Statutory authority
Explanation of agency authority
The legislature, via Wis. Stats. ss.
15.08 (5) (b), and
227.11 (2) (a), conferred upon the Medical Examining Board general powers to promulgate rules for the guidance of the profession and to interpret the provisions of statutes it enforces. Section
448.05 (5) authorizes the Board to promulgate rules that establish licensing and practice standards for physician assistants. Section
448.40 (2) (f), Stats., directs the board to promulgate rules regarding the prescriptive practice of physician assistants. Therefore, the Medical Examining Board is both generally and specifically authorized to promulgate these proposed rules.
Section
448.20 (3) (a) confers upon the Council on Physician Assistants the authority to advise the Medical Examining Board on revisions of standards in licensing, practice, education and training of physician assistants.
Related statute or rule
Plain language analysis
Physician assistants practice as part of a physician-led team with physicians supervising the health care services they provide. Currently, one physician may supervise no more than two physician assistants at one time without permission from the Medical Examining Board (Board). The proposed rule increases the maximum number of physician assistants a physician may concurrently supervise from 2 to 4.
Under current law the Board may, in an exercise of discretion, authorize a physician to supervise more than two physician assistants concurrently. A physician requesting an increase in the numbers of physician assistants to be supervised must submit a written plan for the Board's review. The Board may grant the request if the Board is satisfied that the increased number of physician assistants will not compromise patient safety. The proposed rules retain the Board's authority to increase the number of physician assistants a physician may concurrently supervise on a case-by-cases basis.
The proposed rule defines terms necessary to clarify responsibilities in the physician-led teams in which physician assistants work. It further eliminates any reference to the outdated term, “substitute supervising physician."
Current law provides that applicants for licensure as physician assistants may be required to submit to an oral examination. The existing term is outdated and does not reflect that during a personal appearance the Board may also require an applicant to submit to an interview, or a review of credentials, or both. The proposed rule clarifies that the Board may require, as a prerequisite to licensure, successful completion of an oral examination or a personal appearance or both.
Finally, the proposed rule explains that the periodic review of physician assistant prescribing practices must occur at least annually, with more frequent review optional, depending upon applicable standards of care and other factors.
SECTION 1. Renumbers and amends Med 8.01
SECTION 2. creates a statement of intent and add it to the authority and purpose provision.
SECTION 3. Renumbers Med 8.02 (1) to 8.02 (1m).
SECTION 4. Defines the terms “adequate supervision", “general supervision" and “supervising physician".
SECTION 5. Clarifies that in addition to written and oral examinations, the Board may require satisfactory performance of a personal appearance for the purpose of an interview, a review of credential, or both.
SECTION 6. Amends Med 8.05(2) (b) (7) to remove outdated references to particular mental health disorders.
SECTION 7. Amends Med 8.05 (2) (c) to allow a personal appearance as well as an oral examination if required by the application review panel.
SECTION 8. Creates Med 8.05 (2) (e) a provision regarding the components of a satisfactory personal appearance.
SECTION 9. Amends Med 8.07(1) by clarifying that a physician assistant's practice may be supervised by one or more supervising physicians.
SECTION 10. Creates Med 8.07 (1) (a) and (b) regarding physician assistant's scope of practice.
SECTION 11. Amends Med 8.07 (2) (a) and (e) by striking repetitive and ambiguous language.
SECTION 12. Amends Med 8.08 (title) and Med 8.08 (1) to specify that the supervising physician and the physician assistant shall review guidelines for supervised prescriptive practice at least annually and clarifies the requirement that the guidelines for supervised prescriptive practice shall include the process and schedule for the supervising physician's review.
SECTION 13. Creates Med 8.08 (1) (a), (b), (c) and (d) specifying the contents of the written guidelines for the required supervised prescriptive practice.
SECTION 14. Repeals and recreates Med 8.08 (2) to simplify when physician assistants are authorized to prescribe.
SECTION 15. Repeals and recreates Med 8.08 (3) (a).
SECTION 16. Amends Med 8.08 (3)(b) to require supervising physicians to document review of the physician assistant's prescriptive practice in the patient records.
SECTION 17. Creates Med 8.08 (3) (c) and (d) regarding documenting the periodic review.
SECTION 18. Amends Med 8.10 (1) by increasing the number of physician assistants a physician may supervise from 2 to 4, and clarifying the nature of supervision.
SECTION 19. Repeals Med 8.10 (2) eliminating the provision regarding substitute supervising physicians.
SECTION 20. Amends Med 8.10 (3) and (4) striking repetitive language regarding supervising physicians.
Summary of, and comparison with, existing or proposed federal legislation
There is no comparative existing or proposed federal rule.
Comparison with rules in adjacent states
Illinois: The state of Illinois limits the physician assistant to physician ratio to 2:1; unless the supervising physician designates an alternate supervising physician. An alternate supervising physician may supervise more than two physician assistants at the same time when the supervising physician is unable to fulfill the duties. 225 Ill. Comp. Stat. 95/7
Iowa: The state of Iowa limits the physician assistant to physician ratio to 2:1. 645 IAC 326.8 (3) (148 C)
Michigan: The state of Michigan allows a physician assistant to physician ratio of 4:1 when the supervising physician is a solo practitioner who practices in a group of physicians and treats patients on an outpatient basis. Physicians who have privileges at a health facility or agency or a state correctional facility may supervise more than four physician assistants; but the physician assistant to physician ratio is 2:1 if the physician supervises a physician assistant at more than one location. MCLS s.
333.17048
Minnesota: The state of Minnesota allows a physician to supervise five physician assistants simultaneously. In the case of an emergency a physician may supervise more than five physician assistants at any given time. Minn. Stat. s. 147A.01
Summary of factual data and analytical methodologies
In recognition of physician work-force shortages and at the request of the Council on Physician Assistants, the Medical Examining Board created a work group to research and advise the board on whether or not to increase the supervision ratio of physician assistants to physicians, and if so under what circumstances. The work group consisted of members of the Medical Examining Board, who are licensed physicians, the chairperson of the Council on Physician Assistants and consultation from the State Medical Society, the Wisconsin Council of Physician Assistants and the Wisconsin Hospital Association. Members of the work group examined the statutes and regulations of other states as well as recommendations of the Federation of State Medical Boards, the American Medical Association, the American Association of Family Practitioners and the American Academy of Physician Assistants.
The national trend, as recognized by the Federation of State Medical Boards and the American Academy of Physician Assistants, is to increase the number of physician assistants a physician may supervise. Both organizations have, as a national model, recommended that regulatory bodies refrain from specifying a particular number of physician assistants a physician may concurrently supervise. Rather, the recommendation is that supervising physicians make the determination based on prevailing standards for competent medical practice, day-to-day realities, and the nature of the physician's actual practice.
The work group presented its findings to the Medical Examining Board with a recommendation that the board increase the ratio from 1:5. The board considered several factors including practice setting in which physician and physician assistants carry out their duties and patient care issues such as a growing shortage of health care practitioners in underserved communities. The board emphasized the need for adequate physician supervision of physician assistant's practice and adopted the work group's recommendation to increase the ratio of physician assistants a physician may supervise. However, after extensive discussion, the board decided to authorize a physician to physician assistant supervision ratio of 1:4. The proposed rule would continue to allow the board, in its discretion, to increase the ratio in individual circumstances.
Analysis and supporting documents used to determine effect on small business or in preparation of economic report
The department finds that this rule will have no effect on small business as small business is defined in 227.114 (1), Stats.
Anticipated Costs Incurred by the Private Sector
The department finds that this rule will incur no additional costs to the private sector.
Fiscal Estimate and Economic Impact Analysis
The proposed rule is not anticipated to have any fiscal impact on businesses, public utility rate payers, local government units or the state's economy as a whole. The proposed rule was posted on the department's website for 14 days. Comments were solicited. The department did not receive any comments regarding an economic impact from local government units, specific business sectors or public utility rate payers. Therefore, the department finds the proposed rule will have no economic impact.
Effect on Small Business
The department finds that this rule will have no effect on small business as small business is defined in s.
227.114 (1), Stats. The Department's Regulatory Review Coordinator may be contacted at
Bill.Wendle@wisconsin.gov or by calling (608) 267-2435.
Initial Regulatory Flexibility Analysis
It is anticipated that this rule will have no effect on small business as small business is defined in 227.114 (1), Stats.
Agency Contact Person
Shawn Leatherwood, Paralegal, Department of Safety and Professional Services, 1400 East Washington Avenue, P.O. Box 8935, Madison, Wisconsin 53708; telephone 608-261-4438; email at
Shancethea.Leatherwood@wisconsin.gov.
STATE OF WISCONSIN
DEPARTMENT OF ADMINISTRATION
DOA 2049 (R 07/2011)
ADMINISTRATIVE RULES
FISCAL ESTIMATE AND
ECONOMIC IMPACT ANALYSIS
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Type of Estimate and Analysis
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X Original
Updated Corrected
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Administrative Rule Chapter, Title and Number
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Wis. Admin Code Med 8
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Subject
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Increasing the number of physician assistants a physician may supervise
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Fund Sources Affected
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Chapter 20 , Stats. Appropriations Affected
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GPR FED PRO PRS SEG SEG-S
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Fiscal Effect of Implementing the Rule
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X No Fiscal Effect
Indeterminate
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Increase Existing Revenues
Decrease Existing Revenues
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Increase Costs
Could Absorb Within Agency's Budget
Decrease Costs
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The Rule Will Impact the Following (Check All That Apply)
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State's Economy
Local Government Units
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X Specific Businesses/Sectors
Public Utility Rate Payers
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Would Implementation and Compliance Costs Be Greater Than $20 million?
Yes
X No
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Policy Problem Addressed by the Rule
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The proposed rule addresses the issue of whether to increase the number of physician assistants a physician may concurrently supervise. Currently, a physician may simultaneously supervise two physician assistants at one time. If a physician wishes to supervise more than two physician assistants he or she must submit a written plan to the Medical Examining Board for review and approval. The proposed rule will increase the number of physician assistants a physician may simultaneously supervise from 2 to 4.
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Summary of Rule's Economic and Fiscal Impact on Specific Businesses, Business Sectors, Public Utility Rate Payers, Local Governmental Units and the State's Economy as a Whole (Include Implementation and Compliance Costs Expected to be Incurred)
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The proposed rule is not anticipated to have any fiscal impact on businesses, public utility rate payers, local government units or the state's economy as a whole. The proposed rule was posted on the department's website for 14 days. Comments were solicited. The department did not receive any comments regarding an economic impact from local government units, specific business sectors or public utility rate payers. Therefore, the department finds the proposed rule will have no economic impact.
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Benefits of Implementing the Rule and Alternative(s) to Implementing the Rule
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The national trend, as recognized by the Federation of State Medical Boards, is to increase the number of physician assistants a physician may supervise as one of the means to address the problem of physician workforce shortages. Implementing this proposed rule will bring Wisconsin in line with the national trend and allow greater flexibility for physicians and physician assistants in providing health care. The alternative to implementing the rule is to allow the current physician to physician assistant ratio to remain the same.
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Long Range Implications of Implementing the Rule
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The primary long term effect of implementing this rule will be building physician and physician assistant health care teams that are equipped to meet the demands of providing adequate health care in spite of growing physician workforce shortages.
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Compare With Approaches Being Used by Federal Government
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There are no comparative federal rules.
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Compare With Approaches Being Used by Neighboring States (Illinois, Iowa, Michigan and Minnesota)
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Similar to the current rule, Illinois and Iowa limit the ration of physician assistants a physician may supervise to 2:1. Illinois allows “alternate supervising physicians" to supervise more than two physician assistants when the supervising physician is unable to perform supervisory duties. Michigan allows a physician assistant to physician ratio of 4:1 when the supervising physician practices within a group of physicians. If the supervising physician has privileges at a health facility, agency or state correctional facility he or she may supervise more than 4. However, if the physician assistant and physician are not in the same location the ratio is limited to 2:1. The proposed rule is most similar to Minnesota which allows a physician to simultaneously supervise five physician assistants at once. In an emergency, a Minnesota physician may supervise more than five physician assistants.
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Name and Phone Number of Contact Person
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Shawn Leatherwood 608-261-4438
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Notice of Hearing
Safety and Professional Services
Board of Nursing
NOTICE IS HEREBY GIVEN that pursuant to authority vested in the Board of Nursing in sections 15.08 (5) (b), 227.11 (2) and 441.01, Wis. Stats., and interpreting sections 441.06 (1) and 441.10 (3) (d), Wis. Stats., the Board of Nursing will hold a public hearing at the time and place indicated below to consider an order to amend sections
N 3.03 (1) (a) 3.,
N 3.03 (1) (b) 6.,
N 3.03 (2) (a) 3., and
N 3.03 (2) (b) 6., relating to endorsement licensure.
Hearing Information
Date: Thursday, February 23, 2012
Time: 8:00 A.M.
Location: 1400 East Washington Avenue
Room ABC
3365 W. Brewster St.
Appleton, WI 54914
Appearances at the Hearing
Interested persons are invited to present information at the hearing. Persons appearing may make an oral presentation but are urged to submit facts, opinions and argument in writing as well. Facts, opinions and argument may also be submitted in writing without a personal appearance by mail addressed to the Department of Safety and Professional Services, Division of Board Services, P.O. Box 8935, Madison, Wisconsin 53708. Written comments must be received at or before the public hearing to be included in the record of rule-making proceedings.
Place Where Comments Are to be Submitted and Deadline For Submission
Comments may be submitted to Sharon Henes, Paralegal, Department of Safety and Professional Services, Division of Board Services, 1400 East Washington Avenue, Room 151, P.O. Box 8935, Madison, WI 53708, or by email to
sharon.henes@wisconsin.gov. Comments must be received at or before the public hearing to be held at 8:00 a.m. on
February 23, 2012 to be included in the record of rule-making proceedings.
Copies of Rule
Copies of this proposed rule are available upon request to Sharon Henes, Paralegal, Department of Safety and Professional Services, Division of Board Services, 1400 East Washington Avenue, P.O. Box 8935, Madison, Wisconsin 53708, or by email at
sharon.henes@wisconsin.gov.
Analysis Prepared by the Department of Safety and Professional Services
Statutes interpreted
Statutory authority
Explanation of statutory authority
An examining board shall promulgate rules for its own guidance and for the guidance of the profession to which it pertains. The Board may establish rules to prevent unauthorized persons from practicing professional nursing.
Related statute or rule
Plain language analysis
Currently, a person licensed as a nurse in another state, territory, province or other jurisdiction is prohibited from obtaining licensure as a registered nurse or licensed practical nurse through the endorsement process if there has ever been disciplinary action against their nurse license in any state, territory, province or other jurisdiction.
Section 1-4 are amended to allow the Board to license by endorsement those who have had disciplinary action except in the circumstances that within the Board's discretion the discipline does not warrant licensure in order to protect the public.
Summary of, and comparison with, existing or proposed federal regulations
None.
Comparison with rules in adjacent states
Illinois: The Illinois Board of Nursing permits licensing by endorsement for professional and practical nurses, provided the other state's licensing requirements are similar to Illinois. The Illinois Board of Nursing looks at the disciplinary history from the last five years in making a decision to license by endorsement. While a decision is pending on licensure a temporary endorsement license is issued if the person holds an unencumbered license from another state and will be terminated if it is discovered that within the last five years, the applicant has had a license or permit related to the practice of nursing revoked, suspended or placed on probation by another jurisdiction, if at least one of the grounds is substantially equivalent to grounds in Illinois.
Iowa: The Iowa Board of Nursing permits licensing by endorsement and may consider in the application process a record of prior disciplinary action regardless of jurisdiction.
Michigan: The Michigan Board of Nursing permits licensing by endorsement provided the other state's licensing requirements are substantially the same as Michigan's requirements. The Board's rules do not address the issue of discipline in another state.
Minnesota: The Minnesota Board of Nursing permits licensing by endorsement provided the applicant has the qualifications equivalent to Minnesota's requirements. The rules do not preclude an applicant from licensure solely on the basis of prior discipline and allows for Board discretion.
