Transcript Hot Topics with Mid

Understanding the Public
Health Code
MARC MOOTE, M.S., P.A.-C
CHIEF PHYSICIAN ASSISTANT
UNIVERSITY OF MICHIGAN HEALTH SYSTEM
Objectives
 Understanding the Michigan Public Health Code
(MPHC) as it pertains to PA Practice
 Understanding the MPHC as it pertains to NP
Practice
 Understanding the Health Code’s importance in
advocacy efforts
Terminology Matters…
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Allied Health Professional (AHP)?
Licensed Independent Practitioner (LIP)?
Non-physician Provider (NPP)?
Midlevel Provider (MLP)?
Advanced Practice Professional (APP)?
Physician’s Assistant?
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MAPA Legislative goal = remove apostrophe ‘S’
 Preferred = Physician Assistant (PA)
 See AAPA policy: HP-3100.1.1, HP-3100.1.2, HP-
3100.1.3, HP-3100.1.3.1
So What?
 “What can a PA do?”
 “Can a PA really do this/that?”
 “Supervision requirements are so much more complex
for PAs.”
 “PAs cannot do that!”
 “My hospital says a PA cannot do X, what is MAPA doing
about that?”
Know the Landscape – Regulatory Drivers that
Affect PA Scope of Practice
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Medicare Conditions of Participation
The Joint Commission
Medical Staff Bylaws, Rules and Regulations
State Scope of Practice Statutes
State Rules and Regulations
State Medicaid Policy
Other Third Party Payer Rules
Federal Level
 Medicare Hospital Conditions of Participation (CoPs):
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Section 482.12(c), in place since 1986.
"Every Medicare patient is under the care of: (i) A doctor of medicine
or osteopathy (This provision is not to be construed to limit the
authority of a doctor of medicine or osteopathy to delegate tasks to
other qualified health care personnel to the extent recognized under
State law or a State's regulatory mechanism.) ."
 TJC uses similar language to allow for delegation to
qualified PAs to the extent authorized by state law and
organizational policy.
 Both CMS and TJC defer to state law.
Hospital Level
 Hospitals/Facilities can always choose to be
more restrictive than state law
 Key Point for Advocacy: knowing the regulations well
enough to challenge existing policies based upon facts
Hospital/facility policies should generally not be
more restrictive than state law RE: PA practice
Often
requires physician champions to challenge
long held beliefs and/or policies
Get it in writing!
I. GENERAL SCOPE OF PRACTICE
Physician Assistants
State Level
 PAs are licensed to practice
medicine under physician supervision
pursuant to Article 15, Part 170 of the
Michigan Public Health Code.
MPHC Definitions
 “Practice as a Physician Assistant” means the practice of
medicine, osteopathic medicine and surgery, and
podiatric medicine and surgery and is defined as a health
profession subfield (MCL 333.17001, 333.17008).
 "Practice of medicine" means the diagnosis, treatment,
prevention, cure, or relieving of a human disease,
ailment, defect, complaint, or other physical or mental
condition, by attendance, advice, device, diagnostic test,
or other means, or offering, undertaking, attempting to
do, or holding oneself out as able to do, any of these acts
(MCL333.17001).
Scope of Practice
 The boundaries of each PA’s scope of practice are
typically determined by four parameters:
 Delegated by Supervising Physician
 PA’s Education and Experience
 State Law
 Hospital Policy
Scope of Practice
 Physicians may delegate to PAs those medical
duties that are within the physician’s scope of
practice and the PA’s training and experience and
are allowed by law (MCL 333.17049(2),
333.17076).
 Under Michigan Health Code, the things that must
not be delegated to a PA include:
 Tests
to determine refractive state of human eye or
determine lens prescriptions (MCL 333.17014)
 Termination of a pregnancy including prescribing
the morning after pill (MCL 333.17015, MCL 750.15,
R333.108a)
Supervision
 In MI: “Supervision” means the overseeing of or
participation in the work of another individual by a
health professional licensed where the following
conditions exist:
Continuous availability of direct communication in
person or by radio, telephone, or telecommunication.
 Availability on a regularly scheduled basis to review the
practice of the supervised individual, to provide
consultation to the supervised individual, to review
records, and to further educate the supervised
individual in the performance of the individual's
functions.
 MCL 333.16109
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Responsibilities of Supervising Physician
 Must verify the PA’s credentials, evaluate
performance, and monitor the practice and provision
of medical care (MCL333.17409(1)).
 A physician group may designate one or more
physicians to fulfill these requirements.
 Must also keep on file at the practice site a
permanent written record of the physician’s
name/license number and the name/license number
of each PA supervised by the physician.
Limitations on Number of PA’s Supervised
 Solo physicians or group practices that treat patients
on an outpatient basis cannot supervise more than 4
PAs. If such a physician practices at more than one
site, they may not supervise more than 2 PAs.
 Physicians employed by, or under
contract/subcontract to, or with privileges at a health
facility may supervise more than 4 PAs (MCL
333.17048(2)).
 ***MAPA Legislative Goal = Remove
Ratios***
No Countersigning Requirement
 A physician is not required to countersign orders
written by PAs (MCL 333.17049(6), 333.17549(6)).
 No co-signature requirement for medical record
entries
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Exception: Discharge summaries [CMS Interpretive
Guidelines §482.24(c)(2)(vii)]
Physical Therapy
 Requires the prescription of an individual licensed
under part 166, 170, 175, 180 (MCL 333.17820).
 Dentists
 Allopathic/Osteopathic
Physicians
 Podiatrists
 PAs
 OT & Speech typically follow same rules
What’s New?
 On November 8, 2011 Gov. Rick Snyder signed SB
384 into law, known as Public Act 210 of 2011
 This bill resulted in legislative changes specifically
for PAs (NOT inclusive of APNs) related to:
 Schedule
2 prescribing
 Restraints
 Hospital Rounding
 Physician Signature on Forms
 Name of PA on Prescription Bottles
Schedule 2 Prescribing
 Prescriptive privilege in all 50 states, including
controlled substances in all but 2 (Florida &
Kentucky)
 36 states + District of Columbia authorize
delegation of Schedule 2 medications
 Of
37 jurisdictions, MI was the ONLY one that
limited Sch. 2 prescriptive authority to discharge
prescribing from a facility
Schedule 2 Prescribing
 A PA may prescribe a drug, including a controlled
substance that is included in schedules 2 to 5, as a
delegated act of the supervising physician MCL
333.17076(3).
 Administrative rules were revised to bring alignment
with the MPHC change (R338.2304 & R338.108a).
Restraint Orders
 CMS
 TJC
 State law
 Hospital Policy
Restraints: CMS
 CMS issued final regs 1/8/07 that clarifies when
restraint ordering may be delegated.
 “The use of restraint or seclusion must be in
accordance with the order of a physician or LIP who
is responsible for the care of the patient as specified
under (federal law) Section 482.12(c) and authorized
to order restraint or seclusion by hospital policy in
accordance with state law.”
Restraints: CMS
 Section 482.12(c) CoPs:
 “Every Medicare patient is under the care of: (i) a
doctor of medicine or osteopathy (this provision is
not to be construed to limit the authority of a
doctor of medicine or osteopathy to delegate
tasks to other qualified health care personnel
to the extent recognized under State law or a
State’s regulatory mechanism).”
Restraints: CMS
 Medicare CoPs, 12/2006 rulemaking on restraints and seclusion
provided following clarification:
 "For the purposes of this rule, a LIP is any individual permitted by
State law and hospital policy to order restraints and seclusion for
patients independently, within the scope of the individual’s license
and consistent with the individually granted clinical privileges. This
provision is not to be construed to limit the authority of a
physician to delegate tasks to other qualified healthcare
personnel, that is, physician assistants and advanced
practice nurses, to the extent recognized under State law
or a State’s regulatory mechanism, and hospital policy. It is
not our intent to interfere with State laws governing the role of
physician assistants, advanced practice registered nurses, or other
groups that in some States have been authorized to order restraint
and seclusion or, more broadly, medical interventions or
treatments."
Restraints: TJC
 Standards are tied to behavior of patient, regardless of cause for
behavior.
 TJC Standard do not prohibit delegation of restraint ordering
(PC.03.05.05, EP1 & EP5)
 TJC’s LIP definition mirrors CMS: “…this language is not to be
construed to limit the authority of a licensed independent
practitioner to delegate tasks to other qualified health care
personnel (for example, physician assistants and advanced
practice registered nurses) to the extent authorized by state
law or a state’s regulatory mechanism or federal guidelines
and organizational policy."
 In alignment with CMS, TJC defers to state law regarding the authority
of a physician to delegate the initiation of restraints or seclusion.
Restraints: Michigan Law
 No restriction for PAs ordering restraints under
delegation in MPHC
 No conflict with Mental Health Code**
Debate over use of term “physician” and whether it applies
to PAs
 MAPA has convened a task force to begin addressing
deficiencies in MHC
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 Supported by AG Opinion 5220
 Despite clear guidance from CMS, TJC, MI State Law,
PAs ordering restraints in MI under delegation remained
controversial
Restraints
 A patient or resident is entitled to be free from
mental and physical abuse and from physical and
chemical restraints, except those restraints
authorized in writing by the attending physician or
a physician's assistant to whom the physician has
delegated the performance of medical care… [MCL
333.20201(l)].
Inpatient Rounding
 R325.1027
 (1) “All persons admitted to a hospital shall be under the
continuing daily care of a physician licensed to practice
in Michigan.”
 Put in place 1950s, predating:
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Public Act 420 of 1976 which formally recognized PAs within MPHC
1977 AG 5220
Medicare CoPs in place since 1986
Public Act 247 of 1990 which liberalized supervision requirements of
PAs
 Over-interpretation ignores CMS 482.12(c)…which
contains similar language & is not intended to limit
delegation to PAs
Inpatient Rounding
 Notwithstanding any law or rule to the contrary, a
PA may make calls or go on rounds without
restrictions on the time or frequency of visits by
the physician or PA [MCL 333.17076(2)].
Physician Signature on Forms
 Various forms require “physician” signature
 PAs can sign as delegated act except where specifically
restricted by law (e.g. death certificates)
 Many entities have failed to recognize a PA signature as
extension of physician under delegated authority
 Person performing exam should sign the form
 Notwithstanding any law or rule to the contrary, a
physician is not required to sign an official form
that lists the physician’s signature as the required
signatory if that official form is signed by a PA
under delegation [MCL333.17049(6)].
Name of PA on Prescription Bottle
 When [a] delegated prescription occurs, both the
PA’s and supervising physician’s name shall be
used, recorded, or otherwise indicated in
connection with each individual prescription.”
MCL 333.17048(5)
 A dispensing prescriber shall dispense a drug in a
container that bears a label containing the
prescriber’s name and, if dispensed under the
prescriber’s delegatory authority, the name of the
delegatee MCL 333.17745(7)(d).
II. GENERAL SCOPE OF PRACTICE
Registered Professional Nurses and
Advanced Practice Nurses,
including Nurse Practitioners
MPHC Definition
 MHPC’s broad definition of nursing: “Practice of
nursing” means “the systematic application of
substantial specialized knowledge and skill, derived
from the biological, physical, and behavioral
sciences, to the care, treatment, counsel, and health
teaching of individuals who are experiencing changes
in the normal health processes or who require
assistance in the maintenance of health and the
prevention or management of illness, injury or
disability.”
MCL 333.17201(1)(a)
 Unlike other states, the MHPC does not clearly
delineate the differences in the scope of practice of a
RN and an APN. Rather, the differences are
dependent on educational background.
 The RN’s scope of practice also includes “teaching,
direction, and supervision of less skilled personnel in
the performance of delegated nursing activities.”
MCL 333.17201(c).
A. MEDICALLY DELEGATED
FUNCTIONS AND SUPERVISION
 In addition to the independent activities of a RN
APN, qualified nurses may perform medically
delegated functions under the supervision of a
licensed physician.
MCL 333.16215(1)
 Subject to the same supervision requirements as PAs
(MCL 333.16109).
B. NURSE SPECIALISTS, APNS
 The Michigan Board of Nursing issues specialty
certifications to RNs who have advanced training
and who have demonstrated competency through
examination or evaluation. MCL 333.17210.
 Three types of nurse specialists:
 Nurse anesthethetists (“CRNA”)
 Nurse midwives (“CNM”s)
 Nurse practitioners (“NP”s)
C. PRESCRIBING AUTHORITY
 A physician may delegate the prescribing of a drug
(other than controlled substances) to an RN.
Prescription authority for controlled substances can be
delegated to NPs (other than CRNAs). MCL
333.16215; administrative rules R. 338.2305; R.
338.108b
 Delegation of Schedule 3-5 controlled substances
requires:
1. The name, license number, and signature of the
delegating physician.
 2. The name, license number and signature of the NP.
 3. The limitations or exceptions to the delegation.
 4. The effective date of the delegation.
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Schedule 2 Restrictions
 Restrictions on delegating prescription of
Schedule 2 controlled substances:
 Delegating
physician and the NP are practicing
within a facility in which the patient is located.
 NP may not prescribe a Schedule 2 drug upon
patient discharge for more than a 7-day period.
III. DEA REQUIREMENTS
APPLICABLE TO BOTH PAS & APRNS
DEA Requirements
 A physician may not delegate the use of his or her
signature and DEA registration to another person.
 APNs or PAs who are delegated the authority to
prescribe controlled substances must register with
the DEA and obtain a PA/APRN controlled
substances registration.
 Further requirements for PAs & APRNs
practitioners issuing controlled substances.
Michigan Bureau of Health Systems Alert No. 01203
State Requirements
 A controlled substance prescription shall include the
prescriber’s DEA registration number, printed name,
address and professional designation.
 Such prescriptions written by PAs & APRNs in
Michigan must include the name of the delegating
physician, and both the physician’s and PA/APN
DEA numbers.
 APNs and PAs who are authorized employees or
agents of a hospital are not required to obtain a DEA
registration number for inpatient use. However, if
the PA/APN practitioner will be prescribing
controlled substances on discharge, a DEA
registration is required.
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Michigan Board of Pharmacy Administrative Rule 338.3161
E. SIGNATURE REQUIREMENTS
If the controlled substance prescription in a medical
institution is given under the delegated authority of
a physician, the printed name of the delegatee, the
licensure designation, the delegating prescriber, and
the signature of the delegatee shall be on the written
prescription.
 In medical facilities, orders shall contain the
signatures of the delegatee and the printed name of
the delegating prescriber. There is no requirement
that a delegating prescriber countersign the
prescription, so long as the necessary information
under the DEA regulations and the administrative
rule is included.
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Michigan Board of Pharmacy Administrative Rule 338.3161
AAPA 6 Key Elements to Modern PA Practice Act
 1."Licensure" as the Regulatory Term
 2.Full Prescriptive Authority
 3.Scope of Practice Determined at Practice Level
 4. Adaptable Supervision Requirements
 5.Chart Co-Signature Requirements Determined at
the Practice
 6.Number of PAs a Physician May Supervise
Determined at Practice Level
 Michigan = 5 down, one to go…
Summary
 You must know the MPHC & its importance
Advocacy efforts (facility, state)
 Hospital privileging
 Hospital policies
 TJC/CMS surveys
 Malpractice claims
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 Michigan currently has excellent practice law
 There have been significant updates the past 1-2
years, due to MAPA efforts
 There is still much work to be done…
Thank you!
Appendix
 Michigan Public Health Code Search:
http://www.legislature.mi.gov/(S(ks3zh145jbzzrx55
5qrpqc45))/mileg.aspx?page=GetObject&objectnam
e=mcl-Act-368-of-1978
Appendix
 Administrative Rules (LARA):
http://www7.dleg.state.mi.us/orr/AdminCode.aspx?
AdminCode=Department&Dpt=LR&Level_1=Burea
u+of+Health+Care+Services