Petrie-Norris, Quirk-Silva, Ramos, Reyes, Luz Rivas, Robert Rivas, Rodriguez, Blanca Rubio, Sanchez, Santiago, Schiavo, Soria, Ta, Ting, Valencia, Villapudua, Waldron, Ward, Weber, Wilson, Wood, Zbur, Rendon

NO VOTE RECORDED: Flora, McKinnor, Muratsuchi, Wallis, Wicks

Prepared by: Sarah Mason / B., P. & E.D. /

8/23/23 14:27:18

**** END ****

SENATE COMMITTEE ON

BUSINESS, PROFESSIONS AND ECONOMIC DEVELOPMENT

Senator Richard Roth, Chair

2023 - 2024 Regular

Bill No: AB 1070 Hearing Date: June 5, 2023

Subject: Physician assistants: physician supervision: exceptions

SUMMARY:

Authorizes a physician and surgeon to supervise more than four physician assistants (PAs) if the PA is doing specified activities in a home health evaluation.

Existing law:

1. Establishes the PA Act, administered by the Physician Assistant Board (PAB), which provides for the licensing and regulation of PAs and authorizes a PA to perform medical services under the Act if they do so under the supervision of a licensed physician and surgeon who is not subject to discipline; if the PA renders services pursuant to a practice agreement that meets specified requirements; if they PA is competent to perform the services and; if the PA’s education, training, and experience have prepared the PA to render the services. (Business and Professions Code (BPC) § 3500 et seq., § 3502)
2. Defines “supervising physician” or “supervising physician and surgeon” as a physician and surgeon licensed by the Medical Board of California (MBC) or by the Osteopathic Medical Board of California who supervises one or more physician assistants, who possesses a current valid license to practice medicine, and who is not currently on disciplinary probation prohibiting the employment or supervision of a physician assistant. Specifies that “Supervision” means that a licensed physician and surgeon oversees the activities of, and accepts responsibility for, the medical services rendered by a PA and shall not be construed to require the physical presence of the physician and surgeon, but does require adherence to adequate supervision as agreed to in the practice agreement and the physician and surgeon being available by telephone or other electronic communication method at the time the PA examines the patient. (BPC § 3501(f))
3. Defines “practice agreement” as the writing, developed through collaboration among one or more physicians and surgeons and one or more PAs, that defines the medical services the PA is authorized to perform and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more PAs in the organized health care system. (BPC § 3501(k))
4. Authorizes a PA to perform medical services if the following requirements are met:
5. The PA renders the services under the supervision of a physician and surgeon who is not subject to a disciplinary condition prohibiting that supervision or prohibiting the employment of a PA. (BPC § 3502(a)(1))
6. The PA renders the services under a practice agreement. (BPC § 3502(a)(2))
7. The PA is competent to perform the services. (BPC § 3502(a)(3))
8. The PA’s education, training, and experience have prepared the PA to render the services. (BPC § 3502(a)(4))
9. Requires a practice agreement to include provisions that address the following:
10. The types of medical services a PA is authorized to perform. (BPC § 3502.3(a)(1)(A))
11. Policies and procedures to ensure adequate supervision of the PA, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the PA in the provision of medical services. (BPC § 3502.3(a)(1)(B))
12. The methods for the continuing evaluation of the competency and qualifications of the PA. (BPC § 3502.3(a)(1)(C))
13. The furnishing or ordering of drugs or devices by a PA. (BPC § 3502.3(a)(1)(D))
14. Any additional provisions agreed to by the PA and physician and surgeon. (BPC § 3502.3(a)(1)(E))
15. Prohibits a physician and surgeon from supervising more than four PAs at any one time except in declared emergencies. (BPC §§ 3516(b), 3502.5)

This bill authorizes a physician and surgeon to supervise more than four PAs if the PA is gathering patient information and performing an annual wellness visit, advanced assessment, or health evaluation, including diagnostic screenings, if it does not involve direct patient treatment or prescribing medication, in a home health evaluation.

FISCAL EFFECT:

This bill is keyed fiscal by Legislative Counsel. According to the Assembly Committee on Appropriations, the measure does not have any state costs.

COMMENTS:

1. Purpose. Signify Health is the Sponsor of this bill. According to the Author, “In-home health evaluations are an incredibly valuable service provided by clinicians throughout the state. A clinician can spend an average of 50 minutes either sitting face-to-face or via video conferencing with the member to review current and past health conditions, perform diagnostic tests when appropriate, examine the home for safety hazards, and discuss social determinants of health. The in-home evaluation also allows clinicians an unparalleled line of sight into the member’s clinical, social, functional, behavioral, and environmental condition. They can review medications for contraindications or lack of adherence, check for physical safety concerns and determine whether food insecurity exists, or the individual is socially isolated.

The Author notes that “Many of the individuals who receive clinician visits are affected by issues such as transportation, financial, and other constraints that limit their access to necessary health services. The in-home evaluation links vulnerable Medicare Advantage and Medicaid Managed Care members with a highly skilled clinician and reconnects them to the healthcare system for necessary care and treatment. The value of these in-home evaluations to beneficiaries, their physicians and health plans is evidenced by the continued growth and demand of these services. However, the ability to deliver services to a greater number of aging Californians is constrained by the challenges of finding qualified providers.”

According to the Author, “The COVID-19 pandemic had a profound impact on workforce availability that remains a challenge today. Many beneficiaries have not seen a physician in over a year. Highly trained and credentialed physician assistants are well qualified to perform the in-home assessments and provide the limited scope of services rendered, i.e. the absence of treatment and prescribing, is well within their clinical knowledge and capabilities. Additionally, unnecessary supervision of certain tasks performed by a physician assistant, and related clinical chart review requirements create an administrative burden on physicians.”

1. Background.

PAs and PAB. The concept of a PA originated in a 1961 article in the Journal of the American Medical Association calling for “an advanced medical assistant with special training, intermediate between that of the technician and that of the doctor, who could not only handle any technical procedures but could also take some degree of medical responsibility.” The first PA training program began in 1965 at Duke University with the admission of four ex-military corpsmen into a two-year program. California began regulating the profession in 1970 “to redress the growing shortage and geographic misdistribution of health care services in California.” The PA practice act permitted the supervised delegation of certain medical services to PAs, thus freeing physicians to focus their skills on other procedures.

Today, PAB licenses and regulates approximately 13,000 PAs who provide health care services with the direction and responsible supervision of a doctor of medicine or osteopathy. Within the physician-PA relationship, PAs make clinical decisions and provide a broad range of diagnostic, therapeutic, preventive, and health maintenance services including, but not limited to:

• 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 and graduate from an accredited PA program associated with a medical school that includes classroom studies and clinical experience. The professional curriculum for PA education includes basic medical, behavioral, and social sciences; introduction to clinical medicine and patient assessment; supervised clinical practice; and health policy and professional practice issues.

PAs predominantly practice in primary care service settings such as private practice physician offices and hospitals; however, PAs also provide services in community health clinics and rural health clinics. As reported by the Bureau of Labor Statistics, nationally, the majority of PAs work in physicians’ offices (55%) and in hospital settings (26%).

The PA Act has been updated several times over the decades to reflect changing realities in supervisory requirements and healthcare practices. The PA Act was updated in 2019 through SB 697 (Caballero, Chapter 707, Statutes of 2019) which changed the way PAs and physician and surgeons arrange and handle supervision. Among numerous other provisions, the bill allowed multiple physicians and surgeons to supervise a PA and redefined the supervision agreement. What was once referred to as a delegation of services agreement, is now referred to as a practice agreement. A practice agreement is written between a supervising physician and surgeon and a PA (which could be one or more supervisors/supervisees). The agreement defines the medical services that a PA is authorized to perform, along with policies and procedures to ensure adequate supervision, methods for evaluating competency, the specific authorizations for furnishing or ordering drugs or devices, and any other provisions agreed to by the supervising physician and surgeon and the PA.

Effective, January 1, 2020, a physician and surgeon who supervises a PA does not need to be physically present when a PA is treating a patient, but must have the specifications of the supervision agreed to in the practice agreement and the physician and surgeon must be available by telephone or other electronic communication methods at the time the PA is examining a patient.

This bill does not change any existing requirements for practice agreements and does not provide additional practice authority to PAs. A PA providing services during a home health evaluation would still be subject to PAB oversight and the current pathways for recourse.

Ratio and Access to Care. The PA Act currently allows one physician and surgeon to only supervise up to 4 PAs. According to a 2018 report from the California Healthcare Foundation and Healthforce Center at the University of California San Francisco, “The American Academy of Physician Assistants and both the American College of Physicians and the American Osteopathic Association have adopted a formal policy position stating that physician-to-PA ratios should not be standardized, but rather determined at the practice level and be reflective of practice and community needs.” The report noted that “The statutory limit on the number of PAs a single physician may collaborate with can negatively affect access to care. Such a cap limits the ability of health care organizations to expand to meet demand for services, particularly as community health centers are increasingly reliant on PAs to provide care within tight budget constraints. In addition, PAs are more likely than physicians to provide care in rural areas and to low-income and underserved populations; supervision regulations can impede PA workforce growth in these settings.”

COVID-19 Experience. On March 30, 2020, the Governor issued Executive Order N-39-20 authorizing the Director of the Department of Consumer Affairs to waive any statutory or regulatory professional licensing relating to healing arts during the duration of the COVID-19 pandemic – including rules relating to examination, education, experience, and training.

DCA-20-67 waived BPC § 3516, subdivision (b), which prohibits a physician and surgeon from supervising more than four physician assistants at any one time, and waived statutory and regulatory requirements that a practice agreement or written delegation of services agreement exist for a physician assistant to perform medical services, as specified.

1. Arguments in Support. Signify Health believes that this bill is “the right approach and ensures that nothing shall prohibit a physician assistant from gathering patient information and/or performing a health evaluation including diagnostic screenings that does not involve rendering treatment or prescribing medications.” According to the organization, “Our Physician Assistants are required to be certified by a national accreditation body to be considered for hire. They are trained and coached to ensure the highest standards of clinical accuracy and patient/member satisfaction throughout their tenures.”

The California Academy of Physician Assistants notes that the bill is “a common sense measure aimed at bringing the most basic kind of health care to hard-to-reach populations.”

1. Arguments in Opposition. The Medical Board of California “is concerned that the language of the bill that defines the work to be performed in a home health evaluation is vague and may be difficult for consumers to understand, clinicians to follow, and regulators to uphold. Although PAs are a key and valued allied health provider, the Board was also concerned that the bill would lead to ineffective oversight of PAs engaged in the work proposed by the bill.”

The California State Association of Psychiatrists “believes amendments that focus on having physician supervision for PA's at in home care visits should be included. Also, medical procedures – when performed by non-physicians – should only occur when individual practitioners have the requisite training and experience and there is appropriate physician supervision. Also, CSAP requests limits on the number of offices in which one physician can simultaneously supervise nurse practitioners or physician assistants.”

1. Clarification May Improve Intent. Medical services are provided to California patients in a wide range of settings by a variety of healthcare providers. While expanding the ratio of physician and surgeons to PAs in a number of settings would improve the ability for California patients to access quality care, the Author may wish to further clarify, for purposes of this measure, what a “home health evaluation” means. Should the ratio adjustment occur based on the setting or location that services are provided? Should this be based on a definition of “home health” that is established for payment and payor purposes? The Author may wish to work with state agency partners and stakeholders to most appropriately capture the opportunities for a physician and surgeon to supervise an increased number of PAs.

SUPPORT AND OPPOSITION:

Support:

California Academy of Physician Assistants

Signify Health

Opposition:

California State Association of Psychiatrists

Medical Board of California

-- END --

Date of Hearing: April 26, 2023

ASSEMBLY COMMITTEE ON APPROPRIATIONS

Chris Holden, Chair

ABPCA Bill Id:AB 1070

Author:(Low) – As Amended Ver:April 12, 2023

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

SUMMARY:

This bill allows a physician assistant (PA) to gather patient information and perform annual wellness visits, advanced assessments, or health evaluations, including diagnostic screenings, without physician supervision as long as no direct patient treatment or prescribing is involved.

FISCAL EFFECT:

No state costs.

COMMENTS:

1. Purpose. This bill is sponsored by Signify Health, which states it is one of the largest providers of in-home health evaluations in the country. According to the author:

In-home health evaluations are an incredibly valuable service provided by clinicians throughout the state. The in-home evaluation allows physician assistants an unparalleled line of sign into the member’s clinical, social, functional, behavioral and environmental condition. The COVID-19 pandemic not only exposed the lack of access to health care for many Californians, it had a profound impact on workforce availability that remains a challenge today. Many patients have not seen a physician in over a year. Highly trained and credentialed PA’s are well qualified to perform in-home assessments and provide the limited scope of services rendered without supervision. By eliminating the need for physician involvement when licensed PA’s are merely gathering patient information and performing a health evaluation that does not involve treating or prescribing, the system is made more efficient for both the physician and the PA by reducing unnecessary paperwork and by removing any potential obstacles for PA’s to perform these limited in scope evaluations.

1. Background. PAs are healthcare providers who can provide a wide range of medical services under the supervision of a physician, including prescribing, when authorized by a supervising physician under a practice agreement. The practice agreement outlines what a PA may or may not do based on the PA’s competence and the level of physician supervision required. A physician may also supervise up to four PAs at a time. The supervision ratio limit was put in place to prevent physicians from becoming overextended. This bill lifts the supervision requirement, and therefore the ratio, for evaluation services that do not involve direct patient treatment or prescribing medication.

Precedent for Lifting Ratios. On March 4, 2020, the Governor proclaimed a state of emergency due to the COVID-19 pandemic and issued Executive Order N-39-20, authorizing the California Department of Consumer Affairs (DCA) to waive some professional licensing or scope of practice requirements for licensed healthcare professionals, including PAs. On April 14, 2020, the DCA issued a waiver, DCA-20-04 Physician Assistant Supervision Requirements, which waived the four-to-one PA to physician ratio limit and lifted the supervision requirement in practice sites or organized health care systems when a supervising physician was not available. The waiver was extended until March 31, 2022.

1. Prior Legislation. SB 697 (Caballero), Chapter 707, Statutes of 2019, revises the way PAs are supervised by physicians, allowing multiple physicians to supervise a PA, and generally allows a supervising physician to determine the appropriate level of supervision for PA practice, among other provisions.

Analysis Prepared by: Allegra Kim / APPR. / (916) 319-2081

Date of Hearing: April 11, 2023

ASSEMBLY COMMITTEE ON BUSINESS AND PROFESSIONS

Marc Berman, Chair

ABPCA Bill Id:AB 1070

Author:(Low) – As Amended Ver:March 23, 2023

SUBJECT: Physician assistants: physician supervision: exceptions.

SUMMARY: Authorizes a physician assistant (PA) to gather patient information and perform annual wellness visits, advanced assessments, or health evaluations, including diagnostic screenings, without physician supervision so long as no direct patient treatment or prescribing is involved.

EXISTING LAW:

1. Regulates and licenses PAs under the Physician Assistant Practice Act and establishes the Physician Assistant Board (PAB) to administer and enforce the act. (Business and Professions Code (BPC) §§ 3500-3545)
2. Defines “supervising physician” or “supervising physician and surgeon” as a physician and surgeon who supervises one or more physician assistants and who is not currently on disciplinary probation prohibiting the employment or supervision of a physician assistant. (BPC § 3501(e))
3. “Supervision” means that a physician and surgeon oversees the activities of, and accepts responsibility for, the medical services rendered by a PA. (BPC § 3501(f)(1))
4. Specifies that supervision does not require the physical presence of the physician and surgeon, but does require the following:
   1. Adherence to adequate supervision as agreed to in the practice agreement. (BPC § 3501(f)(1)(A))
   2. The physician and surgeon is available by telephone or other electronic communication methods at the time the PA examines the patient. (BPC § 3501(f)(1)(B))
5. Specifies that the PAB may require the physical presence of a physician and surgeon as a term or condition of a PA’s reinstatement, probation, or imposing discipline. (BPC § 3501(f)(2))
6. Defines “practice agreement” as the writing, developed through collaboration among one or more physicians and surgeons and one or more PAs, that defines the medical services the PA is authorized to perform and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more PAs in the organized health care system. (BPC § 3501(k))
7. Authorizes a PA to perform medical services if the following requirements are met:
   1. The PA renders the services under the supervision of a physician and surgeon who is not subject to a disciplinary condition prohibiting that supervision or prohibiting the employment of a PA. (BPC § 3502(a)(1))
   2. The PA renders the services under a practice agreement. (BPC § 3502(a)(2))
   3. The PA is competent to perform the services. (BPC § 3502(a)(3))
   4. The PA’s education, training, and experience have prepared the PA to render the services. (BPC § 3502(a)(4))
8. Requires a practice agreement to include provisions that address the following:
   1. The types of medical services a PA is authorized to perform. (BPC § 3502.3(a)(1)(A))
   2. Policies and procedures to ensure adequate supervision of the PA, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the PA in the provision of medical services. (BPC § 3502.3(a)(1)(B))
   3. The methods for the continuing evaluation of the competency and qualifications of the PA. (BPC § 3502.3(a)(1)(C))
   4. The furnishing or ordering of drugs or devices by a PA. (BPC § 3502.3(a)(1)(D))
   5. Any additional provisions agreed to by the PA and physician and surgeon. (BPC § 3502.3(a)(1)(E))
9. Prohibits a physician and surgeon from supervising more than four PAs at any one time except in declared emergencies. (BPC §§ 3516(b), 3502.5)

FISCAL EFFECT: Unknown. This bill is keyed fiscal by the Legislative Counsel.

COMMENTS:

Purpose. This bill is sponsored by Signify Health. According to the author, “In-home health evaluations are an incredibly valuable service provided by clinicians throughout the state. The in-home evaluation allows physician assistants an unparalleled line of sign into the member’s clinical, social, functional, behavioral and environmental condition. The COVID-19 pandemic not only exposed the lack of access to health care for many Californians, it had a profound impact on workforce availability that remains a challenge today. Many patients have not seen a physician in over a year. Highly trained and credentialed PA’s are well qualified to perform in-home assessments and provide the limited scope of services rendered without supervision. By eliminating the need for physician involvement when licensed PA’s are merely gathering patient information and performing a health evaluation that does not involve treating or prescribing, the system is made more efficient for both the physician and the PA by reducing unnecessary paperwork and by removing any potential obstacles for PA’s to perform these limited in scope evaluations.”

Background. PAs are healthcare providers that can provide a wide range of medical services under the supervision of a physician, including prescribing, when authorized by a supervising physician under a document known as a practice agreement. The practice agreement outlines what a PA may or may not do based on the PA’s competence and the level of physician supervision required. A physician may also supervise more than one PA, but no more than four at a time.

Due to the high level of medical care that PAs are capable of providing, the supervision ratio limit was put in place to prevent physicians from becoming overextended. This bill would lift the supervision requirement, and therefore the ratio, for evaluation and triage services that do not involve direct patient treatment or prescribing medication.

Precedent for Lifting Ratios. On March 4, 2020, the governor proclaimed a state of emergency as a result of the impacts of COVID-19 to help the state prepare to respond to medical care and hospitalization needs. During the emergency, the governor issued Executive Order N-39-20, authorizing the California Department of Consumer Affairs (DCA) to waive professional licensing or scope of practice requirements for licensed healthcare professionals, including PAs.

On April 14, 2020, the DCA issued a waiver titled DCA-20-04 Physician Assistant Supervision Requirements that waived the four PA to one physician ratio requirement and lifted the supervision requirement in practice sites or organized health care systems when a supervising physician was not available. The waiver was extended until March 31, 2022.

ARGUMENTS IN SUPPORT:

Signify Health (sponsor) writes in support:

Signify Health, a CVS company, is a leading healthcare platform that leverages advanced analytics, technology, and a nationwide healthcare provider network to create and power value-based health programs. We are one of the largest providers of in-home health evaluations (IHEs) in the country and provide these evaluations to Medicare Advantage (MA) and Medicaid managed care organization (MCO beneficiaries. Last year, we visited over 2.2 million MA and/or Medicaid MCO beneficiaries including more than 24,000 Californians. Since 2019, we have performed over 66,000 evaluations in the state.

We employ and work with highly skilled clinicians, including physicians, nurse practitioners and physician assistants to perform the in-home evaluation. Our mobile provider network enables us to deploy clinicians where they are needed most and meet people in the comfort of their home. The clinician spends an average of 50 minutes either sitting face-to-face or via video conferencing with the member to review current and past health conditions, perform diagnostic tests when appropriate, examine the home for safety hazards, and discuss social determinants of health….

The Signify clinician does not provide treatment nor issue prescriptions. After the IHE is performed, a summary of the IHE is sent to the member’s known primary care provider (PCP), and members are encouraged to reconnect with their primary care doctor to discuss any follow-up care. In fact, our data shows that 90% of members who complete a Signify Health IHE return to their PCP within one year.

Our Physician Assistants are required to be certified by a national accreditation body to be considered for hire. They are trained and coached to ensure the highest standards of clinical accuracy and patient/member satisfaction throughout their tenures. They are monitored for the quality of their documentation, identification of HEDIS gap, clinical coding accuracy and customer complaints. We have rigorous processes for peer review, quality and compliance oversight, and complaint resolution. Throughout their tenure, these clinicians are trained and coached to ensure the highest standards of clinical accuracy and patient/member satisfaction….

Currently California allows a physician to oversee 4 physician assistants that provide in-home evaluations. With the current need for these important home evaluations, we believe [this bill] is the right approach and ensures that nothing shall prohibit a physician assistant from gathering patient information and/or performing a health evaluation including diagnostic screenings that does not involve rendering treatment or prescribing medications.

ARGUMENTS IN OPPOSITION:

None on file

POLICY ISSUE FOR CONSIDERATION:

Lifting of Physician Supervision. The Physician Assistant Practice Act does not place many restrictions on the types of medical services a PA may provide outside of what is agreed to with a physician in a practice agreement. As a result, physician supervision through a practice agreement is the basis of all PA practice. However, this bill would lift supervision altogether, a departure from the current PA practice model. Focusing on lifting the four PAs to one physician supervision ratio requirement, rather than the overall supervision requirement, may still achieve the sponsor’s goal of removing unnecessary barriers to performing in-home evaluations where treatment or prescriptions are not provided.

AMENDMENTS:

To address the supervision issue, the bill should be amended to lift the four PA to one physician ratio and clarify the settings in which the ratio does not apply by referencing in-home evaluations:

Strike the current contents of Section 1 of the bill and instead insert:

Section 3516 of the Business and Professions Code is amended to read:

(a) Notwithstanding any other provision of law, a physician assistant licensed by the board shall be eligible for employment or supervision by a physician and surgeon who is not subject to a disciplinary condition imposed by the Medical Board of California prohibiting that employment or supervision.

(b) (1) Except as provided in paragraph (2) and Section 3502.5, a physician and surgeon shall not supervise more than four physician assistants at any one time.

(2) Paragraph (1) does not apply to the supervision of a physician assistant doing any of the following when performing a home evaluation:

(A) Gathering patient information.

(B) Performing an annual wellness visit, advanced assessment, or health evaluation, including diagnostic screenings, if it does not involve direct patient treatment or prescribing medication.

(c) The Medical Board of California may restrict a physician and surgeon to supervising specific types of physician assistants including, but not limited to, restricting a physician and surgeon from supervising physician assistants outside of the field of specialty of the physician and surgeon.

REGISTERED SUPPORT:

Signify Health (sponsor)

California Academy of PAs

REGISTERED OPPOSITION:

None on file

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