In welcome news to most anyone who supervises, employs, credentials, or is a physician assistant, amendments to California Business and Professions Code Section 3500 et seq., effective January 1, 2020, significantly simplify the supervision requirements for PAs in California.
Prior to these changes, physicians and PAs had to enter into “delegation of services agreements,” specifically delegating the medical services a PA could perform. If multiple physicians were supervising the PA – such as in a group practice or at a hospital – each had to either sign the delegation of services agreement or create their own. The law also detailed specific, limited ways in which physicians could perform their supervisory tasks; these included chart reviews, countersigning records, the creation of patient-specific protocols, and medical record review meetings.
The changes to the law remove some of the more onerous requirements, streamlining the supervisory process in a way that better reflects current industry practice.
Delegation of Services Agreements Replaced With Practice Agreements
One significant change is the replacement of “delegation of services agreements” with “practice agreements.” Like the old delegation of services agreements, practice agreements are required for the PA to practice, must be developed with at least one physician, and must define the medical services the PA is authorized to perform. However, in a striking break from past requirements, the practice agreements, while “developed through collaboration” with one or more physicians, grants approval for all the physicians on the staff of an “organized health care system” to supervise one or more PAs in the organized health care system.
In other words, whereas delegation of services agreements were like contracts directly between each PA and his or her own supervising physician or physicians, the new practice agreement is more like a standardized procedure, which is the supervisory document that applies to advanced practice registered nurses (APRNs). Like standardized procedures, practice agreements apply to the organized health care system as a whole and allow any physician within the system to supervise any PA subject to the practice agreement.
So what is an “organized health care system”? It’s a new term that Section 3501 defines broadly to include, among other settings, licensed clinics, health care facilities (such as hospitals and nursing facilities), home health agencies, physician’s offices, professional medical corporations, medical partnerships, and medical foundations – essentially, any setting where medical care is lawfully provided. This is a welcome change for hospitals and medical groups that employ PAs to provide hospitalist-type services or services in outpatient clinics with multiple physicians.
Practice Agreements Have Specific Requirements
Section 3502.3 details practice agreement requirements. At minimum, they must include the types of medical services the PA is authorized to perform; policies and procedures for adequate supervision, including communication, availability, consultation, and referrals with physicians; methods for continuing evaluation of the PA’s competency and qualifications; the furnishing or ordering of drugs; and any additional provisions. All the PAs covered by the agreement and at least one physician authorized to approve the practice agreement on behalf of the other physicians on the organized health care system staff must sign the agreement.
So do physicians and PAs across California have to immediately adopt practice agreements that meet the statutory standards? No. The law deems a delegation of services agreement in effect prior to January 1, 2020, to meet the requirements of a practice agreement. However, larger practices and hospitals should consider whether they should exchange their delegation of services agreements with the more nimble practice agreements.
Supervision Requirements and Drug Ordering Provisions Dramatically Streamlined
Another welcome change is the elimination of very specific – and often onerous – supervision requirements. “Supervision” still means that a licensed physician and surgeon (not a podiatrist, dentist, or other practitioner) “oversees the activities of, and accepts responsibility for, the medical services” the PA renders. However, supervision now merely requires the PA to adhere to the supervision agreed upon in the practice agreement, and the physician being available by telephone or other electronic communication whenever the PA examines the patient. Also importantly, PAs are no longer automatically considered the agent of the physician. The PA and the supervising physician may include a provision designating the PA as the physician’s agent in the practice agreement, but the value of such a designation is unclear.
Provisions governing the PA’s furnishing or ordering of drugs and devices also have changed significantly. Replacing the prior complex requirements, the revisions to Section 3502.1 now require only that the PA furnish or order a drug in accordance with the practice agreement and consistent with the PA’s education or clinical competency. The practice agreement must specify which PA or PAs may furnish a drug or device; under what circumstances; the extent of physician supervision; and the method of periodic review of the PA’s competence (which includes peer review). Among other things, this means that for organizations employing multiple PAs, the practice agreement will need to identify clearly which PAs are authorized to furnish or order specified drugs or devices. Although not addressed in the law, this likely can be done by appending a page to the practice agreement identifying each PA and what he or she is authorized to order.
The law has specific requirements for PAs ordering and furnishing Schedule II and III drugs, which can be done in accordance with the practice agreement or with a patient-specific order approved by the treating or supervising physician. The statute includes additional specific requirements the supervising physician and the PA must meet for the PA to furnish or order Schedule II and III drugs. PAs and supervising physicians should carefully review the statute and strictly adhere to these requirements.
Adjusting Practices to the Changes
For years, PAs, physicians, and health care organizations have found the complex PA supervision requirements a burden inconsistent with current practice standards. Additionally, previous requirements significantly differed from APRN supervision requirements, despite education and training that prepared PAs to practice at a medical level of care. The changes to the law should resolve at least some of these issues. However, PAs, physicians, and health care organizations should not confuse practice agreements with APRN standardized procedures, and should ensure that they apply PA requirements (not APRN requirements) to PAs. PAs, physicians, health care organizations and medical groups also should review their current practices and determine whether the adoption of new practice agreements would benefit their organizations and patient care.