2018 State Legislative Compact October 25 - 27 Ft. Lauderdale, FL

1. mafp.com
Michigan Senate Bill 826-
Naturopathic Scope of Practice
Mary Marshall, MD, RN
President
Michigan Academy of Family Physicians
October 27, 2018

2. mafp.com
Map of State Licensure

3. mafp.com
 Michigan State Medical Society
 Michigan Health and Hospital
Association
 Michigan Chapter: American
Academy of Pediatrics
 Michigan Academy of Physician
Assistants
 Michigan Osteopathic Association
 Michigan Association of
Osteopathic Family Physicians
 American Congress of
Obstetricians and Gynecologists
Building a Coalition in Opposition

4. Assistant Physicians in
Missouri
KEITH RATCLIFF, MD, FAAFP
MAFP ADVOCACY COMMISSION
CO-CHAIR

5. The Past
•Missouri Legislation Passed in May, 2014
•Purpose and Intent
•Qualifications
•Scope of Practice
•Promulgation of Rules
•MAFP’s Advocacy Efforts

6. The Present
•Other States AP Efforts
•Expansion Efforts
•Clean Up Language
•Number of APs
• With a Collaborative Agreement
• Without Collaborative Agreement

7. The Future
•Bill Sponsor Update
•Crystal Ball Forecast
•Recommendations

8. Thank you!
Questions?
Or contact Kathy Pabst, Executive Director, MAFP
(573) 635-0830
kpabst@mo-afp.org

9. References
•Missouri Board of Registration for Healing Arts Website:
https://pr.mo.gov/assistantphysicians.asp
•Missouri Secretary of State, Code of State Regulations,
https://www.sos.mo.gov/cmsimages/adrules/csr/current/20csr/20c2150-2.pdf
•Hoekzema, Grant, MD, FAAFP, Missouri Family Physician, Missouri Assistant Physician
Legislation: A Career Physician Educator’s Perspective, April-June 2018 Issue, page 27
•Association of Medical Doctor Assistant Physicians Website:
https://assistantphysicianassociation.com/
•Conley, Jennifer, MD, Missouri Medicine, Innovative Assistant Physician Program Enhances
Patient Care: The Nevada Medical Clinic Experience, November-December 2017 Issue, page 424

10. APRN SCOPE OF PRACTICE:
THE SOUTH CAROLINA EXPERIENCE
AAFP State Legislative Conference
October 27, 2018
Ralph N. Riley, M.D., Chair
SCAFP Legislation Committee

11. Background Information
 The SC Chapter has either been in dialogue with the APRNs regarding changes to the Nurse Practice
Act and Medical Practice Act or addressing legislation that has been introduced for over two decades.
 The last major change in the Nurse Practice Act was in 2004.
 Until the 2018 legislative session, attempts to pass APRN scope of practice legislation through the years
have failed.
 The last four years have been the most active and dramatic with introduction of independent practice
bills. (The SC General Assembly meets in a two-year legislative cycle)

12. Until the new law was enacted, SC law required:
● APRNs be supervised by a South Carolina-licensed physician pursuant to a written protocol.
● Required supervision ratio of one physician to 3 FTE APRNs within a geographic radius of 45 miles.
● Physicians and APRNs could, however, request increases in the ratio and/or radius from the SC Board
of Nursing and the SC Board of Medical Examiners.

13. LEGISLATION PROGRESSION
 2015 - first independent practice bill introduced. At the outset, APRN leaders aggressively pursued
independent practice.
 2017 - companion bills were introduced in the Senate and House that would have provided for
“collaborative practice” for APRNs (other than CRNAs), but collaboration was vaguely defined that it
was meaningless.
 Fall 2017 - representatives of the Academy and the SC Medical Association (SCMA) met with
representatives of the APRN Coalition for Access to Care to determine whether compromise legislation
was possible.

14. LEGISLATION PROGRESSION
 February 7, 2018 - Interested parties including three Nursing School Deans and representatives of the
Academy, SCMA, and the APRN Coalition met in person to discuss a possible compromise.
 Earlier that day, however, a Senate Medical Affairs subcommittee chaired by the bill sponsor favorably
reported out S. 345 with an amendment proposed by the APRN Coalition.
 The APRN Coalition amendment adopted by the subcommittee was not acceptable to the Academy
and SCMA. Key aspects of that amendment included:
- collaborative practice for APRNs with more than 2,000 hours of practice,
with a very vague definition of “collaboration” that would amount to
independent practice;

15. LEGISLATION PROGRESSION
- supervision under a “transition to practice agreement” for APRNs with less than 2,000 hours of practice;
- full prescriptive authority for Schedule II medications;
- authorization for APRNs to perform a number of medical acts or functions, such as prescribe physical
therapy or refer to hospice, outside any agreement with a physician;
 February 12, 2018 - APRN Coalition submitted to the Academy and SCMA a preliminary revised draft
moderating some aspects of their subcommittee amendment.
 February 16, 2018 – SC Academy’s lobbyist crafted a response to the revised Coalition draft.

16. OUTCOME OF ACTIVITY…. A COMPROMISE
After many years of lobbying for independent practice and further negotiations, the APRNs agreed
to a compromise that maintained their close working relationship with physicians! S. 345 was
amended with our new language and does not provide for independent practice.
The language included many changes that most APRNs wanted, i.e., eliminated mileage requirement,
provided prescribing capabilities, etc.
It was clear that legislators wanted a compromise but were not comfortable with eliminating the physicians’
role from the patient care standpoint.
On May 18, 2018, Governor Henry McMaster signed into law S. 345 with an effective date of July 1,
2018

17. SUMMARY OF MAJOR CHANGES
 requires APRNs to practice pursuant to a written “practice agreement” with a physician rather than a
written protocol;
 removed the term “supervision,” but does not use the term “collaboration;”
 eliminated the 45-mile geographic radius, but requires the physician to be actively practicing within the
geographic boundaries of South Carolina;
 expanded the physician-to-APRN ratio to 1 physician to 6 APRN FTEs, but a physician may not work
with/supervise more than 6 APRNs and/or PAs in clinical practice at one time;
 authorizes APRNs to prescribe Schedule II drugs if set out in their practice agreement and subject to
certain statutory limitations;
 authorizes APRNs to perform several specified medical acts unless otherwise provided in their practice
agreement;

18. SUMMARY OF MAJOR CHANGES
 prohibits a physician from entering into a practice agreement with an APRN who will be performing
medical acts that are outside the usual practice of the physician or outside the physician’s training or
experience;
 authorizes APRNs and PAs to practice via telemedicine subject to their practice agreement or scope of
practice guidelines and certain statutory limitations.
KEY ASPECTS OF PRACTICE AGREEMENTS
 The practice agreement is a clinical document (not an employment contract) to be developed by the
APRN and the physician.

19. KEY ASPECTS OF PRACTICE AGREEMENTS
 The practice agreement is to be “customized” for the specific working relationship between the APRN and
the physician taking into account factors such as the type of practice, whether the APRN is on site or off
site, and the APRN’s education, training, and experience.
 A practice agreement may use the term “supervision” or “collaboration” or some other description of the
working relationship.
 The old written protocol will not suffice as a new practice agreement.
 Prior approval of practice agreements by either the Nursing Board or the Medical Board is not
required. Must be submitted within 72 hours if requested by either Board.
 The original practice agreement and any amendments to it must be reviewed at least annually, dated,
and signed by the APRN and physician.

20. KEY ASPECTS OF PRACTICE AGREEMENTS
 Specific medical acts that APRNs may perform (unless the practice agreement states that the APRN
cannot do so or may perform some but not all):
- provide non-controlled prescription drugs at a free clinic;
- certify home or hospital instruction for a student who is unable to attend school;
- refer a patient for physical therapy;
- pronounce death and sign death certificates;
- issue an order for hospice services;
- certify that an individual is handicapped for purposes of the individual applying for a placard. (This list
does not include DNR or POST orders or allow an APRN to certify cause of death. It also does not
expand the authority of APRNs to delegate tasks to unlicensed personnel)

21. KEY ASPECTS OF PRACTICE AGREEMENTS
 prescription authority is limited to drugs and devices utilized to treat medical problems within the specialty
field of NP or CNS (revised language in Section 40-33-34(F)(1)(b)).
 may prescribe Schedules III through V controlled substances if listed in the practice agreement;
 may prescribe Schedule II non-narcotic substances if listed in the practice agreement (prescription limited
to 30-day supply);
 may prescribe Schedule II narcotic substances if listed in the practice agreement (prescription limited to
5-day supply, and another prescription may not be written without the written agreement of the physician
who signed the practice agreement) may prescribe Schedule II narcotic substances for patients in
hospice and palliative care if listed in the practice agreement (prescription must not exceed a 30-day
supply)

22. ASSISTING MEMBERS WITH THE NEW LAW
Practice agreements had to be in place by July 1st
 Our lobbyist, with input from SCAFP leadership, crafted a Practice Agreement Template
 A Frequently Asked Questions (FAQs) document was also created
 Access to the Template and FAQs were sent in an email blast to the membership.
 Materials available on the SCAFP website (with a member login).

23. WHAT WORKED FOR US
 Providing testimony at subcommittee hearings (Members were prepared with written testimony, as well
as, how to respond to questions from legislators)
 Members participated in “White Coat Days” at the State House; remained steadfast in their commitment to
contacting legislators.
 SCAFP wrote letters to legislators and members called, emailed and met with their legislators with
consistent messaging.
 Members were kept abreast of developments via email blasts and personal contacts.
 Having our lobbyist drafting most of the key compromise language.
Key element - Active advocacy though the years was key in crafting and developing the
APRN legislation that was ultimately passed. The SC Chapter has had an effective lobbyist
for over 25 years who is also an attorney with in-depth knowledge of state scope of practice
issues and has substantive knowledge in drafting capabilities. The SC Academy has also
established a strong, favorable reputation for family medicine.

24. LESSONS LEARNED
We recognize all state chapters are different and have various resources. Lessons we learned include:
 Commitment of Academy leadership. Have leader buy-in into the issue and their willingness to actively
participate in the process.
 Building relationships with legislators and their key staff; having a legislative presence at the State House.
 Grassroot efforts are needed; members knowing their legislators personally.
 Substantive knowledge of the issues and in-depth understanding of the state laws you are proposing to
amend or repeal.
 Consistent advocacy and messaging.
 Know that you do not have to capitulate to the opposing side, hang tough and know what you are willing
to give up in the legislation and what you will not negotiate on.