Transcript of "Law Offices of Christopher L. Nuland"
Law Offices of Christopher L. Nuland
1000 Riverside Avenue, Suite 115
Jacksonville, FL 32204
Dear FGS Board of Directors:
During the 2005-2006 year, our office was pleased to provide the FGS with an expanded
level of service that still came within budgeted amounts. Although the FGS Insurance
Corporation project was suspended for business reasons, the entity remains and can be
used for other ventures as circumstances dictate.
For the first time, our office provided weekly legislative updates and ensured that the
interests of gastroenterologists were monitored in Tallahassee. While 2006 saw no direct
FGS intervention, the Florida Chapter of the ACP has a mature legislative program
designed to protect the interests of all internal medicine physicians. Through this
“leveraging,” the FGS was able to have an inexpensive, viable legislative program.
Florida House Bill 699 was signed into law on June 19, 2006. Among the
important provisions of this legislation are physician supervision requirements for
satellites offices (offices other than a physician’s primary office) that utilize nurse
practitioners and physician assistants,with special rules for those satellite offices that
practice primarily aesthetic skin care services.. Additionally, the number and location of
satellite offices that can be supervised will be limited in number. The bill also reduces
physician CME requirements for HIV and domestic violence.
A section by section analysis follows:
Section 1: Changes the current biennial requirement for a one hour domestic violence
course to a two hour course every third biennial.
This reduces the burden of taking mandatory domestic violence CME.
Section 2: Changes the current biennial requirement for HIV CME from once every
biennium to once, just before the first renewal.
This reduces the burden of taking mandatory HIV CME.
Section 3: Mandates that ARNP protocols be part of the ARNP’s practitioner profile.
Allows public access to such protocols, likely leading to better-drafted and explicit
Section 4: Technical section implementing Sections 1 and 2.
Section 5: Amends Florida Statute 458.348 to regulate supervisory relationships in
medical office settings.
The provision states, "A supervisory relationship in medical office setting: A physician
who supervises an advanced registered nurse practitioner or physician assistant at a
medical office other than the physician's primary practice location, where the advanced
registered nurse practitioner or physician assistant is not under the onsite supervision of
a supervising physician, must comply with the standards set forth in this subsection, or
the purpose of this subsection, a "physician's primary practice location" means the
address reflected on the physician's profile published pursuant to F.S. 456.041
(a) A physician who is engaged in providing primary health care services may not
supervise more than four offices in addition to the physician's primary practice location.
For the purpose of this subsection, "primary health care" means health care services that
are commonly provided to patients without referral from another practitioner, including
obstetrical and gynecological services, and excludes practices providing primarily
dermatological and skin care services, which include aesthetic skin care service."
This section limits to four the number of satellite facilities (in addition to a primary
care physician's office) a primary care physician may supervise. A further
discussion of the rules for those who provide primarily skin care services is provided
in subsection (c).
(b) A physician who is engaged in providing specialty health care services may not
supervise more than two offices in addition to the physician's primary practice location.
For the purpose of this subsection, "specialty health care" means health care services
that are commonly provided to patients with a referral from another practitioner and
excludes practices providing primarily dermatological and skin services, which aesthetic
skin care services.
(c) A physician who supervises an advanced registered nurse practitioner or physician
assistant at a medical office other than the physician's primary practice location, where
the advanced registered nurse practitioner or physician assistant is not under the onsite
supervision of a supervising physician and the services offered at the office are primarily
dermatological or skin care services, which include aesthetic skin care services other
than plastic surgery, must comply with the standards listed in subparagraphs 1-4,
Notwithstanding s-458.347 (4) (e) 8., a physician supervising a physician assistant
pursuant to this paragraph may not be required to review and cosign charts or medical
records prepared by such physician assistant.
1. The physician shall submit to the board (Board of Medicine) the addresses of all
offices where he or she is supervising an advanced registered nurse practitioner or
physician's assistant which are not the physician's primary practice location.
2. The physician must be board-certified or board-eligible in dermatology or plastic
surgery as recognized by the board pursuant to s. 458.3312.
3. All such offices that are not the physician's primary place of practice must be within
25 miles of the physician's primary place of practice or in the count that is contiguous to
the count of the physician's primary place of practice. However, the distance between
any of the offices may not exceed 75 miles.
4. The physician may supervise only one office other than the physician's primary place
of practice except that until July 1, 2011, the physician may supervise up to two medical
offices other than the physician's primary place of practice if the addresses of the offices
are submitted to the board before July 1, 2006. Effective July 1, 2011, the physician may
supervise only one office other than the physician's primary place of practice, regardless
of when the addresses of the offices were submitted to the board.
This is the most controversial of the sections, and will require modification by some
physicians. However, it is instructive to review what the above does NOT do.
Subsection (c) does not affect
1. Facilities in which neither PAs nor ARNPs perform “primarily” skin
care services. As long as such a satellite performs primary care, which
may include skin care services, it is regulated under subsection (a);
2. Facilities in which the only service being performed by the ARNP or PA
is hair removal;
If the GI owns a satellite which is dedicated to the services described and is unable
to add primary care services, he or she may (a) either engage a plastic surgeon or
dermatologist as a medical director to provide the required supervision or (b) limit
the services to nonmedical services and not engage an ARNP or PA.
(d) A physician who supervises an office in addition to the physician's primary practice
location must conspicuously post in each of the physician's offices a current schedule of
the regular hours when the physician is present in that office and the hours when the
office is open while the physician is not present.
This section affects all satellites, but does NOT require any minimum presence by
the physician, only that the patient is notified if and when a physician is likely to be
The Section also provides exceptions and requires specialists who receive referrals to
give the patient the option of seeing the physician and the type of practitioner in writing.
In any event, the specialist must review the chart or written report of the initial
examination and issue a written report to the referring physician within 10 days. This
section responds to the concerns of PCPs who often would refer a patient, only to
have that patient seen by an extender without the specialist physician ever seeing the
Section 6. Repeals obsolete language in the D.O. statutes.
Section 7. Applies section 5 to D.O.s
Section 8. Requires the Board of Nursing to review ARNP protocols for compliance with
state law. Under current law such protocols are filed but not reviewed.
Section 9. Instructs the Office of Program Policy Analysis and Government
Accountability to study the state's nursing shortage.
In other news, on June 12, 2006, the Governor capped several years of effort by signing
Florida House Bill 587, the Truth in Medical Education (TIME). Under this legislation,
all health care providers will be required to disclose to patients (either orally, in writing,
or by wearing a nametag that includes this information) the license under which they are
operating. Moreover, all health practitioner advertising also must disclose this
information. The law, which becomes effective July 1, 2006, will enable patients to
know the true educational and professional training of those wishing to treat them, and
includes a legislative finding of fact that several practitioners are misrepresenting their
credentials and thereby creating a threat to patient safety. Special thanks to House
sponsor Bill Galvano, and Senate sponsor Mike Bennett for making this fine bill a reality
Board of Medicine
I personally attended each and every Rules Committee and Surgical Care Committee of
the Board of Medicine. While several initiatives were offered, we were successful in
limiting new regulation to updates of existing rules. It should be noted, however, that the
Board has recognized a disconcerting number of perforated bowels during colonoscopies
and is paying special attention to what it deems to be a disconcerting trend.
In its 2005 Surgical Care Committee Report. Overall, the Committee was optimistic in
tone, noting decreases in office surgery deaths and wrong-site procedures and
complimenting the level of cooperation between the Committee, providers, and
professional associations such as ours. Of the three deaths noted (the lowest total since
such statistics have been officially kept), two involved radiological procedures, while one
involved a vascular stent. Six of 2005's 64 total incidents involved endoscopic
The Report also notes that, of the 41 wrong-site surgery cases considered by the Board
from August of 2004 through June of 2005, only two involved incidents occurring after
the Board's "Time-Out" rule became effective on February 18, 2004.
As anticipated, the Board of Medicine promulgated the following amendments, all of
which are consistent with FGS policy.
A. The OSR will apply to all facilities not otherwise licensed under Chapter 390 or
Chapter 395. Under old law, health care clinics not owned by physicians technically
could be exempted.
B. The surgical logs now must also include the time the patient arrived in the surgical
suite, the name of the physician providing the medical clearances, the surgeon's name, the
diagnosis, the CPT codes, ASA classification, the level of surgery, the anesthesia
provider, the duration of recovery, the disposition of the patient upon discharge, and a list
of medications used during surgery and recovery. The logs still are confidential and need
not be reported to the Board.
C. All physicians performing office surgery must be qualified by education, training
and experience to perform the procedure in the office surgery setting. This is the
most fundamental of all the OSR provisions, and one consistent with our long-
standing policy of ensuring the highest standards for the office-based surgeon. We
did, however, have to hold a hearing on this subject, as the original language would
have required GIs to be able to perform the entire range of possible office
procedures, not only those associated with gastroenterology.
D. The Board of Medicine amended the surgical "time-out" rule to make compliance
mandatory not only for the surgeon, but also the anesthesia provider. This should help
surgeons (including gastroenterologists performing invasive procedures) by making
anesthesiologists also accountable for compliance.
E. The Board of Medicine enacted its annual revisions to the crash cart contents
needed in a Level II and III office surgery. In most cases, the new regulations simply
provide a minimum dosage amount and are meant to comply with the latest AHA
guidelines. The additional new requirements are:
Adenosine 6mg/2 ml x3
Amiodarone 150 mg x2
Atropine 0.4 mg/ml; 3 ml replacing 0.1mg/ml; 5ml
Requiring at least 50 ml of Dextrose 50%
Diphenhydramine 50 mg
Requiring at least 200 mg of Dopamine
Flumazenil 0.1 mg/ml; 5ml x 2
Furosemide 40 mg
Hydrocortisone or Methylprednisone or Dexamethasone
Requiring at least 100 mg of lidocaine
Requiring at least 1 mg x 2 magnesium sulfate
Requiring 0.4 mg/ml; 3 ml of naxolene
Propranolol 1 mg x 1
Succynylcholine 1 vial
Vasopressin 20 units x 2
Requiring 5 mg x 2 of Verapamil
A Benzodiazepine must be stocked, but not on the crash cart
Contents No Longer Needed
Finally, as you may have heard, the FMA has filed suit against a proposed Board of
Pharmacy rule that would allow pharmacists to make therapeutic substitutions without
consulting the prescribing physician. Our society has been invited to add our name to the
growing list of specialty societies opposing this proposal, and we have done so.
With increasing CMS and FCSO attention on the use of Remicade, our office has been in
contact with the manufacturer, Centocor, to alert physicians as to how to respond to audit
requests. GIs are reminded to review LCD 5672 and to ensure that its provisions are
followed precisely when drafting letters of medical necessity.
I hope that the above is useful. Should you have any questions, please do not hesitate to
It is a pleasure and honor to serve.