2013 Modernization of the SC Physician Assistant Practice Act; how it evolved?
By Paul F. Jacques, DHSc, PA-C and Rebecca Zerwick, MSPAS, PA-C
The last major rewrite of the PA Practice Act was in 2000. A minor change occurred in 2006 which allowed PAs to prescribe Category III-V controlled substances. However, there remain many administrative-legal barriers to the effective and efficient licensure and employment of PAs in SC. Many physicians seem more inclined to hire advanced practice registered nurses (APRN) than PAs because of the limitations imposed by the PA practice act.
The American Academy of Physician Assistants (AAPA) developed a model for modernization of the PA practice acts across the nation and is detailed in the “Six Key Elements of a Modern PA Practice Act”. When looking at these 6 key elements, SC law contained only 1 of the 6 and that single component was licensure, however, licensure in SC had its limitations, since the PA needs to have a supervising physician before a license is issued and that license is suspended when the employment agreement terminates. Leadership at AAPA depicted the SC PA Practice act as being one of the most restrictive practice acts in the nation. This paper details SCAPA’s legislative activities to change this characterization.
Beginning in April 2012, SCAPA developed an ongoing dialogue with the SC Medical Association (SCMA) lobbyist, Regina Hitchcock, and expressed our desire to modernize the practice act. SCAPA began pursuit of further discussions with SCMA over the summer of 2012, which finally culminated in a meeting September 2012, with Dr. Ropp, a member of the SCMA board of directors, the SCMA lobbyist, and Sally Rogers, the lobbyist for the SC Academy of Family Physicians (SCAFP). At this meeting SCAPA President, Rebecca Zerwick, immediate Past President, Tim Stuart and the SCAPA Legislative Committee Chair, Paul Jacques advanced the six key elements that would modernize the SC Practice Act. SCAPA’s approach to the discussion was centered on advancing the physician-led team and thereby, increasing access to healthcare for SC citizens. As a direct result of this meeting, SCAFP lobbyist, Sally Rogers, generated a talking points document which embraced the concept of removing the BME from the process of approving Scope of Practice (SOP) guidelines, elimination of the on-site requirement of the supervising physician for both on-site and off-site practices, decrease the chart co-signature requirement from 100% to 10% and increase the radius in which an off-site practice may be from the primary practice site from 45 miles to 60 miles. The talking points also agreed with full prescriptive authority allowing physicians to delegate to PAs the right to prescribe category II controlled substances. The SCAFP agreed to increase the ratio of PAs to physician from the current 2:1 to 3 FTEs: 1.
With the SCAFP document of support, SCAPA drafted a bill for discussion and vetting. The draft was reviewed by Stephanie Radix, JD, Director, AAPA Constituent Organization Outreach and Advocacy. Her advice and provision of various written resources has been invaluable to the progression of the bill throughout the process. January 2013 she noted that SCAPA could be advancing the separation of licensure from the approval process and this concept was rapidly adopted and incorporated.
SCAPA next approached the BME to advance the changes to the practice act. In union with SCAFP and SCMA, SCAPA met with the BME on February 4th. The BME envisions their primary goal as protecting public safety and making certain the PA has appropriate supervision for the PA’s benefit and the patient. Therefore, the BME did not endorse removal of the BME from the process of scope of practice (SOP) approval. However, they did embrace the separation of licensure from approval to practice. The BME proposed the idea of a PA/physician ratio of 4:1 and endorsed full prescriptive privileges. Following this meeting, SCAPA continued the bill vetting process and entered into discussions with SCAFP. The family physicians expressed discomfort with the possibility of a physician supervising 4 PAs and 3 APRNs and they advocated an amendment to the PA practice act that would limit a physician to supervising a combined total of 5 PAs and/or APRNs. To achieve this objective, the PA practice act would have to mention APRNs and the nursing community was not supportive of this language. Specifying and limiting the number of APRNs which a physician may supervise within the PA practice act would have caused the nursing lobby to oppose the PA practice act with all of their resources. Therefore, SCAPA with agreement of the SCAFP, reduced the ratio from 4 FTE:1 to 3 FTE: 1 in order to avoid this controversy.
February 2013 SCAPA introduced bills H 3618 and S 448. However the vetting process continued. In order to eliminate the onerous “On the Job Training” requirements that are currently in law, language was drafted and amended. Physicians should be allowed to expand the PAs knowledge by showing them specific procedures, demonstrating how the procedure is done and providing direct supervision. The physician/PA team will be required to document the PA’s competence with a specific procedure before it can be added to the SOP.
Representative Crawford, from Florence, SC is an emergency room physician and an advocate for the PA profession. As the key sponsor for H. 3618 he negotiated with the BME to include language that specifies the BME will approve SOPs within 10 business days. If there are any questions about the SOP, a physician member of the BME is to place a call to the supervising physician and detail the concerns. A timely process for approval of SOPs is important for patient care and for the timely employment of PAs.
April 2013 has been an intense month. The General Assembly has a rule that a bill must “pass over” from the House to the Senate or the Senate to the House by May 1st or the bill’s progress stalls until the next legislative session beginning January 2014. The House 3M subcommittee heard testimony and referred the bill to the full 3M committee. The Senate Medical Affairs subcommittee heard testimony from the SC Anesthesiology against allowing PAs to prescribe Category II medications. The subcommittee postponed voting on S. 448 pending resolution of the Category II prescribing language. Working with SCMA, SCAEM, and the BME, SCAPA was able to find a compromise solution. Although not ideal, it will help PAs prescribe short-course therapy for acute pain management and reauthorize continuing medical therapy for patients on long-term Category II medications. The compromise language was amended to S. 448, as well as H. 3618 and both bills were reported out of Committee to their respective bodies.
Saga in the House
On April 24, 2013 H. 3618 was read for a second time in the House. Representatives Howard, Ott and Hayes submitted an amendment that would allow foreign trained physicians (FMGs) and American medical school graduates to be licensed in SC as PAs. Thankfully, this amendment was voted down by a vote of 22 – 72. The bill, as vetted by SCAPA, was voted upon and passed unanimously; 103 – 0. The second reading of S. 448 in the Senate was favorably voted 42-0.
Saga moves to the Senate
Representative Bales, who originated the FMG amendment, has persuaded Senator John Scott to introduce the same amendment in the Senate. Sen. Scott lodged an objection to S. 448 which, if not removed, would result in stalling the bill from any further consideration. He was using the objection as a means of seeking a compromise solution from the key authors of the PA practice act bills. There is no compromise solution that would be acceptable to the PA profession or the SCAPA leadership. SCAPA is actively engaged bring pressure onto Sen. Scott to lift his objection and bring S. 448 to a vote in the Senate. Drs. Steve Gardner and Louis Costa from the BME have expressed opinions that the FMG amendment is unacceptable and that the bill should pass as proposed.
April 30th, Sen. Scott removed his objection and the S. 448 is read for the 3rd time in the Senate and the FMG amendment was not discussed in the Senate. The bill was passed by a unanimous vote 42-0 and sent to the House. On that same day, Representative Crawford, the House bill sponsor had the bill placed on the calendar without reference and it was read the first time. May 2nd the bill is read in the House a second time and passed by a vote of 105 ayes to 0 nays. The bill was referred for third reading on Friday, May 3rd and passed. The bill awaited ratification and referral to the Governor’s Office for the final approval process. Governor Nikki Haley had 5 days to sign the bill, veto or have it enacted without her endorsement. The bill was signed by the Governor on May 21, 2013.