HOUSE OF REPRESENTATIVES
THIRTIETH LEGISLATURE, 2019
STATE OF HAWAII
A BILL FOR AN ACT
Relating to Health.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF HAWAII:
SECTION 1. The legislature finds that there is a significant shortage of doctors available to provide health care, both nationally and in Hawaii, despite the rising number of medical school graduates. According to the Association of American Medical Colleges, medical school deans are concerned about growing medical school enrollment outpacing the number of residency slots available nationally.
The legislature finds that several states, including Missouri, Arkansas, Kansas, and Utah, have enacted legislation that addresses this doctor shortage by creating a new category of licensed professionals called assistant physicians. Assistant physicians are recent medical school graduates who have passed certain medical exams but have not been placed into a residency program. An assistant physician license allows medical school graduates to work under the supervision of a licensed physician to provide primary care in medically underserved areas. These laws aim to connect physicians in need of jobs with communities in need of physicians.
The legislature further finds that Hawaii currently has about twenty-two per cent fewer doctors than needed across all specialties. The legislature also finds that from 2017 to 2018, the State lost fifty-one full-time doctors. Currently, there are approximately 2,927 full-time doctors practicing in the State, about seven hundred fifty short of the number necessary to meet the medical needs of Hawaii's residents.
The purpose of this Act is to increase the number of providers of medical services in the State by establishing a three-year pilot program creating a new category of professional licensure for assistant physicians.
SECTION 2. Chapter 453, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:
"Part . ASSIStant physicians
§453- Definitions. Whenever used in this part, unless a different meaning clearly appears from the context:
"Assistant physician" means any medical school graduate who:
(1) Is a citizen of the United States or legal resident alien;
(2) Is proficient in the English language;
(3) Has successfully completed Step 1 and Step 2 of the United States Medical Licensing Examination or the equivalent step of any other board-approved medical licensing examination within the four-year period immediately preceding application for licensure as an assistant physician, but in no event more than four years after graduation from a medical college or osteopathic medical college; and
(4) Has not completed an approved postgraduate residency but has successfully completed Step 2 of the United States Medical Licensing Examination or the equivalent step of any other board-approved medical licensing examination within the immediately preceding four-year period, unless the four-year anniversary occurred while the graduate was serving as a resident physician in an accredited residency in the United States and continued to serve in that position within thirty days prior to application for licensure as an assistant physician.
"Collaborating physician" means a physician or osteopathic physician licensed under this chapter who has entered into a collaborative practice arrangement with an assistant physician.
"Collaborative practice arrangement" means an agreement between a collaborating physician and an assistant physician that meets the requirements of this part.
"Medical school graduate" means any person who has graduated from a medical college or osteopathic medical college.
§453- Assistant physicians; licensure; insurance reimbursement. (a) Any medical school graduate who meets the criteria for licensure pursuant to this part may apply for licensure.
(b) An assistant physician shall be clearly identified as an assistant physician. No assistant physician shall practice or attempt to practice without a collaborative practice arrangement, except as otherwise provided in this part or in an emergency situation.
(c) A collaborative practice arrangement shall limit the assistant physician to providing primary care services in medically underserved rural or urban areas of this State, in health care facilities with internship or residency training programs, or in pilot project areas established in which assistant physicians may practice.
(d) For an assistant physician working in a rural health clinic under the federal Rural Health Clinic Services Act of 1977, P.L. 95-210, as amended:
(1) An assistant physician shall be considered a physician assistant for purposes of regulations of the federal Centers for Medicare and Medicaid Services; and
(2) No supervision requirements in addition to the minimum federal law shall be required.
(e) An assistant physician shall be considered a physician assistant for the purposes of receiving insurance reimbursement. The department of human services shall seek any necessary waivers or medicaid plan amendments to implement the insurance reimbursement provisions of this part.
(f) Each health carrier or health benefit plan that offers or issues health benefit plans that are delivered, issued for delivery, continued, or renewed in the State shall reimburse an assistant physician for the diagnosis, consultation, or treatment of an insured or enrollee on the same basis that the health carrier or health benefit plan covers the service when it is delivered by another comparable mid-level health care provider including but not limited to a physician assistant.
(g) The director of health or the director's designee shall collaborate as necessary with assistant physicians for the treatment of substance abuse disorders.
§453- Collaborative practice arrangements. (a) A physician or osteopathic physician licensed under this chapter may enter into a collaborative practice arrangement with an assistant physician. A collaborative practice arrangement:
(1) Shall be in the form of a written agreement, jointly agreed-upon protocols, or standing orders for the delivery of health care services;
(2) Shall be in writing; and
(3) May delegate to an assistant physician the authority to administer or dispense prescription drugs and provide treatment; provided that the delivery of those health care services is within the scope of practice of the assistant physician and is consistent with the assistant physician's skill, training, and competence and the skill and training of the collaborating physician.
(b) The collaborating physician shall be responsible at all times for the oversight of the activities of and accept responsibility for services rendered by the assistant physician.
(c) A collaborative practice arrangement shall include, at minimum, the following provisions:
(1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the assistant physician;
(2) A list of all other offices or locations where the collaborating physician has authorized the assistant physician to practice;
(3) A requirement that there shall be displayed in a prominent location at every office where the assistant physician is authorized to practice in collaboration with a collaborating physician, a disclosure statement notifying patients that they may be seen or examined by an assistant physician and have the right to be seen or examined by the collaborating physician;
(4) Any specialty or board certifications held by the collaborating physician and any certifications held by the assistant physician;
(5) The manner of collaboration between the collaborating physician and the assistant physician, including the methods by which the collaborating physician and the assistant physician shall:
(A) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;
(B) Maintain geographic proximity; provided that:
(i) The collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of twenty-eight days per calendar year for a rural health clinic as defined by the Rural Health Clinic Services Act of 1977, P.L. 95-210, as amended, as long as the collaborative practice arrangement includes alternative plans;
(ii) The exception to geographic proximity shall apply only to an independent rural health clinic, provider-based rural health clinic of which the provider is a critical access hospital as provided in title 42 United States Code section 1395i-4, or a provider-based rural health clinic for which the main location of the hospital sponsor is greater than fifty miles from the clinic; and
(iii) The collaborating physician shall maintain documentation related to the geographic proximity conditions of the collaborative practice arrangement and present it to the board when requested; and
(C) Provide for coverage during the absence, incapacity, infirmity, or emergency of the collaborating physician;
(6) A description of the assistant physician's controlled substance prescriptive authority in collaboration with the collaborating physician, including:
(A) A list of the controlled substances that the collaborating physician has authorized the assistant physician to prescribe; and
(B) Documentation that the controlled substance prescriptive authority is consistent with each professional's education, knowledge, skill, and competence;
(7) A list of all other written collaborative practice arrangements to which the collaborating physician and the assistant physician are parties;
(8) The duration of the written collaborative practice arrangement between the collaborating physician and the assistant physician;
(9) A description of the time and manner of the collaborating physician's review of the assistant physician's delivery of health care services; provided that the description shall include a provision that, every fourteen days, the assistant physician shall submit a minimum of ten per cent of the patient charts documenting the assistant physician's delivery of health care services to the collaborating physician for review by the collaborating physician or any other physician designated in the collaborative practice arrangement; and
(10) Every fourteen days, the collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review a minimum of twenty per cent of the patient charts in which the assistant physician prescribes controlled substances; provided that the patient charts reviewed may be counted in the number of patient charts required to be reviewed under this part.
(d) A collaborating physician shall not enter into a collaborative practice arrangement with more than three full-time equivalent assistant physicians. This limitation shall not apply to a collaborative arrangement of a hospital employee who provides inpatient care services in a hospital or population-based public health services.
(e) Within thirty days of any change and on each license renewal, the Hawaii medical board shall require a physician to:
(1) Identify whether the physician is engaged in any written collaborative practice arrangement, including a written collaborative practice arrangement delegating the authority to prescribe controlled substances; and
(2) Report to the board the name of each assistant physician with whom the physician has entered into a collaborative practice arrangement.
The board shall make the information required under this subsection available to the public. The board shall track the reported information and shall routinely conduct random reviews of the collaborative practice arrangements to ensure that the arrangements comply with this part.
(f) The Hawaii medical board shall not deny, revoke, suspend, or otherwise take disciplinary action against a collaborating physician in relation to health care services that are delegated to an assistant physician; provided that the collaborating physician is in compliance with this part and the rules adopted thereunder.
§453- Rules. (a) The Hawaii medical board shall adopt rules pursuant to chapter 91 for the licensure of assistant physicians that establish licensure and renewal procedures, supervision requirements, fees, and any other matters that are necessary to protect the public and discipline of the profession. A licensure fee for an assistant physician shall not exceed the amount of any licensure fee for a physician assistant.
(b) An application for licensure may be denied or the license of an assistant physician may be suspended or revoked by the board in the same manner and for violation of the standards of conduct established by the board. No rule adopted by the board shall require an assistant physician to complete more hours of continuing medical education than that of a licensed physician.
(c) The Hawaii medical board shall adopt rules pursuant to chapter 91 regulating the use of collaborative practice arrangements for assistant physicians that specify:
(1) Geographic areas to be covered;
(2) The methods of treatment that may be covered by collaborative practice arrangements;
(3) The development and implementation, in conjunction with the dean of the John A. Burns school of medicine and primary care residency program directors in the State, of educational methods and programs undertaken during the collaborative practice arrangements service that shall facilitate the advancement of the assistant physician's medical knowledge and capabilities, and that may lead to credit toward a future residency program for programs that deem such documented educational achievements acceptable; and
(4) The requirements for review of services provided under collaborative practice arrangements, including delegating authority to prescribe controlled substances; dispense medications or devices by prescription; or make prescription drug orders.
(d) Any rules adopted by the Hawaii medical board relating to dispensing or distribution of controlled substances by prescription or prescription drug orders under this part shall be subject to the approval of the department of public safety.
(e) Rules adopted by the Hawaii medical board shall be consistent with guidelines for federally-funded clinics. The board's rulemaking authority pursuant to this part shall not apply to collaborative practice arrangements of hospital employees who provide inpatient care within a hospital or population-based public health services."
SECTION 3. This Act shall take effect on July 1, 2019, and shall be repealed on June 30, 2022.
Health; Assistant Physicians; Licensure; Pilot Program
Establishes a three-year pilot program to create a new category of professional licensure for assistant physicians: recent medical school graduates who have passed certain medical exams but have not been placed into a residency program and who work under the supervision of a licensed physician to provide primary care in medically underserved areas.
The summary description of legislation appearing on this page is for informational purposes only and is not legislation or evidence of legislative intent.