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Cancer Center in Houston, called the bill “a gift from heaven,” for two reasons. First, the negotiations brought together the three profes- sions he says are at the heart of providing primary care. “Any time we can get together and agree on how to serve our patients in safe teams is a tremendous asset for any com- munity, state, hospital, or practice,” said Mr. Pickard, chair of TAPA’s Legislative Affairs Committee. Second, the measure does away with regulatory barriers

he says keep cancer patients waiting for pain medications be- cause a doctor is unavailable to come to the bedside. The bill also removes rules that have physicians and PAs in rural areas, in particular, spending hours in their cars or filling out chart logs when they could be treating patients. “When people are in pain, you don’t want to keep them waiting. Nowadays, the reality is, we [physicians, nurses, and PAs] talk all the time in person or through electronic records, Skype, and cell phones. How else do you practice team care?”

A better system Key features of the legislation would:

• Replace site-based requirements, such as mileage limita- tions and percentage of chart reviews, with a prescriptive authority agreement;

• Establish minimum standards for prescriptive authority agreements, such as face-to-face quality assurance meetings, while giving physicians and other practitioners flexibility to determine the specifics, such as where the meetings occur and the percentage of charts that must be reviewed;

• Allow hospital-based practices and practices serving medi- cally underserved populations to remain unlimited in the number of APRNs and PAs to which a physician may del- egate prescriptive authority;

• Increase the number of APRNs and PAs to whom a physi- cian may delegate prescriptive authority from four to seven at any other practice sites;

• Ensure patient safety by improving communication and coordination between TMB, the Texas Board of Nursing (BON), and the Texas Physician Assistant Board (PAB) re- garding those who have entered into prescriptive authority agreements; and

• Allow physicians to delegate prescriptive authority for Schedule II controlled substances to APRNs and PAs in hos- pitals and hospices only.

Dr. Floyd says the changes help streamline the myriad of

current requirements for practice protocols through the use of an overarching prescriptive authority agreement. Physicians and the APRNs and PAs they supervise would

have to sign on to the document, which, among other require- ments, must detail the types of drugs or medical devices mid- level practitioners may prescribe upon delegation by a physi- cian, and must identify any alternate supervising physicians who may oversee those and other activities. The bill also requires that the agreement outline a quality

assurance plan that specifies, for example, a level of chart re- view determined by the team and periodic face-to-face meet- ings wherever they choose. While there are minimum requirements for implement- ing the agreement, physicians and their teams also can tailor other agreed-upon provisions as they see fit, Dr. Floyd says. “This allows the team to de- velop a quality assurance plan within the environment they work in” while maintaining a regulatory mechanism. Dr. Fiesinger also empha- sized what the bill does not change. For example, it preserves

exceptions to the cap on the number of APRNs and PAs a physician can supervise in ru- ral and facility-based settings. And, prescriptive authority agreements still must be reg- istered with the state medical board.

Gary Floyd, MD, consultant to the TMA Council on Legislation, testifies at a Senate hearing to urge lawmakers to pass legislation improving the system for physician delegation of midlevel practitioners.


On the other hand, the big- gest shift under the legislation is permitting the prescription delegation of Schedule II med- ications to APRNs and PAs in


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