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SECOND REGULAR SESSION
HOUSE BILL NO. 3039
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE P ARKER.
6819H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal sections 334.735 and 334.747, RSMo, and to enact in lieu thereof two new sections
relating to the prescriptive authority of physician assistants.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 334.735 and 334.747, RSMo, are repealed and two new sections
2 enacted in lieu thereof, to be known as sections 334.735 and 334.747, to read as follows:
334.735. 1. As used in sections 334.735 to 334.749, the following terms mean:
2 (1) "Applicant", any individual who seeks to become licensed as a physician
3 assistant;
4 (2) "Certification" or "registration", a process by a certifying entity that grants
5 recognition to applicants meeting predetermined qualifications specified by such certifying
6 entity;
7 (3) "Certifying entity", the nongovernmental agency or association which certifies or
8 registers individuals who have completed academic and training requirements;
9 (4) "Collaborative practice arrangement", written agreements, jointly agreed upon
10 protocols, or standing orders, all of which shall be in writing, for the delivery of health care
11 services;
12 (5) "Department", the department of commerce and insurance or a designated agency
13 thereof;
14 (6) "License", a document issued to an applicant by the board acknowledging that the
15 applicant is entitled to practice as a physician assistant;
16 (7) "Physician assistant", a person who has graduated from a physician assistant
17 program accredited by the Accreditation Review Commission on Education for the Physician
EXPLANA TION — Matter enclosed in bold-faced brackets [thus] in the above bill is not enacted and is
intended to be omitted from the law . Matter in bold-face type in the above bill is proposed language.
18 Assistant or its successor agency , prior to 2001, or the Committee on Allied Health Education
19 and Accreditation or the Commission on Accreditation of Allied Health Education Programs,
20 who has passed the certifying examination administered by the National Commission on
21 Certification of Physician Assistants and has active certification by the National Commission
22 on Certification of Physician Assistants who provides health care services delegated by a
23 licensed physician. A person who has been employed as a physician assistant for three years
24 prior to August 28, 1989, who has passed the National Commission on Certification of
25 Physician Assistants examination, and has active certification of the National Commission on
26 Certification of Physician Assistants;
27 (8) "Recognition", the formal process of becoming a certifying entity as required by
28 the provisions of sections 334.735 to 334.749.
29 2. The scope of practice of a physician assistant shall consist only of the following
30 services and procedures:
31 (1) T aking patient histories;
32 (2) Performing physical examinations of a patient;
33 (3) Performing or assisting in the performance of routine of fice laboratory and patient
34 screening procedures;
35 (4) Performing routine therapeutic procedures;
36 (5) Recording diagnostic impressions and evaluating situations calling for attention of
37 a physician to institute treatment procedures;
38 (6) Instructing and counseling patients regarding mental and physical health using
39 procedures reviewed and approved by a collaborating physician;
40 (7) Assisting the supervising physician in institutional settings, including reviewing
41 of treatment plans, ordering of tests and diagnostic laboratory and radiological services, and
42 ordering of therapies, using procedures reviewed and approved by a licensed physician;
43 (8) Assisting in surge ry; and
44 (9) Performing such other tasks not prohibited by law under the collaborative practice
45 arrangement with a licensed physician as the physician assistant has been trained and is
46 proficient to perform.
47 3. Physician assistants shall not perform or prescribe abortions.
48 4. Physician assistants shall not prescribe any drug, medicine, device or therapy
49 unless pursuant to a collaborative practice arrangement in accordance with the law , nor
50 prescribe lenses, prisms or contact lenses for the aid, relief or correction of vision or the
51 measurement of visual power or visual ef ficiency of the human eye, nor administer or monitor
52 general or regional block anesthesia during diagnostic tests, sur gery or obstetric procedures.
53 Prescribing of drugs, medications, devices or therapies by a physician assistant shall be
54 pursuant to a collaborative practice arrangement which is specific to the clinical conditions
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55 treated by the supervising physician and the physician assistant shall be subject to the
56 following:
57 (1) A physician assistant shall only prescribe controlled substances in accordance
58 with section 334.747;
59 (2) The types of drugs, medications, devices or therapies prescribed by a physician
60 assistant shall be consistent with the scopes of practice of the physician assistant and the
61 collaborating physician;
62 (3) All prescriptions shall conform with state and federal laws and regulations and
63 shall include the name, address and telephone number of the physician assistant;
64 (4) A physician assistant, or advanced practice registered nurse as defined in section
65 335.016 may request, receive and sign for noncontrolled professional samples and may
66 distribute professional samples to patients; and
67 (5) A physician assistant shall not prescribe any drugs, medicines, devices or
68 therapies the collaborating physician is not qualified or authorized to prescribe.
69 5. A physician assistant shall clearly identify himself or herself as a physician
70 assistant and shall not use or permit to be used in the physician assistant's behalf the terms
71 "doctor", "Dr ." or "doc" nor hold himself or herself out in any way to be a physician or
72 sur geon. No physician assistant shall practice or attempt to practice without physician
73 collaboration or in any location where the collaborating physician is not immediately
74 available for consultation, assistance and intervention, except as otherwise provided in this
75 section, and in an emer gency situation, nor shall any physician assistant bill a patient
76 independently or directly for any services or procedure by the physician assistant; except that,
77 nothing in this subsection shall be construed to prohibit a physician assistant from enrolling
78 with a third-party plan or the department of social services as a MO HealthNet or Medicaid
79 provider while acting under a collaborative practice arrangement between the physician and
80 physician assistant.
81 6. The licensing of physician assistants shall take place within processes established
82 by the state board of registration for the healing arts through rule and regulation. The board
83 of healing arts is authorized to establish rules pursuant to chapter 536 establishing licensing
84 and renewal procedures, collaboration, collaborative practice arrangements, fees, and
85 addressing such other matters as are necessary to protect the public and discipline the
86 profession. An application for licensing may be denied or the license of a physician assistant
87 may be suspended or revoked by the board in the same manner and for violation of the
88 standards as set forth by section 334.100, or such other standards of conduct set by the board
89 by rule or regulation. Persons licensed pursuant to the provisions of chapter 335 shall not be
90 required to be licensed as physician assistants. All applicants for physician assistant licensure
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91 who complete a physician assistant training program after January 1, 2008, shall have a
92 master's degree from a physician assistant program.
93 7. At all times the physician is responsible for the oversight of the activities of, and
94 accepts responsibility for , health care services rendered by the physician assistant.
95 8. (1) A physician may enter into collaborative practice arrangements with physician
96 assistants. Collaborative practice arrangements, which shall be in writing, may delegate to a
97 physician assistant the authority to prescribe, administer , or dispense drugs and provide
98 treatment which is within the skill, training, and competence of the physician assistant.
99 Collaborative practice arrangements may delegate to a physician assistant, as defined in
100 section 334.735, the authority to administer , dispense, or prescribe controlled substances
101 listed in Schedules III, IV , and V of section 195.017, and Schedule II - hydrocodone and
102 oxycodone . Schedule III narcotic controlled substances and Schedule II - hydrocodone
103 prescriptions shall be limited to a one hundred twenty-hour supply without refill. Schedule II
104 - oxycodone shall be limited to an inpatient setting or , in the case of an outpatient
105 setting, a supply for up to five days following the date of discharge fr om the hospital
106 without a ref ill. Such collaborative practice arrangements shall be in the form of a written
107 arrangement, jointly agreed-upon protocols, or standing orders for the delivery of health care
108 services.
109 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
110 practice arrangement may delegate to a physician assistant the authority to administer ,
111 dispense, or prescribe Schedule II controlled substances for hospice patients; provided, that
112 the physician assistant is employed by a hospice provider certified pursuant to chapter 197
113 and the physician assistant is providing care to hospice patients pursuant to a collaborative
114 practice arrangement that designates the certified hospice as a location where the physician
115 assistant is authorized to practice and prescribe.
116 9. The written collaborative practice arrangement shall contain at least the following
117 provisions:
118 (1) Complete names, home and business addresses, zip codes, and telephone numbers
119 of the collaborating physician and the physician assistant;
120 (2) A list of all other of fices or locations, other than those listed in subdivision (1) of
121 this subsection, where the collaborating physician has authorized the physician assistant to
122 prescribe;
123 (3) A requirement that there shall be posted at every of fice where the physician
124 assistant is authorized to prescribe, in collaboration with a physician, a prominently displayed
125 disclosure statement informing patients that they may be seen by a physician assistant and
126 have the right to see the collaborating physician;
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127 (4) All specialty or board certifications of the collaborating physician and all
128 certifications of the physician assistant;
129 (5) The manner of collaboration between the collaborating physician and the
130 physician assistant, including how the collaborating physician and the physician assistant
131 will:
132 (a) Engage in collaborative practice consistent with each professional's skill, training,
133 education, and competence;
134 (b) Maintain geographic proximity , as determined by the board of registration for the
135 healing arts; and
136 (c) Provide coverage during absence, incapacity , infirmity , or emer gency of the
137 collaborating physician;
138 (6) A list of all other written collaborative practice arrangements of the collaborating
139 physician and the physician assistant;
140 (7) The duration of the written practice arrangement between the collaborating
141 physician and the physician assistant;
142 (8) A description of the time and manner of the collaborating physician's review of
143 the physician assistant's delivery of health care services. The description shall include
144 provisions that the physician assistant shall submit a minimum of ten percent of the charts
145 documenting the physician assistant's delivery of health care services to the collaborating
146 physician for review by the collaborating physician, or any other physician designated in the
147 collaborative practice arrangement, every fourteen days. Reviews may be conducted
148 electronically;
149 (9) The collaborating physician, or any other physician designated in the
15 0 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
151 percent of the charts in which the physician assistant prescribes controlled substances. The
152 charts reviewed under this subdivision may be counted in the number of charts required to be
153 reviewed under subdivision (8) of this subsection;
154 (10) A statement that no collaboration requirements in addition to the federal law
155 shall be required for a physician-physician assistant team working in a certified community
156 behavioral health clinic as defined by Pub.L. 1 13-93, or a rural health clinic under the federal
157 Rural Health Services Act, Pub.L. 95-210, as amended, or a federally qualified health center
158 as defined in 42 U.S.C. Section 1395x, as amended; and
159 (1 1) If a collaborative practice arrangement is used in clinical situations where a
160 collaborating physician assistant provides health care services that include the diagnosis and
161 initiation of treatment for acutely or chronically ill or injured persons, then the collaborating
162 physician or any other physician designated in the collaborative practice arrangement shall be
163 present for suff icient periods of time, at least once every two weeks, except in extraordinary
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164 circumstances that shall be documented, to participate in a chart review and to provide
165 necessary medical direction, medical services, consultations, and supervision of the health
166 care staff .
167 10. The state board of registration for the healing arts under section 334.125 may
168 promulgate rules regulating the use of collaborative practice arrangements.
169 1 1. The state board of registration for the healing arts shall not deny , revoke, suspend,
170 or otherwise take disciplinary action against a collaborating physician for health care services
171 delegated to a physician assistant, provided that the provisions of this section and the rules
172 promulgated thereunder are satisfied.
173 12. W ithin thirty days of any change and on each renewal, the state board of
174 registration for the healing arts shall require every physician to identify whether the physician
175 is engaged in any collaborative practice arrangement, including collaborative practice
176 arrangements delegating the authority to prescribe controlled substances, and also report to
177 the board the name of each physician assistant with whom the physician has entered into such
178 arrangement. The board may make such information available to the public. The board shall
179 track the reported information and may routinely conduct random reviews of such
180 arrangements to ensure that the arrangements are carried out in compliance with this chapter .
181 13. The collaborating physician shall determine and document the completion of a
182 period of time during which the physician assistant shall practice with the collaborating
183 physician continuously present before practicing in a setting where the collaborating
184 physician is not continuously present. This limitation shall not apply to collaborative
185 arrangements of providers of population-based public health services as defined by 20 CSR
186 2150-5.100 as of April 30, 2009.
187 14. No contract or other arrangement shall require a physician to act as a
188 collaborating physician for a physician assistant against the physician's will. A physician
189 shall have the right to refuse to act as a supervising physician, without penalty , for a particular
190 physician assistant. No contract or other agreement shall limit the collaborating physician's
191 ultimate authority over any protocols or standing orders or in the delegation of the physician's
192 authority to any physician assistant. No contract or other arrangement shall require any
193 physician assistant to collaborate with any physician against the physician assistant's will. A
194 physician assistant shall have the right to refuse to collaborate, without penalty , with a
195 particular physician.
196 15. Physician assistants shall file with the board a copy of their collaborating
197 physician form.
198 16. No physician shall be designated to serve as a collaborating physician for more
199 than six full-time equivalent licensed physician assistants, full-time equivalent advanced
200 practice registered nurses, or full-time equivalent assistant physicians, or any combination
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201 thereof. This limitation shall not apply to physician assistant collaborative practice
202 arrangements of hospital employees providing inpatient care service in hospitals as defined in
203 chapter 197, or to a certified registered nurse anesthetist providing anesthesia services under
204 the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is
205 immediately available if needed as set out in subsection 7 of section 334.104.
206 17. No arrangement made under this section shall supercede current hospital licensing
207 regulations governing hospital medication orders under protocols or standing orders for the
208 purpose of delivering inpatient or emer gency care within a hospital, as defined in section
209 197.020, if such protocols or standing orders have been approved by the hospital's medical
210 staf f and pharmaceutical therapeutics committee.
334.747. 1. (1) A physician assistant with a certificate of controlled substance
2 prescriptive authority as provided in this section may prescribe any controlled substance
3 listed in Schedule III, IV , or V of section 195.017, and may have restricted authority in
4 Schedule II, when delegated the authority to prescribe controlled substances in a collaborative
5 practice arrangement. Such authority shall be listed on the collaborating physician form on
6 file with the state board of healing arts. The collaborating physician shall maintain the right
7 to limit a specific scheduled drug or scheduled drug category that the physician assistant is
8 permitted to prescribe. Any limitations shall be listed on the collaborating physician form.
9 Prescriptions for Schedule II medications prescribed by a physician assistant with authority to
10 prescribe delegated in a collaborative practice arrangement are restricted to only those
11 medications containing hydrocodone or oxycodone . Physician assistants shall not prescribe
12 controlled substances for themselves or members of their families. Schedule III narcotic
13 controlled substances and Schedule II - hydrocodone prescriptions shall be limited to a five-
14 day supply without refill, except that buprenorphine may be prescribed for up to a thirty-day
15 supply without refill for patients receiving medication-assisted treatment for substance use
16 disorders under the direction of the collaborating physician. Schedule II - oxycodone shall
17 be limited to an inpatient setting or , in the case of an outpatient setting, a supply for up
18 to five days following the date of discharge fr om the hospital without a ref ill. Physician
19 assistants who are authorized to prescribe controlled substances under this section shall
20 register with the federal Drug Enforcement Administration and the state bureau of narcotics
21 and dangerous drugs, and shall include the Drug Enforcement Administration registration
22 number on prescriptions for controlled substances.
23 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
24 practice arrangement may delegate to a physician assistant the authority to administer ,
25 dispense, or prescribe Schedule II controlled substances for hospice patients; provided, that
26 the physician assistant is employed by a hospice provider certified pursuant to chapter 197
27 and the physician assistant is providing care to hospice patients pursuant to a collaborative
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28 practice arrangement that designates the certified hospice as a location where the physician
29 assistant is authorized to practice and prescribe.
30 2. The collaborating physician shall be responsible to determine and document the
31 completion of at least one hundred twenty hours in a four -month period by the physician
32 assistant during which the physician assistant shall practice with the collaborating physician
33 on-site prior to prescribing controlled substances when the collaborating physician is not on-
34 site. Such limitation shall not apply to physician assistants of population-based public health
35 services as defined in 20 CSR 2150-5.100 as of April 30, 2009.
36 3. A physician assistant shall receive a certificate of controlled substance prescriptive
37 authority from the board of healing arts upon verification of the completion of the following
38 educational requirements:
39 (1) Successful completion of an advanced pharmacology course that includes clinical
40 training in the prescription of drugs, medicines, and therapeutic devices. A course or courses
41 with advanced pharmacological content in a physician assistant program accredited by the
42 Accreditation Review Commission on Education for the Physician Assistant (ARC-P A) or its
43 predecessor agency shall satisfy such requirement;
44 (2) Completion of a minimum of three hundred clock hours of clinical training by the
45 collaborating physician in the prescription of drugs, medicines, and therapeutic devices;
46 (3) Completion of a minimum of one year of supervised clinical practice or
47 supervised clinical rotations. One year of clinical rotations in a program accredited by the
48 Accreditation Review Commission on Education for the Physician Assistant (ARC-P A) or its
49 predecessor agency , which includes pharmacotherapeutics as a component of its clinical
50 training, shall satisfy such requirement. Proof of such training shall serve to document
51 experience in the prescribing of drugs, medicines, and therapeutic devices;
52 (4) A physician assistant previously licensed in a jurisdiction where physician
53 assistants are authorized to prescribe controlled substances may obtain a state bureau of
54 narcotics and dangerous drugs registration if a collaborating physician can attest that the
55 physician assistant has met the requirements of subdivisions (1) to (3) of this subsection and
56 provides documentation of existing federal Drug Enforcement Agency registration.
✔
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