Modifies provisions relating to collaborative practice arrangements with physicians

SECOND REGULAR SESSION
HOUSE BILL NO. 3217
103RD GENERAL ASSEMBL Y
INTRODUCED BY REPRESENT A TIVE OVERCAST .
7064H.01I JOSEPH ENGLER, Chief Clerk
AN ACT
T o repeal sections 334.037, 334.104, and 334.735, RSMo, and to enact in lieu thereof three
new sections relating to collaborative practice arrangements.
Be it enacted by the General Assembly of the state of Missouri, as follows:
Section A. Sections 334.037, 334.104, and 334.735, RSMo, are repealed and three
2 new sections enacted in lieu thereof, to be known as sections 334.037, 334.104, and 334.735,
3 to read as follows:
334.037. 1. A physician may enter into collaborative practice arrangements with
2 assistant physicians. Collaborative practice arrangements shall be in the form of written
3 agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care
4 services. Collaborative practice arrangements, which shall be in writing, may delegate to an
5 assistant physician the authority to administer or dispense drugs and provide treatment as long
6 as the delivery of such health care services is within the scope of practice of the assistant
7 physician and is consistent with that assistant physician's skill, training, and competence and
8 the skill and training of the collaborating physician.
9 2. The written collaborative practice arrangement shall contain at least the following
10 provisions:
11 (1) Complete names, home and business addresses, zip codes, and telephone numbers
12 of the collaborating physician and the assistant physician;
13 (2) A list of all other of fices or locations besides those listed in subdivision (1) of this
14 subsection where the collaborating physician authorized the assistant physician to prescribe;
15 (3) A requirement that there shall be posted at every of fice where the assistant
16 physician is authorized to prescribe, in collaboration with a physician, a prominently
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.
17 displayed disclosure statement informing patients that they may be seen by an assistant
18 physician and have the right to see the collaborating physician;
19 (4) All specialty or board certifications of the collaborating physician and all
20 certifications of the assistant physician;
21 (5) The manner of collaboration between the collaborating physician and the assistant
22 physician, including how the collaborating physician and the assistant physician shall:
23 (a) Engage in collaborative practice consistent with each professional's skill, training,
24 education, and competence;
25 (b) Maintain geographic proximity; except, the collaborative practice arrangement
26 may allow for geographic proximity to be waived for a maximum of twenty-eight days per
27 calendar year for rural health clinics as defined by Pub. L. 95-210 (42 U.S.C. Section 1395x),
28 as amended, as long as the collaborative practice arrangement includes alternative plans as
29 required in paragraph (c) of this subdivision. Such exception to geographic proximity shall
30 apply only to independent rural health clinics, provider -based rural health clinics if the
31 provider is a critical access hospital as provided in 42 U.S.C. Section 1395i-4, and provider -
32 based rural health clinics if the main location of the hospital sponsor is greater than fifty miles
33 from the clinic. The collaborating physician shall maintain documentation related to such
34 requirement and present it to the state board of registration for the healing arts when
35 requested; and
36 (c) Provide coverage during absence, incapacity , infirmity , or emer gency by the
37 collaborating physician;
38 (6) A description of the assistant physician's controlled substance prescriptive
39 authority in collaboration with the physician, including a list of the controlled substances the
40 physician authorizes the assistant physician to prescribe and documentation that it is
41 consistent with each professional's education, knowledge, skill, and competence;
42 (7) A list of all other written practice agreements of the collaborating physician and
43 the assistant physician;
44 (8) The duration of the written practice agreement between the collaborating
45 physician and the assistant physician;
46 (9) A description of the time and manner of the collaborating physician's review of
47 the assistant physician's delivery of health care services. The description shall include
48 provisions that the assistant physician shall submit a minimum of ten percent of the charts
49 documenting the assistant physician's delivery of health care services to the collaborating
50 physician for review by the collaborating physician, or any other physician designated in the
51 collaborative practice arrangement, every fourteen days; and
52 (10) The collaborating physician, or any other physician designated in the
53 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
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54 percent of the charts in which the assistant physician prescribes controlled substances. The
55 charts reviewed under this subdivision may be counted in the number of charts required to be
56 reviewed under subdivision (9) of this subsection.
57 3. The state board of registration for the healing arts under section 334.125 shall
58 promulgate rules regulating the use of collaborative practice arrangements for assistant
59 physicians. Such rules shall specify:
60 (1) Geographic areas to be covered;
61 (2) The methods of treatment that may be covered by collaborative practice
62 arrangements;
63 (3) In conjunction with deans of medical schools and primary care residency program
64 directors in the state, the development and implementation of educational methods and
65 programs undertaken during the collaborative practice service which shall facilitate the
66 advancement of the assistant physician's medical knowledge and capabilities, and which may
67 lead to credit toward a future residency program for programs that deem such documented
68 educational achievements acceptable; and
69 (4) The requirements for review of services provided under collaborative practice
70 arrangements, including delegating authority to prescribe controlled substances.
71
72 Any rules relating to dispensing or distribution of medications or devices by prescription or
73 prescription drug orders under this section shall be subject to the approval of the state board
74 of pharmacy . Any rules relating to dispensing or distribution of controlled substances by
75 prescription or prescription drug orders under this section shall be subject to the approval of
76 the department of health and senior services and the state board of pharmacy . The state board
77 of registration for the healing arts shall promulgate rules applicable to assistant physicians
78 that shall be consistent with guidelines for federally funded clinics. The rulemaking authority
79 granted in this subsection shall not extend to collaborative practice arrangements of hospital
80 employees providing inpatient care within hospitals as defined in chapter 197 or population-
81 based public health services as defined by 20 CSR 2150-5.100 as of April 30, 2008.
82 4. The state board of registration for the healing arts shall not deny , revoke, suspend,
83 or otherwise take disciplinary action against a collaborating physician for health care services
84 delegated to an assistant physician provided the provisions of this section and the rules
85 promulgated thereunder are satisfied.
86 5. W ithin thirty days of any change and on each renewal, the state board of
87 registration for the healing arts shall require every physician to identify whether the physician
88 is engaged in any collaborative practice arrangement, including collaborative practice
89 arrangements delegating the authority to prescribe controlled substances, and also report to
90 the board the name of each assistant physician with whom the physician has entered into such
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91 arrangement. The board may make such information available to the public. The board shall
92 track the reported information and may routinely conduct random reviews of such
93 arrangements to ensure that arrangements are carried out for compliance under this chapter .
94 6. A collaborating physician shall not enter into a collaborative practice arrangement
95 with more than [ six ] ten full-time equivalent assistant physicians, full-time equivalent
96 physician assistants, or full-time equivalent advance practice registered nurses, or any
97 combination thereof. Such limitation shall not apply to collaborative arrangements of
98 hospital employees providing inpatient care service in hospitals as defined in chapter 197 or
99 population-based public health services as defined by 20 CSR 2150-5.100 as of April 30,
100 2008, or to a certified registered nurse anesthetist providing anesthesia services under the
101 supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately
102 available if needed as set out in subsection 7 of section 334.104.
103 7. The collaborating physician shall determine and document the completion of at
104 least a one-month period of time during which the assistant physician shall practice with the
105 collaborating physician continuously present before practicing in a setting where the
106 collaborating physician is not continuously present. No rule or regulation shall require the
107 collaborating physician to review more than ten percent of the assistant physician's patient
108 charts or records during such one-month period. Such limitation shall not apply to
109 collaborative arrangements of providers of population-based public health services as defined
110 by 20 CSR 2150-5.100 as of April 30, 2008.
111 8. No agreement made under this section shall supersede current hospital licensing
112 regulations governing hospital medication orders under protocols or standing orders for the
113 purpose of delivering inpatient or emer gency care within a hospital as defined in section
114 197.020 if such protocols or standing orders have been approved by the hospital's medical
115 staf f and pharmaceutical therapeutics committee.
116 9. No contract or other agreement shall require a physician to act as a collaborating
117 physician for an assistant physician against the physician's will. A physician shall have the
118 right to refuse to act as a collaborating physician, without penalty , for a particular assistant
119 physician. No contract or other agreement shall limit the collaborating physician's ultimate
120 authority over any protocols or standing orders or in the delegation of the physician's
121 authority to any assistant physician, but such requirement shall not authorize a physician in
122 implementing such protocols, standing orders, or delegation to violate applicable standards
123 for safe medical practice established by a hospital's medical staff .
124 10. No contract or other agreement shall require any assistant physician to serve as a
125 collaborating assistant physician for any collaborating physician against the assistant
126 physician's will. An assistant physician shall have the right to refuse to collaborate, without
127 penalty , with a particular physician.
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128 1 1. All collaborating physicians and assistant physicians in collaborative practice
129 arrangements shall wear identification badges while acting within the scope of their
130 collaborative practice arrangement. The identification badges shall prominently display the
131 licensure status of such collaborating physicians and assistant physicians.
132 12. (1) An assistant physician with a certificate of controlled substance prescriptive
133 authority as provided in this section may prescribe any controlled substance listed in Schedule
134 III, IV , or V of section 195.017, and may have restricted authority in Schedule II, when
135 delegated the authority to prescribe controlled substances in a collaborative practice
136 arrangement. Prescriptions for Schedule II medications prescribed by an assistant physician
137 who has a certificate of controlled substance prescriptive authority are restricted to only those
138 medications containing hydrocodone. Such authority shall be filed with the state board of
139 registration for the healing arts. The collaborating physician shall maintain the right to limit a
140 specific scheduled drug or scheduled drug category that the assistant physician is permitted to
141 prescribe. Any limitations shall be listed in the collaborative practice arrangement. Assistant
142 physicians shall not prescribe controlled substances for themselves or members of their
143 families. Schedule III controlled substances and Schedule II - hydrocodone prescriptions
144 shall be limited to a five-day supply without refill, except that buprenorphine may be
145 prescribed for up to a thirty-day supply without refill for patients receiving medication-
146 assisted treatment for substance use disorders under the direction of the collaborating
147 physician. Assistant physicians who are authorized to prescribe controlled substances under
148 this section shall register with the federal Drug Enforcement Administration and the state
149 bureau of narcotics and dangerous drugs, and shall include the Drug Enforcement
150 Administration registration number on prescriptions for controlled substances.
151 (2) The collaborating physician shall be responsible to determine and document the
152 completion of at least one hundred twenty hours in a four -month period by the assistant
153 physician during which the assistant physician shall practice with the collaborating physician
154 on-site prior to prescribing controlled substances when the collaborating physician is not on-
155 site. Such limitation shall not apply to assistant physicians of population-based public health
156 services as defined in 20 CSR 2150-5.100 as of April 30, 2009, or assistant physicians
157 providing opioid addiction treatment.
158 (3) An assistant physician shall receive a certificate of controlled substance
159 prescriptive authority from the state board of registration for the healing arts upon verification
160 of licensure under section 334.036.
161 13. Nothing in this section or section 334.036 shall be construed to limit the authority
162 of hospitals or hospital medical staf f to make employment or medical staf f credentialing or
163 privileging decisions.
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334.104. 1. A physician may enter into collaborative practice arrangements with
2 registered professional nurses. Collaborative practice arrangements shall be in the form of
3 written agreements, jointly agreed-upon protocols, or standing orders for the delivery of
4 health care services. Collaborative practice arrangements, which shall be in writing, may
5 delegate to a registered professional nurse the authority to administer or dispense drugs and
6 provide treatment as long as the delivery of such health care services is within the scope of
7 practice of the registered professional nurse and is consistent with that nurse's skill, training
8 and competence.
9 2. (1) Collaborative practice arrangements, which shall be in writing, may delegate to
10 a registered professional nurse the authority to administer , dispense or prescribe drugs and
11 provide treatment if the registered professional nurse is an advanced practice registered nurse
12 as defined in subdivision (2) of section 335.016. Collaborative practice arrangements may
13 delegate to an advanced practice registered nurse, as defined in section 335.016, the authority
14 to administer , dispense, or prescribe controlled substances listed in Schedules III, IV , and V of
15 section 195.017, and Schedule II - hydrocodone; except that, the collaborative practice
16 arrangement shall not delegate the authority to administer any controlled substances listed in
17 Schedules III, IV , and V of section 195.017, or Schedule II - hydrocodone for the purpose of
18 inducing sedation or general anesthesia for therapeutic, diagnostic, or surg ical procedures.
19 Schedule III narcotic controlled substance and Schedule II - hydrocodone prescriptions shall
20 be limited to a one hundred twenty-hour supply without refill.
21 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
22 practice arrangement may delegate to an advanced practice registered nurse the authority to
23 administer , dispense, or prescribe Schedule II controlled substances for hospice patients;
24 provided, that the advanced practice registered nurse is employed by a hospice provider
25 certified pursuant to chapter 197 and the advanced practice registered nurse is providing care
26 to hospice patients pursuant to a collaborative practice arrangement that designates the
27 certified hospice as a location where the advanced practice registered nurse is authorized to
28 practice and prescribe.
29 (3) Such collaborative practice arrangements shall be in the form of written
30 agreements, jointly agreed-upon protocols or standing orders for the delivery of health care
31 services.
32 (4) An advanced practice registered nurse may prescribe buprenorphine for up to a
33 thirty-day supply without refill for patients receiving medication-assisted treatment for
34 substance use disorders under the direction of the collaborating physician.
35 3. The written collaborative practice arrangement shall contain at least the following
36 provisions:
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37 (1) Complete names, home and business addresses, zip codes, and telephone numbers
38 of the collaborating physician and the advanced practice registered nurse;
39 (2) A list of all other of fices or locations besides those listed in subdivision (1) of this
40 subsection where the collaborating physician authorized the advanced practice registered
41 nurse to prescribe;
42 (3) A requirement that there shall be posted at every of fice where the advanced
43 practice registered nurse is authorized to prescribe, in collaboration with a physician, a
44 prominently displayed disclosure statement informing patients that they may be seen by an
45 advanced practice registered nurse and have the right to see the collaborating physician;
46 (4) All specialty or board certifications of the collaborating physician and all
47 certifications of the advanced practice registered nurse;
48 (5) The manner of collaboration between the collaborating physician and the
49 advanced practice registered nurse, including how the collaborating physician and the
50 advanced practice registered nurse will:
51 (a) Engage in collaborative practice consistent with each professional's skill, training,
52 education, and competence;
53 (b) Maintain geographic proximity , except as specified in this paragraph. The
54 following provisions shall apply with respect to this requirement:
55 a. Until August 28, 2025, an advanced practice registered nurse providing services in
56 a correctional center , as defined in section 217.010, and his or her collaborating physician
57 shall satisfy the geographic proximity requirement if they practice within two hundred miles
58 by road of one another . An incarcerated patient who requests or requires a physician
59 consultation shall be treated by a physician as soon as appropriate;
60 b. The collaborative practice arrangement may allow for geographic proximity to be
61 waived for a maximum of twenty-eight days per calendar year for rural health clinics as
62 defined by Pub.L. 95-210 (42 U.S.C. Section 1395x, as amended), as long as the collaborative
63 practice arrangement includes alternative plans as required in paragraph (c) of this
64 subdivision. This exception to geographic proximity shall apply only to independent rural
65 health clinics, provider -based rural health clinics where the provider is a critical access
66 hospital as provided in 42 U.S.C. Section 1395i-4, and provider -based rural health clinics
67 where the main location of the hospital sponsor is greater than fifty miles from the clinic;
68 c. The collaborative practice arrangement may allow for geographic proximity to be
69 waived when the arrangement outlines the use of telehealth, as defined in section 191.1 145;
70 d. In addition to the waivers and exemptions provided in this subsection, an
71 application for a waiver for any other reason of any applicable geographic proximity shall be
72 available if a physician is collaborating with an advanced practice registered nurse in excess
73 of any geographic proximity limit. The board of nursing and the state board of registration
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74 for the healing arts shall review each application for a waiver of geographic proximity and
75 approve the application if the boards determine that adequate supervision exists between the
76 collaborating physician and the advanced practice registered nurse. The boards shall have
77 forty-five calendar days to review the completed application for the waiver of geographic
78 proximity . If no action is taken by the boards within forty-five days after the submission of
79 the application for a waiver , then the application shall be deemed approved. If the application
80 is denied by the boards, the provisions of section 536.063 for contested cases shall apply and
81 govern proceedings for appellate purposes; and
82 e. The collaborating physician is required to maintain documentation related to this
83 requirement and to present it to the state board of registration for the healing arts when
84 requested; and
85 (c) Provide coverage during absence, incapacity , infirmity , or emer gency by the
86 collaborating physician;
87 (6) A description of the advanced practice registered nurse's controlled substance
88 prescriptive authority in collaboration with the physician, including a list of the controlled
89 substances the physician authorizes the nurse to prescribe and documentation that it is
90 consistent with each professional's education, knowledge, skill, and competence;
91 (7) A list of all other written practice agreements of the collaborating physician and
92 the advanced practice registered nurse;
93 (8) The duration of the written practice agreement between the collaborating
94 physician and the advanced practice registered nurse;
95 (9) A description of the time and manner of the collaborating physician's review of
96 the advanced practice registered nurse's delivery of health care services. The description shall
97 include provisions that the advanced practice registered nurse shall submit a minimum of ten
98 percent of the charts documenting the advanced practice registered nurse's delivery of health
99 care services to the collaborating physician for review by the collaborating physician, or any
100 other physician designated in the collaborative practice arrangement, every fourteen days;
101 (10) The collaborating physician, or any other physician designated in the
102 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
103 percent of the charts in which the advanced practice registered nurse prescribes controlled
104 substances. The charts reviewed under this subdivision may be counted in the number of
105 charts required to be reviewed under subdivision (9) of this subsection; and
106 (1 1) If a collaborative practice arrangement is used in clinical situations where a
107 collaborating advanced practice registered nurse provides health care services that include the
108 diagnosis and initiation of treatment for acutely or chronically ill or injured persons, then the
109 collaborating physician or any other physician designated in the collaborative practice
110 arrangement shall be present for suf ficient periods of time, at least once every two weeks,
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111 except in extraordinary circumstances that shall be documented, to participate in a chart
112 review and to provide necessary medical direction, medical services, consultations, and
113 supervision of the health care staf f.
114 4. The state board of registration for the healing arts pursuant to section 334.125 and
115 the board of nursing pursuant to section 335.036 may jointly promulgate rules regulating the
116 use of collaborative practice arrangements. Such rules shall be limited to the methods of
117 treatment that may be covered by collaborative practice arrangements and the requirements
118 for review of services provided pursuant to collaborative practice arrangements including
119 delegating authority to prescribe controlled substances. Any rules relating to geographic
120 proximity shall allow a collaborating physician and a collaborating advanced practice
121 registered nurse to practice within two hundred miles by road of one another until August 28,
122 2025, if the nurse is providing services in a correctional center , as defined in section 217.010.
123 Any rules relating to dispensing or distribution of medications or devices by prescription or
124 prescription drug orders under this section shall be subject to the approval of the state board
125 of pharmacy . Any rules relating to dispensing or distribution of controlled substances by
126 prescription or prescription drug orders under this section shall be subject to the approval of
127 the department of health and senior services and the state board of pharmacy . In order to take
128 ef fect, such rules shall be approved by a majority vote of a quorum of each board. Neither the
129 state board of registration for the healing arts nor the board of nursing may separately
130 promulgate rules relating to collaborative practice arrangements. Such jointly promulgated
131 rules shall be consistent with guidelines for federally funded clinics. The rulemaking
132 authority granted in this subsection shall not extend to collaborative practice arrangements of
133 hospital employees providing inpatient care within hospitals as defined pursuant to chapter
134 197 or population-based public health services as defined by 20 CSR 2150-5.100 as of April
135 30, 2008.
136 5. The state board of registration for the healing arts shall not deny , revoke, suspend
137 or otherwise take disciplinary action against a physician for health care services delegated to a
138 registered professional nurse provided the provisions of this section and the rules
13 9 promulgated thereunder are satisfied. Upon the written request of a physician subject to a
140 disciplinary action imposed as a result of an agreement between a physician and a registered
141 professional nurse or registered physician assistant, whether written or not, prior to August
142 28, 1993, all records of such disciplinary licensure action and all records pertaining to the
143 filing, investigation or review of an alleged violation of this chapter incurred as a result of
144 such an agreement shall be removed from the records of the state board of registration for the
145 healing arts and the division of professional registration and shall not be disclosed to any
146 public or private entity seeking such information from the board or the division. The state
147 board of registration for the healing arts shall take action to correct reports of alleged
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148 violations and disciplinary actions as described in this section which have been submitted to
149 the National Practitioner Data Bank. In subsequent applications or representations relating to
150 his or her medical practice, a physician completing forms or documents shall not be required
151 to report any actions of the state board of registration for the healing arts for which the
152 records are subject to removal under this section.
153 6. W ithin thirty days of any change and on each renewal, the state board of
154 registration for the healing arts shall require every physician to identify whether the physician
155 is engaged in any collaborative practice arrangement, including collaborative practice
156 arrangements delegating the authority to prescribe controlled substances, or physician
157 assistant collaborative practice arrangement and also report to the board the name of each
158 licensed professional with whom the physician has entered into such arrangement. The board
159 shall make this information available to the public. The board shall track the reported
160 information and may routinely conduct random reviews of such arrangements to ensure that
161 arrangements are carried out for compliance under this chapter .
162 7. Notwithstanding any law to the contrary , a certified registered nurse anesthetist as
163 defined in subdivision (8) of section 335.016 shall be permitted to provide anesthesia services
164 without a collaborative practice arrangement provided that he or she is under the supervision
165 of an anesthesiologist or other physician, dentist, or podiatrist who is immediately available if
166 needed. Nothing in this subsection shall be construed to prohibit or prevent a certified
167 registered nurse anesthetist as defined in subdivision (8) of section 335.016 from entering into
168 a collaborative practice arrangement under this section, except that the collaborative practice
169 arrangement may not delegate the authority to prescribe any controlled substances listed in
170 Schedules III, IV , and V of section 195.017, or Schedule II - hydrocodone.
171 8. A collaborating physician shall not enter into a collaborative practice arrangement
172 with more than [ six ] ten full-time equivalent advanced practice registered nurses, full-time
173 equivalent licensed physician assistants, or full-time equivalent assistant physicians, or any
174 combination thereof. This limitation shall not apply to collaborative arrangements of hospital
175 employees providing inpatient care service in hospitals as defined in chapter 197 or
176 population-based public health services as defined by 20 CSR 2150-5.100 as of April 30,
177 2008, or to a certified registered nurse anesthetist providing anesthesia services under the
178 supervision of an anesthesiologist or other physician, dentist, or podiatrist who is immediately
179 available if needed as set out in subsection 7 of this section.
180 9. It is the responsibility of the collaborating physician to determine and document
181 the completion of at least a one-month period of time during which the advanced practice
182 registered nurse shall practice with the collaborating physician continuously present before
183 practicing in a setting where the collaborating physician is not continuously present. This
184 limitation shall not apply to collaborative arrangements of providers of population-based
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185 public health services, as defined by 20 CSR 2150-5.100 as of April 30, 2008, or to
186 collaborative practice arrangements between a primary care physician and a primary care
187 advanced practice registered nurse or a behavioral health physician and a behavioral health
188 advanced practice registered nurse, where the collaborating physician is new to a patient
189 population to which the advanced practice registered nurse is familiar .
190 10. No agreement made under this section shall supersede current hospital licensing
191 regulations governing hospital medication orders under protocols or standing orders for the
192 purpose of delivering inpatient or emer gency care within a hospital as defined in section
193 197.020 if such protocols or standing orders have been approved by the hospital's medical
194 staf f and pharmaceutical therapeutics committee.
195 1 1. No contract or other term of employment shall require a physician to act as a
196 collaborating physician for an advanced practice registered nurse against the physician's will.
197 A physician shall have the right to refuse to act as a collaborating physician, without penalty ,
198 for a particular advanced practice registered nurse. No contract or other agreement shall limit
199 the collaborating physician's ultimate authority over any protocols or standing orders or in the
200 delegation of the physician's authority to any advanced practice registered nurse, but this
201 requirement shall not authorize a physician in implementing such protocols, standing orders,
202 or delegation to violate applicable standards for safe medical practice established by hospital's
203 medical staf f.
204 12. No contract or other term of employment shall require any advanced practice
205 registered nurse to serve as a collaborating advanced practice registered nurse for any
206 collaborating physician against the advanced practice registered nurse's will. An advanced
207 practice registered nurse shall have the right to refuse to collaborate, without penalty , with a
208 particular physician.
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;
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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
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 , and 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
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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
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
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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
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.
102 Schedule III narcotic controlled substances and Schedule II - hydrocodone prescriptions shall
103 be limited to a one hundred twenty-hour supply without refill. Such collaborative practice
104 arrangements shall be in the form of a written arrangement, jointly agreed-upon protocols, or
105 standing orders for the delivery of health care services.
106 (2) Notwithstanding any other provision of this section to the contrary , a collaborative
107 practice arrangement may delegate to a physician assistant the authority to administer ,
108 dispense, or prescribe Schedule II controlled substances for hospice patients; provided, that
109 the physician assistant is employed by a hospice provider certified pursuant to chapter 197
110 and the physician assistant is providing care to hospice patients pursuant to a collaborative
111 practice arrangement that designates the certified hospice as a location where the physician
112 assistant is authorized to practice and prescribe.
113 9. The written collaborative practice arrangement shall contain at least the following
114 provisions:
115 (1) Complete names, home and business addresses, zip codes, and telephone numbers
116 of the collaborating physician and the physician assistant;
117 (2) A list of all other of fices or locations, other than those listed in subdivision (1) of
118 this subsection, where the collaborating physician has authorized the physician assistant to
119 prescribe;
120 (3) A requirement that there shall be posted at every of fice where the physician
121 assistant is authorized to prescribe, in collaboration with a physician, a prominently displayed
122 disclosure statement informing patients that they may be seen by a physician assistant and
123 have the right to see the collaborating physician;
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124 (4) All specialty or board certifications of the collaborating physician and all
125 certifications of the physician assistant;
126 (5) The manner of collaboration between the collaborating physician and the
127 physician assistant, including how the collaborating physician and the physician assistant
128 will:
129 (a) Engage in collaborative practice consistent with each professional's skill, training,
130 education, and competence;
131 (b) Maintain geographic proximity , as determined by the board of registration for the
132 healing arts; and
133 (c) Provide coverage during absence, incapacity , infirmity , or emer gency of the
134 collaborating physician;
135 (6) A list of all other written collaborative practice arrangements of the collaborating
136 physician and the physician assistant;
137 (7) The duration of the written practice arrangement between the collaborating
138 physician and the physician assistant;
139 (8) A description of the time and manner of the collaborating physician's review of
140 the physician assistant's delivery of health care services. The description shall include
141 provisions that the physician assistant shall submit a minimum of ten percent of the charts
142 documenting the physician assistant's delivery of health care services to the collaborating
143 physician for review by the collaborating physician, or any other physician designated in the
144 collaborative practice arrangement, every fourteen days. Reviews may be conducted
145 electronically;
146 (9) The collaborating physician, or any other physician designated in the
14 7 collaborative practice arrangement, shall review every fourteen days a minimum of twenty
148 percent of the charts in which the physician assistant prescribes controlled substances. The
149 charts reviewed under this subdivision may be counted in the number of charts required to be
150 reviewed under subdivision (8) of this subsection;
151 (10) A statement that no collaboration requirements in addition to the federal law
152 shall be required for a physician-physician assistant team working in a certified community
153 behavioral health clinic as defined by Pub.L. 1 13-93, or a rural health clinic under the federal
154 Rural Health Services Act, Pub.L. 95-210, as amended, or a federally qualified health center
155 as defined in 42 U.S.C. Section 1395x, as amended; and
156 (1 1) If a collaborative practice arrangement is used in clinical situations where a
157 collaborating physician assistant provides health care services that include the diagnosis and
158 initiation of treatment for acutely or chronically ill or injured persons, then the collaborating
159 physician or any other physician designated in the collaborative practice arrangement shall be
160 present for suff icient periods of time, at least once every two weeks, except in extraordinary
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161 circumstances that shall be documented, to participate in a chart review and to provide
162 necessary medical direction, medical services, consultations, and supervision of the health
163 care staff .
164 10. The state board of registration for the healing arts under section 334.125 may
165 promulgate rules regulating the use of collaborative practice arrangements.
166 1 1. The state board of registration for the healing arts shall not deny , revoke, suspend,
167 or otherwise take disciplinary action against a collaborating physician for health care services
168 delegated to a physician assistant, provided that the provisions of this section and the rules
169 promulgated thereunder are satisfied.
170 12. W ithin thirty days of any change and on each renewal, the state board of
171 registration for the healing arts shall require every physician to identify whether the physician
172 is engaged in any collaborative practice arrangement, including collaborative practice
173 arrangements delegating the authority to prescribe controlled substances, and also report to
174 the board the name of each physician assistant with whom the physician has entered into such
175 arrangement. The board may make such information available to the public. The board shall
176 track the reported information and may routinely conduct random reviews of such
177 arrangements to ensure that the arrangements are carried out in compliance with this chapter .
178 13. The collaborating physician shall determine and document the completion of a
179 period of time during which the physician assistant shall practice with the collaborating
180 physician continuously present before practicing in a setting where the collaborating
181 physician is not continuously present. This limitation shall not apply to collaborative
182 arrangements of providers of population-based public health services as defined by 20 CSR
183 2150-5.100 as of April 30, 2009.
184 14. No contract or other arrangement shall require a physician to act as a
185 collaborating physician for a physician assistant against the physician's will. A physician
186 shall have the right to refuse to act as a supervising physician, without penalty , for a particular
187 physician assistant. No contract or other agreement shall limit the collaborating physician's
188 ultimate authority over any protocols or standing orders or in the delegation of the physician's
189 authority to any physician assistant. No contract or other arrangement shall require any
190 physician assistant to collaborate with any physician against the physician assistant's will. A
191 physician assistant shall have the right to refuse to collaborate, without penalty , with a
192 particular physician.
193 15. Physician assistants shall file with the board a copy of their collaborating
194 physician form.
195 16. No physician shall be designated to serve as a collaborating physician for more
196 than [ six ] ten full-time equivalent licensed physician assistants, full-time equivalent advanced
197 practice registered nurses, or full-time equivalent assistant physicians, or any combination
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198 thereof. This limitation shall not apply to physician assistant collaborative practice
199 arrangements of hospital employees providing inpatient care service in hospitals as defined in
200 chapter 197, or to a certified registered nurse anesthetist providing anesthesia services under
201 the supervision of an anesthesiologist or other physician, dentist, or podiatrist who is
202 immediately available if needed as set out in subsection 7 of section 334.104.
203 17. No arrangement made under this section shall supercede current hospital licensing
204 regulations governing hospital medication orders under protocols or standing orders for the
205 purpose of delivering inpatient or emer gency care within a hospital, as defined in section
206 197.020, if such protocols or standing orders have been approved by the hospital's medical
207 staf f and pharmaceutical therapeutics committee.
✔
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