Nuts & Bolts : SB 337

Jeremy Adler, PA-C

Greg Mennie, PA-C

Bob Miller, PA

SB 337 GOALS

• Increase flexibility and improve utilization of PAs in California’s Workforce

• Recognize that PA and physicians are both PROFESSIONALs and should be empowered to determine how to best work together to provide high quality care

• Ease administrative burdens and eliminate cosignatures consistent with AAPA model practice act

• Shift to the focus to the quality outcome and welfare of patients treated by PA/physician team, rather than focus on the relationship between the PA and physician

• Ensure medical decisions dominate patient care, rather than administrative. Rescheduling of HCP to CII demanded substantial new administrative burden

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SB 337 : From Egg to Chicken

• Introduced by Senator Fran Pavley 2/23/15

• Amended in Senate 4/13/15

• Senate Business & Professions Committee 4/20/15

• Senate Appropriations Committee 5/12/16

• Senate Floor Vote 5/26/15

• Amended in Assembly 6/16/15

• Assembly Business & Professions Committee 6/23/16

• Assembly Appropriations Committee 7/8/15

• Assembly Floor Vote – Consent 7/16/15

• Senate Concurrence – Ordered back to Assembly for Amendments 7/16/15

• Amended in Assembly 9/1/15

• Assembly Floor Vote 9/3/15

• Enrolled and sent to Governor 9/8/15

• Approved by Governor and Chaptered 10/6/15 (PA DAY!)

• CAPA members letters and SP letters of support

• Meetings with Senators and Assembly members. Sacramento Lobby Day

• Not to forget stakeholder meetings, calls, discussion with PA Board, Medical Board of California, California Medical Association, California Academy of Family Physicians, Osteopathic Physicians and Surgeons of California, California Pharmacists Association and others

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HCP Rescheduled from III to II

Effective 10/6/14

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Concerns of Opposition

• California Pharmacist AssociationThe DEA is attempting to curb overprescribing of HCPs (Hydrocodone Combination Products to

reduce abuse and ensure more judicious use of these drugs. This bill would counter the efforts of the

DEA by reducing supervision of PAs relative to their prescribing of HCPs and all other Schedule II

drugs.

• Medical Board of California“[the MBC] recognizes that the intent of this bill is to provide flexibility and allow for a more team-based approach in

PA supervision, which the [MBC] believes is a laudable goal. The recent amendments addressed concerns raised by the

[MBC]…. However, the [MBC] still has concerns related to the reduced physician review of Schedule II drug orders from

100 percent to 20 percent, as this is a significant reduction of supervising physician review for types of opioid

medications that are prevalent for abuse.”

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Concerns of Opposition

• PA Board

A Growing Problem with EHR

How to Comply?

CCR, 1399.546. Reporting of PA Supervision.

Each time a physician assistant provides care for a patient and enters his or her name, signature, initials, or computer code on a patient’s record, chart or written order, the physician assistant shall also enter the name of his or her supervising physician who is responsible for the patient. When a physician assistant transmits an oral order, he or she shall also state the name of the supervising physician responsible for the patient.

B

SB 337 Added to B&P Code

3502. (a) … The medical record, for each episode of care for a

patient, shall identify the physician and surgeon who is

responsible for the supervision of the physician assistant.

B

Compliance Made Possible

For 1399.546

3502. (f) Compliance by a physician assistant and supervising

physician and surgeon with this section shall be deemed

compliance with Section 1399.546 of Title 16 of the California

Code of Regulations.

B

SA-CME Question #1

When functioning under protocols, the mechanism of

supervision documentation for PA/SP teams must be identified in

the Delegation of Services Agreement.

TRUE

FALSE

G

Physician Required to Countersign

Documents and MRs

• 1399.540 (b) A delegation of services agreement shall be

signed and dated by the physician assistant and each

supervising physician.

• 3502. (c)(1)(D) Protocols shall be signed and dated by the

supervising physician and surgeon and the physician assistant.

• 3502 __ … Countersign MRs reviewed by SP. Jointly sign

“documentation” of Med. Record Review Meetings

• 3502.1 (e) MRs for Schedule II orders. Minimum 20% IF PA

has passed the Controlled Substance Education Course

B

SA-CME Question #1 - ANSWER

When functioning under protocols, the mechanism of

supervision documentation for PA/SP teams must be identified in

the Delegation of Services Agreement.

TRUE

FALSE

There is NO PROVISION that requires the mechanism of

documenting supervision be included in the DSA

B

SA-CME Question #2

A PA must hold a certificate of completion of a Controlled

Substance Education Course in order to obtain a DEA Registration

to prescribe controlled substances.

TRUE

FALSE

B

SA-CME Question #2 - ANSWER

A PA must hold a certificate of completion of a Controlled Substance Education Course in order to obtain a DEA Registration to prescribe controlled substances.

TRUE

FALSE

DEA Registration is required to prescribe a controlled substance, but DEA DOES NOT require completion of course

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SA-CME Question #3

When a PA prescribes a schedule II controlled substance, the

medical records must always be cosigned by a SP.

TRUE

FALSE

B

SA-CME Question #4

A PA must take a Controlled Substance Education Course to

prescribe controlled substances in California.

TRUE

FALSE

B

Countersignatures for Schedule II

(If No Controlled Substance Course)

3502.1 (c)(2)A physician assistant may not administer, provide, or issue a drug order to a patient for Schedule II through Schedule V controlled substances without advance approval by a supervising physician and surgeon for that particular patient …

AND

3502.1 (e)(1) The medical record of any patient cared for by a physician assistant for whom the physician assistant’s Schedule II drug order has been issued or carried out shall be reviewed, countersigned, and dated by a supervising physician and surgeon within seven days.

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If The PA Has Passed The Controlled Substance

Education Course:3502.1 (c)(2) … advanced approval … unless the physician assistant has completed an education course …

AND

3502.1 (e)(2) … the supervising physician and surgeon shall review, countersign, and date, within seven days, a sample consisting of the medical records of at least 20 percent of the patients cared for by the physician assistant for whom the physician assistant’s Schedule II drug order has been issued or carried out.

AND

3502.1 (e)(2) … Physician assistants who have a certificate of completion of the course … shall be deemed to have met the education course Requirement.

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SA-CME Question #5

If a PA has taken the Controlled Substance Education Course

prior to the implementation of SB 337, they will need to retake

the course to be able to have the cosignatures decreased for

medical records when schedule II medication is prescribed.

TRUE

FALSE

B

SA-CME Question #4 - ANSWER

A PA must take a Controlled Substance Education Course to prescribe controlled substances in California.

TRUE

FALSE

PAs are not required to take course, but must obtain advanced approval and have 100% of schedule II controlled substance medical records cosigned within 7 days

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SA-CME Question #5 - ANSWER

If a PA has taken the Controlled Substance Education Course

prior to the implementation of SB 337, they will need to retake

the course to be able to have the cosignatures decreased for

medical records when schedule II medication is prescribed.

TRUE

FALSE

“Physician assistants who have a certificate of completion of the course …

shall be deemed to have met the education course Requirement”J

SA-CME Question #6

To enjoy the expanded scope of practice from the Controlled

Substance Education Course, it must be taken at a frequency of:

a. Every 2 years

b. Every 6 years

c. Only once, it doesn’t need to be retaken

d. Every 10 years

B

SA-CME Question #6 - ANSWER

To enjoy the expanded scope of practice from the Controlled

Substance Education Course, it must be taken at a frequency of:

a. Every 2 years

b. Every 6 years

c. Only once, it doesn’t need to be retaken

d. Every 10 years

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SA-CME Question #7

A PA has completed a Controlled Substance Education Course and prescribes 20 patients schedule II medications over the month. What minimum percent of the medical records that month require cosignatures by the SP? (Note, if a cosignature is required, it must be dated within 7 days of treatment by the PA)

a. 100% - all 20 medical records

b. 5% - 1 medical records

c. 20% - 4 medical records

d. None – 0%

B

SA-CME Question #7 - ANSWER

A PA has completed a Controlled Substance Education Course and prescribes 20 patients schedule II medications over the month. What minimum percent of the medical records that month require cosignatures by the SP? (Note, if a cosignature is required, it must be dated within 7 days of treatment by the PA)

a. 100% - all 20 medical records

b. 5% - 1 medical records

c. 20% - 4 medical records

d. None – 0%

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SA-CME Question #8

Upon completion of the Controlled Substance Education Course, all of the following are true when a PA is functioning with protocols EXCEPT:

a. A controlled substance may be prescribed without the prior approval of a SP

b. A SP must cosign a minimum of 20% of the medical records when schedule II medications are prescribed

c. When prescribing a controlled substance, a PA is no longer subject to reasonable quantitative limitations consistent with the

customary medical practice of the SP

d. A PA holding a successful completion certificate of the Controlled Substance Education Course, do not need to retake the course

to enjoy the benefits implemented in SB337

B

SA-CME Question #8 - ANSWER

Upon completion of the Controlled Substance Education Course, all of the following are true when a PA is functioning with protocols EXCEPT:

a. A controlled substance may be prescribed without the prior approval of a SP

b. A SP must cosign a minimum of 20% of the medical records when schedule II medications are prescribed

c. When prescribing a controlled substance, a PA is no longer subject to reasonable quantitative limitations consistent with the

customary medical practice of the SP

d. A PA holding a successful completion certificate of the Controlled Substance Education Course, do not need to retake

the course to enjoy the benefits implemented in SB337PAs still are subject to reasonable quantitative limitations for controlled

substance prescribing

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SB 337 Added Options

For Documentation

3502. (c)(2)(A) The supervising physician and surgeon shall use

one or more of the following mechanisms to ensure adequate

supervision of the physician assistant functioning under the

protocols:

B

SB 337

• PA Practice Act

– 3502. (2)(A) (i), (ii), (iii)

B

Option (i) Existing Since 2008

3502. (c)(2)(A)(i) The supervising physician and surgeon shall

review, countersign, and date a sample consisting of, at a

minimum, 5 percent of the medical records of patients treated

by the physician assistant functioning under the protocols within

30 days of the date of treatment by the physician assistant.

B

An Example Year – 5% Cosign

J 5%

F 5%

M 5%

A 5%

M 5%

J 5%

J 5%

A 5%

S 5%

O 5%

N 5%

D 5%

No Schedule II Controlled Substances Prescribed

B

G

SA-CME Question #9

What percent of medical records must be COSIGNED within 30

days of treatment by the PA if schedule II medications are not

prescribed and the PA has chosen medical records review

meetings while functioning under protocols?

a. 0%

b. 5%

c. 20%

d. 100%

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SA- CME Question #10

All of the following are true regarding Medical Records Review Meetings EXCEPT:

a. The total number of records reviewed must at minimum include 10 per month for 10 months of the year.

b. Medical Records Review Meetings must occur in person.

c. The PA and SP shall both jointly sign documentation to memorialize that the meeting(s) occurred, but do not require details of the content of the meeting(s).

d. It is acceptable for a Medical Records Review Meeting to have occurred when casually walking down a hospital corridor and the documentation for that meeting need not be in the patient’s medical record.

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What’s New –

Medical Records Review Meeting

3501. (a)(12) “Medical records review meeting”

means a meeting between the supervising

physician and surgeon and the physician

assistant during which medical records are

reviewed to ensure adequate supervision of the

physician assistant functioning under protocols.

Medical records review meetings may occur in

person or by electronic communication.

G

Option (ii) is NEW – Medical Records Review Meeting

Do 10/10

• PA Practice Act

– 3502. (c)(2)(A) (ii),

The supervising physician and surgeon and physician assistant

shall conduct a medical records review meeting at least once a month during at least 10 months of the year. During any

month in which a medical records review meeting occurs, the

supervising physician and surgeon and physician assistant shall

review an aggregate of at least 10 medical records of patientstreated by the physician assistant functioning under protocols.

Documentation of medical records reviewed during the month

shall be jointly signed and dated by the supervising physicianand surgeon and the physician assistant.

G

SA-CME Question #9 - ANSWER

What percent of medical records must be COSIGNED within 30

days of treatment by the PA if schedule II medications are not

prescribed and the PA has chosen medical records review

meetings while functioning under protocols?

a. 0%

b. 5%

c. 20%

d. 100%

Medical Records Review Meeting documentation requirements DO NOT include medical

record cosignatures.G

The Universe’s 10% Law

• The 10% Rule means that when energy is

passed in an ecosystem from one trophic level

to the next, only ten percent of the energy will

be passed on.

G

SB 337 (ii) 10/10 rule

• Less Time

• Less Energy

• Bigger return

• CHOICE

If you choose to

G

10/10

• Minimum 10 Charts/month

• 10 months out of the year

• Minimum 100 charts

• Reviewing– Skyping and Talking

– Sitting and Talking

– Walking and Talking

– Calling and Talking

• Let’s do Lunch

– Document the meeting

G

SA- CME Question #10 - ANSWER

All of the following are true regarding Medical Records Review Meetings EXCEPT:

a. The total number of records reviewed must at minimum include 10 per month for 10 months of the year.

b. Medical Records Review Meetings must occur in person.

c. The PA and SP shall both jointly sign documentation to memorialize that the meeting(s) occurred, but do not require details of the content of the meeting(s).

d. It is acceptable for a Medical Records Review Meeting to have occurred when casually walking down a hospital corridor and the documentation for that meeting need not be in the patient’s medical record.

Meetings may occur in person or by electronic communication

G

MATH

• 76 = Average number of patients seen per

week for PA’s.

• 44 = Average number of weeks worked per

year.

• =5% minimum number of charts needing

signature.

• 167 charts

2014 Statistical Profile of Certified Physician Assistants. NCCPA.

G

NOT a SA-CME Question

Which is Less?

a. 167

b. 100

G

G

One EXAMPLE of documentation sheet

G

Option (iii) is NEW – Combination

• PA Practice Act

– 3502. (c)(2)(A) (iii),

3502. (c)(2)(A)(iii) The supervising physician and surgeon shall

review a sample of at least 10 medical records per month, at least

10 months during the year, using a combination of the

countersignature mechanism described in clause (i) and the

medical records review meeting mechanism described in clause (ii)

During each month for which a sample is reviewed, at least one of

the medical records in the sample shall be reviewed using the

mechanism described in clause (i) and at least one of the medical

records in the sample shall be reviewed using the mechanism

described in clause (ii).

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WHAT#&@?!

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Wait a second….

This is EASIER!

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SA-CME Question #11A PA/SP team chose to document with all available mechanisms, including cosignatures, medical record review meetings and the combination mechanism of both. If 500 patients were seen by the PA over the month, and no schedule II medications were prescribed, all of the following are compliant with documentation EXCEPT:

a. 5% cosignature of the medical records which is 25 cosignatures

b. 10 medical records reviewed through medical record review meetings

c. 1 medical record reviewed through a medical record review meeting and 9 medical records cosigned

d. This month, NO medical records were reviewed through cosignatures or medical records review meetings because the requirements were met using the mechanisms in answers B and/or C above for 10 months during the year, and this is an off month.

e. All of the above are TRUE

G

SB 337 Added Options

For Documentation

3502. (c)(2)(A) The supervising physician and surgeon shall use

one or more of the following mechanisms to ensure adequate

supervision of the physician assistant functioning under the

protocols:

J

An Example Year

J MRM (10)

F MRM (10)

M MRM (10)

A signed (5) + MRM (5)

M signed (1) + MRM (9)

J MRM (10)

J None

A MRM (10)

S signed (4)+ MRM (6)

O signed 5%

N None

D MRM (10)

MRM= Medical Record Review meeting (ii) Signed = Supervising Physician countersign (i)

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SA-CME Question #11 - ANSWERA PA/SP team chose to document with all available mechanisms, including cosignatures, medical record review meetings and the combination mechanism of both. If 500 patients were seen by the PA over the month, and no schedule II medications were prescribed, all of the following are compliant with documentation EXCEPT:

a. 5% cosignature of the medical records which is 25 cosignatures

b. 10 medical records reviewed through medical record review meetings

c. 1 medical record reviewed through a medical record review meeting and 9 medical records cosigned

d. This month, NO medical records were reviewed through cosignatures or medical records review meetings because the requirements were met using the mechanisms in answers B and/or C above for 10 months during the year, and this is an off month.

e. All of the above are TRUE

B

SB 337 Highlights – Putting it Together

– Each and every time entering SP is now once per episode of care

– Certificate of Completion from CSEC enables cosignature reduction from 100% down to 20% on schedule II controlled substance medical records

– New mechanisms to document supervision through Medical Records Review Meetings and combination options

– Greater flexibility in options empowers PA/SP teams

QUESTIONS?

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