BILL ANALYSIS



C.S.H.B. 1520
By: Berlanga
05-04-95
Committee Report (Substituted)


BACKGROUND

In 1989, the Texas Legislature passed the Omnibus Health Care
Rescue Act that 1) established the Center for Rural Health
Initiatives, 2) authorized physicians to delegate the carrying out
of prescription drug orders to registered nurses and physician
assistants at rural health centers and other sites serving
medically underserved populations, and 3) established the Health
Professions Resource Center to collect and analyze, in cooperation
with the Higher Education Coordinating Board, educational and
employment trends for health professions.  In 1989, there were less
than 10 rural health clinics and today over 300 exist.  Despite
this increase in numbers, there has been no comprehensive study of
rural health clinics to evaluate their overall impact on rural
health care or if their effectiveness can be improved.  Rural
areas, for example, continue to lack adequate facilities and
services for the elderly and disabled.  They also continue to find
it difficult to attract the numbers of health care providers needed
and to provide the support health care providers need in rural
practices.

PURPOSE

H.B. 1520 provides additional support to rural areas to attract
adequate health care providers to rural settings and give them the
support necessary to retain them in rural practices and to increase
facilities and services to the elderly and disabled populations in
rural areas.  It also permits a more effective utilization of
advanced nurse practitioners and physicians assistants working in
collaboration with physicians.

RULEMAKING AUTHORITY

It is the committee's opinion that this bill expressly grants
additional rulemaking authority to  the Texas Board of Health in
Section 12 (Subsection (d)(5), Section 3.06, Medical Practice Act
(Article 4495b, V.T.C.S.)); to the Texas State Board of Medical
Examiners in Section 13 (Section 3.06(d), Medical Practice Act
(Article 4495b, V.T.C.S.)); and to the Board of Nurse Examiners in
Section 14 (Article 4514(8), Revised Statutes).

SECTION BY SECTION ANALYSIS

SECTION 1.  Adds Section 105.007, Health and Safety Code, (a) to
require the Texas Department of Health (department), as part of the
comprehensive health professions resource center, to develop and
establish a clearinghouse for health professionals seeking
collaborative practice, and b) permits the department to set and
collect a reasonable fee to offset the cost of complying with
requirements of this section; solicit and receive grants, gifts and
donations; and to contract with public or private entities to carry
out its responsibilities under this section.

SECTION 2.  Adds Section 106.025(a)(8)(A) and Section
106.025(a)(15) - (17), Health and Safety Code, relating to the
requirements specified for the Center for Rural Health Initiatives
(Center), as follows:
     
     Subsection (a)(8)(A) requires the Center to promote
     telemedicine and distance learning through a transmission rate
     structure which accommodates rural needs and through the
     improvement of the telecommunications infrastructure in rural
     areas. 

     Subsection (a)(15) requires the Center to develop a study to
     determine the efficiency and effectiveness of rural health
     clinics; assess the impact on access to health care; address
     efficiency barriers for the professional and clinical
     relationship of physicians, nurses, and physician assistants;
     assess the success of attracting primary care physicians and
     allied health professionals to rural areas; assess the
     appropriateness of the current clinic designation process. 

     Subsection (a)(16) requires the Center to develop and initiate
     a quality assessment program to evaluate the health outcomes
     of rural patients treated in rural health clinics.

      Subsection (a)(17) requires the Center to encourage active
     participation by health-care providers in the Early and
     Periodic, Screening, Diagnosis and Treatment Program. 

SECTION 3.  Amends Section 262.034, Health and Safety Code, to
specify that the authority may acquire, construct, own, operate,
enlarge, improve, furnish, or equip certain facilities or services,
and that this section applies to municipal hospital authorities
that own or operate hospitals under Chapter 241, Health and Safety
Code, (regarding the licensing of hospitals), and are located in a
county with less than 35,000 population, rural or nonurbanized
area.

SECTION 4.  Adds Subchapter H, entitled "LONG TERM CARE AND RELATED
FACILITIES"  to Chapter 285, Health and Safety Code, as follows:

     (a) States that this chapter applies only to a hospital
     district or authority created and operated under Article IX of
     the Texas Constitution, a special law, or Title 4 of the
     Health and Safety Code and located in a county with 35,000
     population or less, or in a specified rural or nonurbanized
     area. 

     (b) Permits these districts or authorities to construct,
     acquire, own, operate, enlarge, improve, furnish, or equip one
     or more of the following types of facilities or services for
     the care of the elderly or disabled: long-term care, elderly
     housing, assisted living, home health, personal care, special
     care, continuing care, and durable medical equipment; lease or
     enter into an operations management agreement; close,
     transfer, sell, or otherwise convey all or part of a facility
     and discontinue service; and issue revenue bonds or other
     notes to acquire, construct, or improve a facility or
     implement the delivery of service for the elderly or disabled. 

     (c) States that a facility or service created under Subsection
     (b) is considered to be a hospital project under Chapter 223,
     regarding hospital project financing.

SECTION 5. Amends the definitions of "designated agent" and
"prescription" in Section 483.001, Health and Safety Code, to
reflect changes in authority of physicians to delegate the signing
of prescription drug orders to advanced nurse practitioners and
physician assistants under SECTION 13 of this Act. In defining
prescription, Subdivision (F) of Section 483.001(13), Health and
Safety Code, is deleted and Subdivision (H), Section 483.001(13),
Health and Safety Code, is added. Subdivision (H) states that a
prescription includes the name, address, and telephone number of
the registered nurse or physician assistant, if signed by a
registered nurse or physician assistant.

SECTION 6. Amends Section 483.042(a), Health and Safety Code, to
add language relating to the delivery of prescription drugs based
on changes in authority of physicians to delegate to advanced nurse
practitioners and physician assistants specified under SECTION 13
of this Act.

SECTION 7. Amends Section 671.001(d), Health and Safety Code, to
permit a physician assistant to pronounce death in a licensed
facility, institution, or entity providing services to a patient or
resident if permitted by written policies of the facility,
institution or entity. Requires these policies to include physician
assistants who are credentialed or otherwise permitted to practice
at the facility.

SECTION 8.  Amends Section 671.002, Health and Safety Code, to add
language extending to physician assistants who determine death the
same limitation on liability currently provided physicians and
registered nurses who determine death.

SECTION 9.  Amends Section 51.918(c), Education Code, to expand the
requirement that the Center develop relief service programs for
rural physicians and allied health personnel to facilitate ready
access to continuing medical education to include practice coverage
for purposes other than continuing medical education.

SECTION 10. Amends Section 501.059(g)(4), Government Code, so that
the Managed Health Care Advisory Committee to the Texas Department
of Criminal Justice will include in its development of a managed
health care plan for all inmates at the institutional division a
provision requiring acceptance of Medicare certification of
hospitals, home health and hospice providers as an alternative to
accreditation by the Joint Commission on Accreditation of
Healthcare Organizations.

SECTION 11. Amends the definitions of "designated agent" and
"prescription drug order" in    Section 5(19) and (42), Texas
Pharmacy Act (Article 4542-1, V.T.C.S.) based on changes in
authority of physicians to delegate the signing of prescription
drug orders to advanced nurse practitioners and physician
assistants specified under SECTION 13 of this Act.

SECTION 12.  Amends Section 3.06(d)(5), Medical Practice Act
(Article 4495b, V.T.C.S.), relating to physicians delegating
prescriptive authority at sites serving medically underserved
areas. Adds for physicians the option of permitting a physician
assistant or registered nurse to utilize single-signature
prescriptions at sites serving medically underserved populations as
opposed to the current double-signature requirement, but limits
this to dangerous drugs; adds language to clarify the specified
contents required in certain protocols and other orders used by
physicians to delegate to physician assistants or registered
nurses; amends the definition of "carrying out or signing a
prescription drug order" to reflect the delegated prescriptive
authority given to a registered nurse or physician's assistant;
sets forth additional information required to be provided with each
prescription; establishes that the department by rule is to develop
a Texas-specific designation of "medically underserved area" which
is to take into account demographics, geographic factors that
affect access to health care, and environmental health care
factors; changes the rule governing the department regarding the
requirement to publish notice of its determination from the
Administrative Procedure and Texas Register Act (Article 6252 13a,
V.T.C.S.). Reletters the subsections throughout this section to
reflect the changes made herein;

SECTION 13.  Adds Section 3.06(d)(6) to the Medical Practice Act as
follows:

     (A) Allows a licensed physician, if certain supervision is
     provided by the physician, to delegate prescriptive authority
     in areas other than sites serving medically underserved
     populations under current Section 3.06(d)(5). States that this
     is limited to dangerous drugs.

     (B) Requires protocols and other orders to be defined to
     promote the exercise of professional judgment by the advanced
     nurse practitioner or physician's assistant commensurate with
     their education and experience. Sets forth the specifications
     of the protocols and other orders.

     (C) Requires the physician supervision of the carrying out and
     signing of prescription drug orders to conform to prudent,
     sound, medical judgment, but allows this to vary with the
     education and experience of the advanced nurse practitioner or
     physician's assistant. Requires a physician to provide
     continuous supervision, but not constant physical presence.

     (D) Allows an alternate physician to provide appropriate
     supervision on a temporary basis as defined and established by
     board rule.

     (E) Requires the carrying out and signing of prescriptive drug
     orders to comply with other applicable laws.

     (F) States that a physician's authority to delegate the
     carrying out and signing of prescriptive drug orders has
     specified limitations.

     (G) Sets forth the meaning of "advanced nurse practitioner,"
     "physician assistant," primary practice site," and "carrying
     out or signing a prescription drug order" for the purposes of
     this subsection.

     (H) Requires a physician licensed by the board to be
     authorized to delegate the carrying out or signing of
     prescription drug orders to one or more adequately supervised
     physician's assistants or advanced nurse practitioner
     practicing in a specified facility if the physician has a
     certain position with regard to the facility. Sets forth the
     limitations on the physician's authority to delegate.

     (I) Allows a physician to delegate to a certified registered
     nurse anesthetist the ordering of drugs and devices necessary
     to administer anesthetic as ordered by the physician in a
     licensed hospital or ambulatory surgical center. States that
     the physician's order does not have to be specific regarding
     the drug, dose or administration of the anesthetic. Allows the
     nurse anesthetist to select, obtain, and administer those
     drugs and apply the appropriate medical devices necessary
     pursuant to and as necessary to accomplish the order and
     maintain the patient's good status. Requires this subsection
     to be liberally construed to permit the full use of safe and
     effective medication orders to utilize the skills and services
     of certified registered nurse anesthetists.

     (J) Allows a physician to delegate to a certified, specialized
     physician's assistant offering obstetrical services or an
     advanced nurse practitioner recognized by the Board as midwife
     the act or acts of administering or providing controlled
     substances to the clients during intra-partum and immediate
     post-partum care. Prohibits the physician from delegating the
     use or issuance of a triplicate prescription form under the
     triplicate prescription program in Sec. 481.075, Health and
     Safety Code.

           (ii) Requires the delegation of authority to administer
           or provide controlled substances to be under a
           physician's order, medical order, standing delegation
           order, or protocol which shall require adequate and
           documented availability for access to medical care.
           (iii) Requires the physician's order, medical order,
           standing delegation order, or protocols to provide for
           reporting or monitoring of clients' progress as
           specified in this subsection.
           (iv) Sets forth the limitations on the authority of the
           physician to delegate.
           (v) Requires the administering or providing of
           controlled substances to comply with other applicable
           laws.
           (vi) Defines "provide" for the purposes of this
           paragraph.
           (vii) Requires the controlled substance to be supplied
           in a labeled, suitable container in compliance with
           applicable drug laws, and requires it to include certain
           specifications.
           (viii) States that this paragraph does not permit the
           physician or nurse midwife or physician's assistant to
           operate a retail pharmacy as defined under the Texas
           Pharmacy Act (Article 4542a-1, V.T.C.S.).
           (ix) Requires this paragraph to be construed to provide
           a physician the authority to delegate the act or acts
           of administering or providing controlled substances to
           a nurse midwife or physician assistant, but not as
           requiring physician delegation of the administration of
           medications to registered nurses or physician
           assistants, other than as provided in this paragraph.
     
     (K) Prohibits a physician from being liable for the act or
     acts of a physician assistant or advanced nurse practitioner
     solely on the basis of having signed an order, medical order,
     standing delegation order, or other order or protocols
     authorizing certain acts unless the physician has reason to
     believe the physician assistant or advanced nurse practitioner
     lacked the competency to perform the act or acts.

     (L) Prohibits the authority granted to a physician to delegate
     from being construed as limiting the authority of a physician
     to delegate under any other subdivision of this subsection.

SECTION 14. Adds Section 8, entitled "APPROVAL OF REGISTERED NURSE
FOR ADVANCED PRACTICE," to Article 4514, Revised Statutes, as
follows:

     (a) Requires the board to adopt rules for approval of
     registered nurses as advanced nurse practitioners or advanced
     practice nurses. Defines the terms "advanced nurse
     practitioner" and "advanced practice nurse."

     (b) Requires the board to adopt rules for the initial approval
     and biennial renewal of an advanced nurse practitioner to
     carry out or sign prescription drug orders under Section
     3.06(d)(5) and (6), Medical Practice Act (Article 4495b,
     V.T.C.S.). Sets forth the specified required minimums for the
     rules.  

SECTION 15. Amends Section 5, Article 4518, Revised Statutes, by
modifying the definition of "professional nursing" to clarify
current language relating to registered nurses requesting
professional drug samples, and to expand the definition to include
the performing of medical acts delegated by a physician. Makes
conforming changes to reflect this act.

SECTION 16.  Emergency clause. Effective upon passage.

COMPARISON OF ORIGINAL TO SUBSTITUTE

The committee substitute for H.B. 1520 deletes the provision in the
original bill creating the Medical Assistance Patient Protection
Act, and the provision amending the utilization review law in the
Insurance Code. The substitute expands the provision in the
original bill relating to physicians delegating prescriptive
authority to physician assistants to 1) include advanced nurse
practitioners, and 2) to include physician assistants and advanced
nurse practitioners whose practice is facility based at a licensed
hospital or long term care facility. The substitute clarifies the
content of protocols and physician orders and physician liability
for physician assistants and advanced nurse practitioners. The
substitute authorizes a physician to delegate the ordering of drugs
and devices to a certified registered nurse anesthetist necessary
for the nurse anesthetist to administer an anesthetic or
anesthesia-related service ordered by the physician. The substitute
authorizes a physician to delegate to a physician assistant
certified as specializing in obstetrics or a certified nurse
midwife the providing of a controlled substances to obstetrical
patients during intra-partum and immediate post-partum care. The
substitute 1) authorizes the Board of Nurse Examiners to approve
registered nurses as advanced nurse practitioners and to establish
pharmacology and other requirements for approval of advanced nurse
practitioners to carry out prescription drug orders delegated by a
physician, and 2) amends the definition of professional nursing to
clarify current language relating to registered nurses requesting
professional drug samples, and to expand the definition of
professional nursing to include the performing of medical acts
delegated by a physician. The substitute makes additional
conforming amendments to the Pharmacy Act and Dangerous Drugs Act
to reflect the expanded authority of physicians to delegate
prescriptive authority.

SUMMARY OF COMMITTEE ACTION

H.B. 1520 was considered by the Public Health Committee in a public
hearing on March 21, 1995. The bill was left pending.

H.B. 1520 was considered by the committee as pending business on
May 4, 1995. The committee considered a complete substitute for the
bill. The substitute was adopted without objection.
The bill was reported favorably as substituted, with the
recommendation that it do pass and be printed, by a record vote of
7 AYES, 0 NAYS, 0 PNV, and 2 ABSENT.