Several new state laws that impact physician assistants (PAs), advanced practice registered nurses (APRNs) and the physicians who work with them in hospitals and other clinical settings go into effect on October 1, 2012. The most substantial change requires that a “written delegation agreement” be entered between PAs and their supervising physicians, and that the agreement be reviewed at least annually thereafter.
Under prior law, the medical functions that a PA could perform were to be set forth in written protocols established by the supervising physician, but little guidance was provided on what the protocols were required to contain. Public Act 12-37 renames the written protocols the “written delegation agreement” and specifies certain requirements which must be contained in the agreement, including:
- A description of the professional relationship between the supervising physician and the PA;
- Identification of the medical services the PA may perform;
- A description of the manner in which the PA’s prescribing of controlled substances must be documented in the patient’s medical record;
- A description of the process for the supervising physician to evaluate the PA’s performance, including, but not limited to, (i) the frequency with which the supervising physician intends to personally review the PA’s performance and (ii) a description of the manner in which and the frequency with which the supervising physician intends to review the PA’s prescription and administration of controlled substances in Schedules II or III; and
- For supervising physicians in a hospital setting, a reference to, or the inclusion of, applicable hospital policies, protocols and procedures is required.
Public Act 12-37 also requires that the written delegation agreement be amended in each of the following circumstances:
- A change in the professional relationship between the parties;
- A change in the medical services the PA is authorized to perform; and/or
- A change in the process for evaluating the PA’s performance.
These changes are particularly important because, in recent years, the Department of Social Services (DSS) has subjected the relationships between PAs, APRNs and physicians to increased scrutiny. If a DSS audit reveals the lack of a proper written delegation agreement, DSS has the ability to disallow entire claims. For this reason, the supervising physician and the PA should sign and date the delegation agreement each year, even if an amendment to their agreement is not necessary upon annual review.
It is also noteworthy that, in response to calls from the Connecticut Academy of Physician Assistants and others for more liberal scope of practice for PAs, the new law does away with the requirement that the supervising physician personally review the PA’s practice at least weekly and, in settings other than a hospital, have face-to-face meetings with the PA for this purpose. Instead, the new law requires a PA’s practice to be reviewed in both the hospital and the non-hospital setting on a “regular basis” in accordance with the written delegation agreement. Lastly, the requirement that a supervising physician document approval of a PA’s prescription of a Schedule II or III controlled substance within one calendar day has been eliminated in favor of an approval process prescribed by the written delegation agreement.
With regard to APRNs, Connecticut providers should be aware that Sections 22 through 41 of Public Act 12-197 revise a number of public health statutes to allow APRNs to certify or sign medical information that previously required a physician’s certification or signature. Most of the certifications covered by the Act involve situations where an individual must provide medical information to third parties in order to be exempt from a general requirement (e.g., certification that participation in physical education classes is contraindicated for a student because of his/her medical condition; certification that certain immunizations are contraindicated for a college student and thus not required for admission; and certification that an individual is ill or incapacitated and thus needs an extension for applying for certain financial relief programs).