Health License Defense » mid-level providers

Can Physician Assistants & Nurse Practitioner’s Own Clinics?

Jon Porter — Thu, 16 Dec 2010 00:20:14 +0000

Currently, there is no law that prohibits this practice. With the legislature coming to town, there may be a push by the Texas Medical Association to ban this practice, but I do not see the legislature doing so this session. There are too many other issues to tackle and it is anti-free market.

However, the Texas Medical Board and the Texas Physician Assistant Board have formed an Ad-Hoc Committee to see if this issue needs to be prohibited, curtailed, regulated or ignored. They recently had their first meeting. The Boards well-know that such clinics currently exist. The fear for the Board’s is the relationship between the mid-level provider, who is the owner and employer and the supervising physician, who is the employee (actually independent contractor) in this relationship.

Such a relationship is currently, and technically legal as long as the physician is an independent contract who maintains independent medical judgment. The argument is a physician cannot maintain independent medical judgment and supervise a mid-level provider while also reliant upon the mid-level provider for a pay check. One Texas Medical Board member expressed a concern that “fringe” doctors are more likely to enter into this relationship than other physicians.

There was a lot of brain-storming on possible regulation that could occur. The Executive Director, Mari Robinson, correctly informed the members of the Boards that regardless of the direction the Boards take they are likely to get sued. She also pointed out to the PA Board that they are obviously limited to Physician Assistants, thus any regulation they put into place; it does not affect Nurse Practitioners. Likewise, with the Medical Board, the regulation only affects the supervising physician.

Nothing was resolved at this first meeting of the ad-hoc committee. The next meeting will be February 3^rd.

Budget Troubles Will Effect Health Licensing Board

Jon Porter — Thu, 09 Dec 2010 15:41:31 +0000

On December 7^th, the Governor, the Lt. Governor, and the Speaker of House sent a letter to all state agencies, including all the health licensing board, and directed them to cut 2.5% of their budget for rest of the 2011 Fiscal Year. The FY 2011 began on September 1^st. The FY 2011 began with a directive to cut 3% of their budget; thus budgets have now been cut 5.5%. As the vast majority of budget for health licensing agencies are salaries for staff, this has meant hiring freezes in some agencies.

For FY 2012 and 2013, the Governor, the Lt. Governor, and the Speaker of House told agencies to offer budget 10% less than their FY 2011 budgets. This will mean lost of more staff, slower time to process new licenses and slower time to investigate cases. The Texas Medical Board reports it believes it will generate less income for the state for due to its budget cuts. The Board did not explain how this would occur.

It is possible, the further cuts will occur. It is even more likely professional renewal fees will increase as will new licensure application fees. The reason these things will occur is the projected budget deficit is 23 billion dollars. Even if the legislature ends all state programs other than education, prisons, roads, law enforcement, and Medicaid, there will still be deficit; therefore, it seems logical to assume more cuts and larges fees are a matter of when, and not if.

Delegation Waivers Limited

Jon Porter — Thu, 30 Sep 2010 22:23:04 +0000

At the August 25^th meeting of the Standing Delegation Committee, there was an open discussion that it was the possession of the committee is that requests for waiver of the mid-level supervision rules filed appear, in the opinion of the committee, were being requested too often for the physician’s convenience with no benefit to the patients. As such, it is the position of the committee that without compelling evidence of public benefit, the committee will generally lean towards denying requests.

Ratio law in California is shown to prevent deaths

Taralynn Mackay — Thu, 06 May 2010 16:11:09 +0000

The ratio law in California that limits the number of patients per nurse was the subject of a research study and the findings support that the ratio is preventing deaths and improving nurse’s beliefs about their job performance. Victoria Colliver’s April 20, 2010 article “Pioneering Law on Nurses Found to Save Lives” describes the findings of the study conducted by the University of Pennsylvania. The California nurses on a medical-surgical floor have 5 patients to every nurse and the differences between California and non-ratio states examined is definitely fuel to support ratios.

When ratios were first discussed, I thought the law would be loosely written so that hospitals could “meet” the law, but there would be no visible improvement for nurses or patients. That seems to be the case with Texas’ staffing law; I just don’t see any improvement and still receive multiple complaints from nurses that are being forced to work under unsafe staffing numbers and when they refuse the unsafe assignments they are charged with abandonment. The article notes that other states are considering ratios. Perhaps Texas will also consider changes to the law to protect nurses and patients, but history does not support this. Nurses need to be politically active and join associations that promote nursing and fight for nursing laws; just complaining will do no good, nurses must take action and support the associations that work on legislative issues on behalf of nursing in Texas. National organizations/associations will not focus on individual state issues so be sure to check into any association/organization you are thinking of joining to see what their legislative mandates/agendas are.

Trying to find a job while under a Board Order

Taralynn Mackay — Wed, 03 Feb 2010 16:30:09 +0000

I have heard from another nurse who is having a difficult time obtaining a job while under a Board Order. This is an ongoing problem especially in this economy. Some employers are refusing to hire a nurse no matter what the basis for the Order. Most nurses cannot afford to fight an Order in court or the facts of the nurse’s case are such that there is a definite violation and fighting in an administrative law court may not gain the nurse much. There are some solutions that can help:

1. Make sure you have malpractice insurance so that you have the financial resources to go to a hearing if you do not agree with the BON’s decision in your case.

2. When looking for a job, ask everyone you know for help in finding a job. It tends to be easier to get a job if someone is on the “inside” vouching for you and your skills. There are also employers out there that understand that most nurses with a Board Order are not “bad” nurses; that the nurse just made a mistake, or was overworked/understaffed, or had a disease relapse etc. These employers recognize that most nurses that have had a Board Order become extremely cautious nurses and become definite assets to the facility.

3. Make sure that you have an experienced and BON knowledgeable attorney assist you with your case before the BON so that you get the best outcome possible.

4. You must present a professional appearance (this includes your resume, your social networking site pages, and any application you complete).

5. Contact your state senators and representatives and ask them to make some changes for the next legislative session in 2011. Some areas that need changes: expand the corrective action provisions to apply to minor practice violations, allow non-public orders for mental health issues and substance abuse (these are diseases, so why allow the publicity?), allow deferred adjudications to be just that and not be considered a conviction by the BON, and change the language in the NPA from shall to may to allow the BON leeway to make determinations based on mitigating factors. As 2010 progresses, I will probably think of more…

I also have more info here: http://nursinglaw.blogspot.com/2009/07/how-to-explain-past-board-orders-to.html

Changes Coming in Delegation of Prescriptive Authority?

Jon Porter — Thu, 12 Nov 2009 15:37:26 +0000

Texas Medical Board staff met with the representatives of the Texas Nursing Board and the Department of Public Safety regarding prescriptive delegation for mid-level providers. They discussed the two methods that mid-level providers to prescribe scheduled drugs:

(1) The mid-level providers can obtain there own certification with the DEA and DPS. Their individual certification number must appear on their prescription pad and they are required to have a supervisor relationship with a licensed physician. This person is viewed as a “sponsor.”

(2) There must be a standing protocol for the mid-level provider to prescribe using the physician’s prescription pad for the listed symptoms and only prescribe medications that are listed in the protocol for the symptoms.

The parties meet to discuss creating a field on the Texas Medical Board’s Physician Profile that will list all of the mid-level providers under the physician’s sponsorship who have prescriptive authority.

The Texas Medical Board’s Standing Delegation Committee voted to create a sub-committee with the Physician Assistant Board and the Nursing Board to look into the guidelines for supervising physicians over PA’s and APN’s who have prescriptive authority under the physician’s supervision. Their goal is to have everyone on the same page as to what the rules are and the risks involved in prescriptive delegation.

My Take: First, physicians and mid-levels need to be sure they are in full compliance with current level and the correct paper work is in the Board denoting the supervisor relationship. Second, look for the rules to be changed in the future. If you have three boards get together, I can assure you the rules will change. Given the current regulatory climate, I suspect that rules will tighten-up. I just hope that before the Boards publish any rule changes, they talk and meet with “stake holders” in this area as any changes to mid-level prescriptive authority will have significant affect over thousands of providers. Please continue to monitor this blog for changes.