1. MARC MOOTE, M.S., P.A.-C CHIEF PHYSICIAN ASSISTANT UNIVERSITY OF MICHIGAN HEALTH SYSTEM Understanding the Public Health Code

2. 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

3. Terminology Matters… Allied Health Professional (AHP)? Licensed Independent Practitioner (LIP)? Non-physician Provider (NPP)? Midlevel Provider (MLP)? Advanced Practice Professional (APP)? Physician’s Assistant?  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

4. 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?”

5. Know the Landscape – Regulatory Drivers that Affect PA Scope of Practice 5 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

6. Federal Level Medicare Hospital Conditions of Participation (CoPs):  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.

7. 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!

8. I. G ENERAL S COPE OF P RACTICE Physician Assistants

9. State Level PAs are licensed to practice medicine under physician supervision pursuant to Article 15, Part 170 of the Michigan Public Health Code.

10. 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).

11. 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

12. 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)

13. 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

14. 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.

15. 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*** ***MAPA Legislative Goal = Remove Ratios***

16. 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  Exception: Discharge summaries [CMS Interpretive Guidelines §482.24(c)(2)(vii)]

17. 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

18. 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

19. 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

20. 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).

21. Restraint Orders CMS TJC State law Hospital Policy

22. 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.”

23. 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).”

24. 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."

25. 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.

26. 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 Supported by AG Opinion 5220 Despite clear guidance from CMS, TJC, MI State Law, PAs ordering restraints in MI under delegation remained controversial

27. 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)].

28. 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:  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

29. 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)].

30. 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)].

31. 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).

32. II. G ENERAL S COPE OF P RACTICE Registered Professional Nurses and Advanced Practice Nurses, including Nurse Practitioners

33. 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)

34. 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).

35. A. M EDICALLY D ELEGATED F UNCTIONS AND S UPERVISION

36. 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).

37. B. N URSE S PECIALISTS, APN S

38. 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)

39. C. P RESCRIBING A UTHORITY

40. 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.

41. 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.

42. III. DEA R EQUIREMENTS A PPLICABLE TO B OTH PA S & APRN S

43. 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

44. 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.

45. 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. Michigan Board of Pharmacy Administrative Rule 338.3161

46. E. S IGNATURE R EQUIREMENTS 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.

47. 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. Michigan Board of Pharmacy Administrative Rule 338.3161

48. 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…

49. Summary You must know the MPHC & its importance  Advocacy efforts (facility, state)  Hospital privileging  Hospital policies  TJC/CMS surveys  Malpractice claims 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…

50. Thank you!

51. 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 http://www.legislature.mi.gov/(S(ks3zh145jbzzrx55 5qrpqc45))/mileg.aspx?page=GetObject&objectnam e=mcl-Act-368-of-1978

52. 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 http://www7.dleg.state.mi.us/orr/AdminCode.aspx? AdminCode=Department&Dpt=LR&Level_1=Burea u+of+Health+Care+Services