S.B. NO.














relating to ASSOCIATE physicians.





SECTION 1. Chapter 453, Hawaii Revised Statutes, is amended by adding a new part to be appropriately designated and to read as follows:


453-A Associate physician; licensure required. (a) The Hawaii medical board shall require each person practicing medicine under a collaborative practice arrangement with a physician, osteopathic physician, or group of physicians, other than a person licensed under section 453-3, to be licensed as an associate physician.

(b) Before any applicant shall be eligible for licensure, the applicant shall furnish proof satisfactory to the board that the applicant:

(1) Is a resident and citizen of the United States or a legal resident alien;

(2) Is a graduate of:

(A) A medical school or college whose program leading to the M.D. degree is accredited by the Liaison Committee on Medical Education or whose program leading to the D.O. degree is approved by the American Osteopathic Association Commission on Osteopathic College Accreditation; or

(B) A foreign medical school, and:

(i) Holds the national certificate of the Educational Commission for Foreign Medical Graduates, or its successor, or for applicants with residency training in Canada, has passed with scores deemed satisfactory by the board, the Medical Council of Canada Evaluating Examination, or its successor; or

(ii) Holds the certificate of the Fifth Pathway Program of the American Medical Association;

(3) Has successfully completed step two of the United States Medical Licensing Examination or its equivalent of any other board-approved medical licensing examination within the three-year period before either:

(A) Applying for licensure as an associate physician unless, when the three-year anniversary occurred, the person was in service as a resident physician in an accredited residency in the United States and continued to do so within thirty days before applying for licensure as an associate physician; or

(B) Graduating from medical school and the graduation occurred within the three-year period immediately preceding the application for licensure as an associate physician; and

(4) Has not completed an approved postgraduate residency.

(c) The board shall require the applicant to successfully pass an examination or examinations given or approved by the board to establish proficiency in English; provided that the applicant graduated from a medical school located outside the United States in a country where the official language is not English.

(d) The board shall establish rules for the following:

(1) Licensure and license renewal procedures;

(2) Physician supervision and collaborative practice arrangements;

(3) Fees; and

(4) Any other matters necessary to protect the public and discipline professionals.

(e) Any license of an associate physician may be denied, not renewed, revoked, limited, or suspended under section 453-8. An associate physician shall not be required to complete more hours of continuing medical education than that of a physician licensed under this chapter.

(f) A person applying for the renewal of an associate physician license shall include the verification of actual practice under a collaborative practice arrangement as prescribed in 453-C during the immediately preceding licensure period.

453-B Associate physician; scope of practice. (a) An associate physician may practice as follows:

(1) By providing only primary care services;

(2) In medically underserved rural or urban areas of the State; and

(3) Under the terms of an associate physician collaborative practice arrangement as prescribed in section 453-C.

(b) For a physician-associate physician team working in a rural health clinic as defined by the Rural Health Clinic Services Act, P.L. 95-210, as amended, related to rural health clinic services:

(1) The associate physician shall be considered a physician assistant for the purposes of Centers for Medicare and Medicaid Services regulations; and

(2) Supervision requirements in addition to the minimum federal supervision requirements shall not be required.

(c) An associate physician shall clearly identify their self as an associate physician. An associate physician may use the terms "doctor", "dr.", or "doc". An associate physician may not practice or attempt to practice without a collaborative practice arrangement as prescribed in section 453-C, except as otherwise provided in this section or in an emergency situation.

(d) The collaborating physician shall be responsible for the oversight of the activities of and shall accept responsibility for primary care services rendered by the associate physician.

(e) Each health insurance 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 associate physician for diagnosing, consulting, or treating an insured person 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 a physician assistant.

453-C Associate physician; collaborative practice arrangement. (a) A physician licensed under this chapter may enter into collaborative practice arrangements with associate physicians.

(b) Collaborative practice arrangements:

(1) Shall be in writing;

(2) May delegate an associate physician the authority to administer or dispense drugs under the authority provided by section 453-1; and

(3) Shall allow the associate physician to provide health care services within the scope of practice of the associate physician and consistent with the associate physician's skill, training, and competence, and the skill and training of the collaborating physician.

(c) Collaborative practice arrangements shall contain following provisions:

(1) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the associate physician;

(2) A list of all other offices or locations besides those listed in paragraph (1) where the collaborating physician authorizes the associate physician to practice;

(3) A requirement that there be posted at every office where the associate physician is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that the patient may be seen by an associate physician and the patient has the right to see the collaborating physician;

(4) All specialty or board certifications of the collaborating physician and all certifications of the associate physician;

(5) The manner of collaboration between the collaborating physician and the associate physician, including how the collaborating physician and the associate physician will:

(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 rural health clinics as defined in title 42 United States Code Section 1395x;

(ii) The geographic proximity waiver shall only apply to an independent rural health clinic, provider-based rural health clinics 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 more than fifty miles from the clinic; and

(iii) The collaborating physician shall maintain documentation related to this requirement and present it to the board on request; and

(C) Provide for alternative coverage during absence, incapacity, or infirmity or an emergency.

(6) A description of the associate physician's controlled substance prescriptive authority in collaboration with the collaborating physician, including:

(A) A list of the controlled substances the collaborating physician authorizes the associate physician to prescribe; and

(B) Documentation that the controlled substance prescriptive authority is consistent with each physician's education, knowledge, skill, and competence;

(7) A list of any other written practice agreement between the collaborating physician and the associate physician;

(8) The duration of any other written practice agreement between the collaborating physician and the associate physician;

(9) A description of the time and manner of the collaborating physician's review of the associate physician's delivery of health care services; provided that the description shall include a provision that, every fourteen days, the associate physician shall submit a minimum of ten per cent of the patient charts documenting the associate 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) A requirement that, 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 charts in which the associate physician prescribes controlled substances; provided that the charts reviewed under this paragraph may be counted in the number of charts required to be reviewed under paragraph (9).

(d) The board shall adopt rules regulating the use of collaborative practice arrangements for associate physicians that specify:

(1) Geographic areas to be covered;

(2) The methods of treatment that may be covered by collaborative practice arrangements;

(3) In conjunction with the dean of the University of Hawaii John A. Burns School of Medicine and primary care residency program directors in the State, the development and implementation of educational methods and programs undertaken during the collaborative practice service that facilitates the advancement of the associate 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.

(e) The board shall adopt rules applicable to associate physicians that are consistent with guidelines for federally funded clinics. The rulemaking authority granted in this subsection does not extend to collaborative practice arrangements of hospital employees providing inpatient care within accredited hospitals.

(f) The board shall not deny, revoke, suspend or otherwise take disciplinary action against the license of a collaborating physician for health care services delegated to an associate physician if this section and the rules adopted pursuant to this section are satisfied.

(g) The board shall require each physician, on licensure renewal, to identify whether the physician is engaged in any collaborative practice arrangement, including collaborative practice arrangements delegating the authority to prescribe controlled substances, and to report to the board the name of each associate physician with whom the physician has a collaborative practice arrangement. The board may make such information available to the public. The board shall track the reported information and may routinely conduct random reviews of the collaborative practice arrangements to ensure they are carried out in compliance with this chapter and the rules adopted pursuant to this chapter.

(h) A collaborating physician shall not enter into a collaborative practice arrangement with more than six full-time equivalent associate physicians or full-time equivalent physician assistants, or any combination thereof.

(i) The collaborating physician shall determine and document the completion of at least a one-month period during which the associate physician practices in a setting in which the collaborating physician is continuously present before practicing when the collaborating physician is not continuously present. Board rules shall not require the collaborating physician to review more than ten per cent of the associate physician's patient charts or records during the one-month period.

(j) A collaborative practice arrangement under this section may not supersede current hospital licensing regulations governing hospital medication orders under protocols or standing orders for the purpose of delivering inpatient or emergency care within an accredited hospital if such protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.

(k) A contract or other agreement shall not require a physician to act as a collaborating physician for an associate physician against the physician's will. A physician may refuse to act as a collaborating physician, without penalty, for a particular associate physician. A contract or other agreement shall not limit the collaborating physician's ultimate authority over any protocols or standing orders or in delegating the physician's authority to any associate physician, and a physician, in implementing such protocols, standing orders, or delegation, shall not violate applicable standards for safe medical practice established by a hospital's medical staff.

(l) A contract or other agreement shall not require any associate physician to serve as a collaborating associate physician for any collaborating physician against the associate physician's will. An associate physician may refuse to collaborate, without penalty, with a particular physician.

(m) Each collaborating physician and associate physician in a collaborative practice arrangement shall wear identification badges while acting within the scope of their collaborative practice arrangement. The identification badges shall prominently display the licensure status of each collaborating physician and associate physician.

(n) This section does not limit the authority of hospitals or hospital medical staff to make employment or medical staff credentialing or privileging decisions.

453-D Associate physicians; controlled substances. (a) An associate physician who is granted controlled substances prescriptive authority as provided in this chapter may prescribe any controlled substance listed in schedule III, IV, or V, and may have restricted authority in schedule II, when delegated the authority to prescribe controlled substances in a collaborative practice arrangement; provided that any prescriptive authority granted shall be filed with the board; provided further that prescriptions for schedule II medications prescribed by an associate physician who has a certificate of controlled substances prescriptive authority shall be restricted to only those medications containing hydrocodone.

(b) The collaborating physician may limit a specific scheduled drug or scheduled drug category that the associate physician is allowed to prescribe; provided that any limits shall be listed in the collaborative practice arrangement.

(c) Associate physicians shall not prescribe controlled substances for themselves or members of their families.

(d) Schedule III controlled substances and schedule II hydrocodone prescriptions are limited to a five-day supply without refill, except that buprenorphine may be prescribed for up to a thirty-day supply without refill for patients receiving medication-assisted treatment for substance use disorders under the direction of the collaborating physician.

(e) Associate physicians authorized to prescribe controlled substances under this chapter shall register with the United States Drug Enforcement Administration and shall include the United States Drug Enforcement Administration Registration Number on prescriptions for controlled substances.

(f) The collaborating physician shall determine and document the completion of at least one hundred twenty hours in a four-month period by the associate physician during which the associate physician practices with the collaborating physician on-site before prescribing controlled substances when the collaborating physician is not on-site."

SECTION 2. This Act shall take effect upon its approval.








Report Title:

Health; Associate Physicians; Licensure



Creates a new category of professional licensure for associate physicians, which are 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. Prescribes the scope of practice of associate physicians. Creates requirements for collaborative practice agreements between associate physicians and collaborating physicians. Authorizes associate physicians to prescribe certain controlled substances.




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