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SB-697 Physician assistants: practice agreement: supervision.(2019-2020)

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Date Published: 10/10/2019 09:00 PM
SB697:v92#DOCUMENT

Senate Bill No. 697
CHAPTER 707

An act to amend Sections 3500, 3501, 3502, 3502.1, 3502.3, 3509, 3516, 3518, 3527, and 3528 of, and to repeal Sections 3516.5, 3521, and 3522 of, the Business and Professions Code, relating to healing arts.

[ Approved by Governor  October 09, 2019. Filed with Secretary of State  October 09, 2019. ]

LEGISLATIVE COUNSEL'S DIGEST


SB 697, Caballero. Physician assistants: practice agreement: supervision.
The Physician Assistant Practice Act provides for licensure and regulation of physician assistants by the Physician Assistant Board, which is within the jurisdiction of the Medical Board of California. The act authorizes a physician assistant to perform medical services as set forth by regulations and the act and when those services are rendered under the supervision of a licensed physician and surgeon. The act requires the Physician Assistant Board to, among other things, make recommendations to the Medical Board of California concerning the formulation of guidelines for the consideration and approval of applications by licensed physicians to supervise physician assistants. The act prohibits a physician and surgeon from supervising more than 4 physician assistants at any one time. The act requires the medical record to identify the physician and surgeon who is responsible for the supervision of the physician assistant. The act requires the supervising physician and surgeon to be physically available to the physician assistant for consultation when that assistance is rendered. The act requires the physician assistant and the supervising physician and surgeon to establish written guidelines for adequate supervision, and authorizes the supervising physician and surgeon to satisfy this requirement by adopting protocols for some or all of the tasks performed by the physician assistant, as provided. The act additionally authorizes a delegation of services agreement to authorize a physician assistant to order durable medical equipment, to approve, sign, modify, or add to a plan of treatment or plan of care for individuals receiving home health services or personal care services, or to certify disability, as provided.
This bill would remove the requirement that the Physician Assistant Board make recommendations to the Medical Board of California concerning the formulation of guidelines for the consideration and approval of applications by licensed physicians and surgeons to supervise physician assistants. The bill would remove the requirements that the medical record identify the responsible supervising physician and surgeon and that those written guidelines for adequate supervision be established. The bill would instead authorize a physician assistant to perform medical services authorized by the act as amended by this bill if certain requirements are met, including that the medical services are rendered pursuant to a practice agreement, as defined, and the physician assistant is competent to perform the medical services. The bill would also require a practice agreement between a physician assistant and a physician and surgeon to meet specified requirements, and would require a practice agreement to establish policies and procedures to identify a physician and surgeon supervising a physician assistant rendering services in a general acute care hospital.
The act authorizes a physician assistant, under the supervision of a physician and surgeon, to administer or provide medication to a patient, or transmit orally, or in writing on a patient’s record or in a drug order, an order to a person who may lawfully furnish the medication or medical device, subject to specified requirements.
This bill would revise and recast these provisions to, among other related changes, authorize a physician assistant to furnish or order a drug or device subject to specified requirements, including that the furnishing or ordering be in accordance with the practice agreement and consistent with the physician assistant’s educational preparation or for which clinical competency has been established and maintained, and that the physician and surgeon be available by telephone or other electronic communication method at the time the physician assistant examines the patient. The bill would also authorize the physician assistant to furnish or order Schedule II or III controlled substances in accordance with the practice agreement or a patient-specific order approved by the treating or supervising physician and surgeon.
The act defines various terms for its purposes.
This bill would revise and change the definitions as applicable to carry out the bill’s provisions. The bill would provide that any reference to “delegation of services agreement” in any other law means “practice agreement,” as defined by the bill. The bill would provide that “supervision,” as specified by the bill, does not require the supervising physician and surgeon to be physically present, but does require adequate supervision as agreed to in the practice agreement and does require that the physician and surgeon be available by telephone or other electronic communication method at the time the physician assistant examines the patient. The bill would prohibit this provision from being construed as prohibiting the board from requiring the physical presence of a physician and surgeon as a term or condition of a PA’s reinstatement, probation, or imposing discipline. The bill would also make various conforming changes.
The act makes a violation of specified provisions punishable as a misdemeanor.
By revising and recasting the provisions of the act, the bill would change the definition of that crime and would, therefore, result in a state-mandated local program.
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.
Vote: MAJORITY   Appropriation: NO   Fiscal Committee: YES   Local Program: YES  

The people of the State of California do enact as follows:


SECTION 1.

 Section 3500 of the Business and Professions Code is amended to read:

3500.
 In its concern with the growing shortage and geographic maldistribution of health care services in California, the Legislature intends to establish in this chapter a framework for another category of health manpower—the physician assistant.
The purpose of this chapter is to encourage the effective utilization of the skills of physicians and surgeons, and physicians and surgeons and podiatrists practicing in the same medical group practice, by enabling them to work with qualified physician assistants to provide quality care.
This chapter is established to encourage the coordinated care between physician assistants, physicians and surgeons, podiatrists, and other qualified health care providers practicing in the same medical group, and to provide health care services. It is also the purpose of this chapter to allow for innovative development of programs for the education, training, and utilization of physician assistants.

SEC. 2.

 Section 3501 of the Business and Professions Code is amended to read:

3501.
 As used in this chapter:
(a) “Board” means the Physician Assistant Board.
(b) “Approved program” means a program for the education of physician assistants that has been formally approved by the board.
(c) “Trainee” means a person who is currently enrolled in an approved program.
(d) “Physician assistant” or “PA” means a person who meets the requirements of this chapter and is licensed by the board.
(e) “Supervising physician” or “supervising physician and surgeon” means a physician and surgeon licensed by the Medical Board of California 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.
(f) (1) “Supervision” means that a licensed physician and surgeon oversees the activities of, and accepts responsibility for, the medical services rendered by a physician assistant. Supervision, as defined in this subdivision, shall not be construed to require the physical presence of the physician and surgeon, but does require the following:
(A) Adherence to adequate supervision as agreed to in the practice agreement.
(B) The physician and surgeon being available by telephone or other electronic communication method at the time the PA examines the patient.
(2) Nothing in this subdivision shall be construed as prohibiting the board from requiring the physical presence of a physician and surgeon as a term or condition of a PA’s reinstatement, probation, or imposing discipline.
(g) “Regulations” means the rules and regulations as set forth in Division 13.8 (commencing with Section 1399.500) of Title 16 of the California Code of Regulations.
(h) “Routine visual screening” means noninvasive, nonpharmacological simple testing for visual acuity, visual field defects, color blindness, and depth perception.
(i) “Program manager” means the staff manager of the diversion program, as designated by the executive officer of the board. The program manager shall have background experience in dealing with substance abuse issues.
(j) “Organized health care system” includes a licensed clinic as described in Chapter 1 (commencing with Section 1200) of Division 2 of the Health and Safety Code, an outpatient setting as described in Chapter 1.3 (commencing with Section 1248) of Division 2 of the Health and Safety Code, a health facility as described in Chapter 2 (commencing with Section 1250) of Division 2 of the Health and Safety Code, a county medical facility as described in Chapter 2.5 (commencing with Section 1440) of Division 2 of the Health and Safety Code, an accountable care organization, a home health agency, a physician’s office, a professional medical corporation, a medical partnership, a medical foundation, and any other entity that lawfully provides medical services and is in compliance with Article 18 (commencing with Section 2400) of Chapter 5.
(k) “Practice agreement” means the writing, developed through collaboration among one or more physicians and surgeons and one or more physician assistants, that defines the medical services the physician assistant is authorized to perform pursuant to Section 3502 and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more physician assistants in the organized health care system. Any reference to a delegation of services agreement relating to physician assistants in any other law shall have the same meaning as a practice agreement.
(l) “Other specified medical services” means tests or examinations performed or ordered by a PA practicing in compliance with this chapter or regulations of the board or the Medical Board of California promulgated under this chapter.

SEC. 3.

 Section 3502 of the Business and Professions Code is amended to read:

3502.
 (a) Notwithstanding any other law, a PA may perform medical services as authorized by this chapter if the following requirements are met:
(1) The PA renders the services under the supervision of a licensed physician and surgeon who is not subject to a disciplinary condition imposed by the Medical Board of California or by the Osteopathic Medical Board of California prohibiting that supervision or prohibiting the employment of a physician assistant.
(2) The PA renders the services pursuant to a practice agreement that meets the requirements of Section 3502.3.
(3) The PA is competent to perform the services.
(4) The PA’s education, training, and experience have prepared the PA to render the services.
(b) (1) Notwithstanding any other law, a physician assistant performing medical services under the supervision of a physician and surgeon may assist a doctor of podiatric medicine who is a partner, shareholder, or employee in the same medical group as the supervising physician and surgeon. A physician assistant who assists a doctor of podiatric medicine pursuant to this subdivision shall do so only according to patient-specific orders from a supervising physician and surgeon.
(2) A supervising physician and surgeon shall be available to the physician assistant for consultation when assistance is rendered pursuant to this subdivision. A physician assistant assisting a doctor of podiatric medicine shall be limited to performing those duties included within the scope of practice of a doctor of podiatric medicine.
(c) Nothing in regulations shall require that a physician and surgeon review or countersign a medical record of a patient treated by a physician assistant, unless required by the practice agreement. The board may, as a condition of probation or reinstatement of a licensee, require the review or countersignature of records of patients treated by a physician assistant for a specified duration.
(d) This chapter does not authorize the performance of medical services in any of the following areas:
(1) The determination of the refractive states of the human eye, or the fitting or adaptation of lenses or frames for the aid thereof.
(2) The prescribing or directing the use of, or using, any optical device in connection with ocular exercises, visual training, or orthoptics.
(3) The prescribing of contact lenses for, or the fitting or adaptation of contact lenses to, the human eye.
(4) The practice of dentistry or dental hygiene or the work of a dental auxiliary as defined in Chapter 4 (commencing with Section 1600).
(e) This section shall not be construed in a manner that shall preclude the performance of routine visual screening as defined in Section 3501.
(f) Notwithstanding any other law, a PA rendering services in a general acute care hospital as defined in Section 1250 of the Health and Safety Code shall be supervised by a physician and surgeon with privileges to practice in that hospital. Within a general acute care hospital, the practice agreement shall establish policies and procedures to identify a physician and surgeon who is supervising the PA.

SEC. 4.

 Section 3502.1 of the Business and Professions Code is amended to read:

3502.1.
 In addition to the medical services authorized in the regulations adopted pursuant to Section 3502, and except as prohibited by Section 3502, a PA may furnish or order a drug or device subject to all of the following:
(a) The PA shall furnish or order a drug or device in accordance with the practice agreement and consistent with the PA’s educational preparation or for which clinical competency has been established and maintained.
(b) (1) A practice agreement authorizing a PA to order or furnish a drug or device shall specify which PA or PAs may furnish or order a drug or device, which drugs or devices may be furnished or ordered, under what circumstances, the extent of physician and surgeon supervision, the method of periodic review of the PA’s competence, including peer review, and review of the practice agreement.
(2) In addition to the requirements in paragraph (1), if the practice agreement authorizes the PA to furnish a Schedule II controlled substance, the practice agreement shall address the diagnosis of the illness, injury, or condition for which the PA may furnish the Schedule II controlled substance.
(c) The PA shall furnish or order drugs or devices under physician and surgeon supervision. This subdivision shall not be construed to 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.
(2) The physician and surgeon be available by telephone or other electronic communication method at the time the PA examines the patient.
(d) (1) Except as provided in paragraph (2), the PA may furnish or order only those Schedule II through Schedule V controlled substances under the California Uniform Controlled Substances Act (Division 10 (commencing with Section 11000) of the Health and Safety Code) that have been agreed upon in the practice agreement.
(2) The PA may furnish or order Schedule II or III controlled substances, as defined in Sections 11055 and 11056, respectively, of the Health and Safety Code, in accordance with the practice agreement or a patient-specific order approved by the treating or supervising physician and surgeon.
(e) (1) The PA has satisfactorily completed a course in pharmacology covering the drugs or devices to be furnished or ordered under this section or has completed a program for instruction of PAs that meet the requirements of Section 1399.530 of Title 16 of the California Code of Regulations, as that provision read on June 7, 2019.
(2) A physician and surgeon through a practice agreement may determine the extent of supervision necessary pursuant to this section in the furnishing or ordering of drugs and devices.
(3) PAs who hold an active license, who are authorized through a practice agreement to furnish Schedule II controlled substances, and who are registered with the United States Drug Enforcement Administration, and who have not successfully completed a one-time course in compliance with Sections 1399.610 and 1399.612 of Title 16 of the California Code of Regulations, as those provisions read on June 7, 2019, shall complete, as part of their continuing education requirements, a course that covers Schedule II controlled substances, and the risks of addiction associated with their use, based on the standards developed by the board. The board shall establish the requirements for satisfactory completion of this subdivision. Evidence of completion of a course meeting the standards, including pharmacological content, established in Sections 1399.610 and 1399.612 of Title 16 of the California Code of Regulations, as those provisions read on June 7, 2019, shall be deemed to meet the requirements of this section.
(f) For purposes of this section:
(1) “Furnishing” or “ordering” shall include the following:
(A) Ordering a drug or device in accordance with the practice agreement.
(B) Transmitting an order of a supervising physician and surgeon.
(C) Dispensing a medication pursuant to Section 4170.
(2) “Drug order” or “order” means an order for medication that is dispensed to or for an ultimate user, issued by a PA as an individual practitioner, within the meaning of Section 1306.02 of Title 21 of the Code of Federal Regulations.
(g) Notwithstanding any other law, (1) a drug order issued pursuant to this section shall be treated in the same manner as a prescription of a supervising physician; (2) all references to “prescription” in this code and the Health and Safety Code shall include drug orders issued by physician assistants; and (3) the signature of a PA on a drug order issued in accordance with this section shall be deemed to be the signature of a prescriber for purposes of this code and the Health and Safety Code.

SEC. 5.

 Section 3502.3 of the Business and Professions Code is amended to read:

3502.3.
 (a) (1) A practice agreement shall include provisions that address the following:
(A) The types of medical services a physician assistant is authorized to perform.
(B) Policies and procedures to ensure adequate supervision of the physician assistant, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the physician assistant in the provision of medical services.
(C) The methods for the continuing evaluation of the competency and qualifications of the physician assistant.
(D) The furnishing or ordering of drugs or devices by a physician assistant pursuant to Section 3502.1.
(E) Any additional provisions agreed to by the physician assistant and physician and surgeon.
(2) A practice agreement shall be signed by both of the following:
(A) The physician assistant.
(B) One or more physicians and surgeons or a physician and surgeon who is authorized to approve the practice agreement on behalf of the staff of the physicians and surgeons on the staff of an organized health care system.
(3) A delegation of services agreement in effect prior to January 1, 2020, shall be deemed to meet the requirements of this subdivision.
(4) A practice agreement may designate a PA as an agent of a supervising physician and surgeon.
(5) Nothing in this section shall be construed to require approval of a practice agreement by the board.
(b) Notwithstanding any other law, in addition to any other practices that meet the general criteria set forth in this chapter or regulations adopted by the board or the Medical Board of California, a practice agreement may authorize a PA to do any of the following:
(1) Order durable medical equipment, subject to any limitations set forth in Section 3502 or the practice agreement. Notwithstanding that authority, nothing in this paragraph shall operate to limit the ability of a third-party payer to require prior approval.
(2) For individuals receiving home health services or personal care services, after consultation with a supervising physician and surgeon, approve, sign, modify, or add to a plan of treatment or plan of care.
(3) After performance of a physical examination by the PA under the supervision of a physician and surgeon consistent with this chapter, certify disability pursuant to Section 2708 of the Unemployment Insurance Code. The Employment Development Department shall implement this paragraph on or before January 1, 2017.
(c) This section shall not be construed to affect the validity of any practice agreement in effect prior to the effective date of this section or those adopted subsequent to the effective date of this section.

SEC. 6.

 Section 3509 of the Business and Professions Code is amended to read:

3509.
 It shall be the duty of the board to:
(a) Establish standards and issue licenses of approval for programs for the education and training of physician assistants.
(b) Make recommendations to the Medical Board of California concerning the scope of practice for physician assistants.
(c) Require the examination of applicants for licensure as a physician assistant who meet the requirements of this chapter.

SEC. 7.

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

3516.
 (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) Except as provided in Section 3502.5, a physician and surgeon shall not supervise more than four physician assistants at any one time.
(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.

SEC. 8.

 Section 3516.5 of the Business and Professions Code is repealed.

SEC. 9.

 Section 3518 of the Business and Professions Code is amended to read:

3518.
 The board shall keep a current register for licensed PAs, if applicable. The register shall show the name of each licensee, the licensee’s last known address of record, and the date of the licensee’s licensure. Any interested person is entitled to obtain a copy of the register in accordance with the Information Practices Act of 1977 (Chapter 1 (commencing with Section 1798) of Title 1.8 of Part 4 of Division 3 of the Civil Code) upon application to the board together with a sum as may be fixed by the board, which amount shall not exceed the cost of this list so furnished.

SEC. 10.

 Section 3521 of the Business and Professions Code is repealed.

SEC. 11.

 Section 3522 of the Business and Professions Code is repealed.

SEC. 12.

 Section 3527 of the Business and Professions Code is amended to read:

3527.
 (a) The board may order the denial of an application for, or the issuance subject to terms and conditions of, or the suspension or revocation of, or the imposition of probationary conditions upon a PA license after a hearing as required in Section 3528 for unprofessional conduct that includes, but is not limited to, a violation of this chapter, a violation of the Medical Practice Act, or a violation of the regulations adopted by the board or the Medical Board of California.
(b) The board may order the denial of an application for, or the suspension or revocation of, or the imposition of probationary conditions upon, an approved program after a hearing as required in Section 3528 for a violation of this chapter or the regulations adopted pursuant thereto.
(c) The Medical Board of California may order the imposition of probationary conditions upon a physician and surgeon’s authority to supervise a PA, after a hearing as required in Section 3528, for unprofessional conduct, which includes, but is not limited to, a violation of this chapter, a violation of the Medical Practice Act, or a violation of the regulations adopted by the board or the Medical Board of California.
(d) The board may order the denial of an application for, or the suspension or revocation of, or the imposition of probationary conditions upon, a PA license, after a hearing as required in Section 3528 for unprofessional conduct that includes, except for good cause, the knowing failure of a licensee to protect patients by failing to follow infection control guidelines of the board, thereby risking transmission of bloodborne infectious diseases from licensee to patient, from patient to patient, and from patient to licensee. In administering this subdivision, the board shall consider referencing the standards, regulations, and guidelines of the State Department of Public Health developed pursuant to Section 1250.11 of the Health and Safety Code and the standards, regulations, and guidelines pursuant to the California Occupational Safety and Health Act of 1973 (Part 1 (commencing with Section 6300) of Division 5 of the Labor Code) for preventing the transmission of HIV, hepatitis B, and other bloodborne pathogens in health care settings. As necessary, the board shall consult with the Medical Board of California, the Osteopathic Medical Board of California, the Podiatric Medical Board of California, the Dental Board of California, the Board of Registered Nursing, and the Board of Vocational Nursing and Psychiatric Technicians of the State of California to encourage appropriate consistency in the implementation of this subdivision.
The board shall seek to ensure that licensees are informed of the responsibility of licensees and others to follow infection control guidelines, and of the most recent scientifically recognized safeguards for minimizing the risk of transmission of bloodborne infectious diseases.
(e) The board may order the licensee to pay the costs of monitoring the probationary conditions imposed on the license.
(f) The expiration, cancellation, forfeiture, or suspension of a PA license by operation of law or by order or decision of the board or a court of law, the placement of a license on a retired status, or the voluntary surrender of a license by a licensee shall not deprive the board of jurisdiction to commence or proceed with any investigation of, or action or disciplinary proceeding against, the licensee or to render a decision suspending or revoking the license.

SEC. 13.

 Section 3528 of the Business and Professions Code is amended to read:

3528.
 Any proceedings involving the denial, suspension, or revocation of the application for licensure or the license of a PA or the application for approval or the approval of an approved program under this chapter shall be conducted in accordance with Chapter 5 (commencing with Section 11500) of Part 1 of Division 3 of Title 2 of the Government Code.

SEC. 14.

 The provisions of this measure are severable. If any provision of this measure or its application is held invalid, that invalidity shall not affect other provisions or applications that can be given effect without the invalid provision or application.

SEC. 15.

 No reimbursement is required by this act pursuant to Section 6 of Article XIII B of the California Constitution because the only costs that may be incurred by a local agency or school district will be incurred because this act creates a new crime or infraction, eliminates a crime or infraction, or changes the penalty for a crime or infraction, within the meaning of Section 17556 of the Government Code, or changes the definition of a crime within the meaning of Section 6 of Article XIII B of the California Constitution.