BILL ANALYSIS C.S.S.B. 673 By: Madla Health and Human Services 5-1-95 Committee Report (Substituted) BACKGROUND The country is rapidly moving towards managed health care plans. Many rural residents and providers have concerns that if the proper safeguards are not in place, this movement may jeopardize the viability of hundreds of rural health clinics, disrupt existing patient-physician relationships, and cause rural residents to travel great distances for care. These concerns are especially critical in light of efforts to convert Medicaid to managed care because many traditional Medicaid providers are not presently a part of managed care networks. PURPOSE As proposed, C.S.S.B. 673 requires the Department of Human Services to establish a clearinghouse of information as part of a comprehensive health professions resource center; requires the Center for Rural Health Initiatives to perform certain functions regarding areas that are medically underserved; sets forth standards for health care facilities and services for the elderly, disabled, and long-term care individuals; and authorizes a physician to delegate certain prescription drug orders. RULEMAKING AUTHORITY It is the committee's opinion that rulemaking authority is granted to the Texas Board of Health under SECTION 11 (Section 3.06(d)(5)(D)(vi), Article 4495b, V.T.C.S.) and to the Texas State Board of Medical Examiners under SECTION 12 (Section 3.06(d)(6)(D), Article 4495b, V.T.C.S.) and under SECTION 13 (Sections 8(a) and (b), Article 4514, V.T.C.S.) of this bill. SECTION BY SECTION ANALYSIS SECTION 1. Amends Chapter 105, Health and Safety Code, by adding Section 105.007, as follows: Sec. 105.007. CLEARINGHOUSE. (a) Requires the Department of Human Services (department) to develop and establish a clearinghouse for health professionals seeking collaborative practice as part of the comprehensive health professions resource center. (b) Authorizes the department to set and collect a fee and solicit, receive, and spend monies from public and private sources to comply with this section and contract with public or private entities in the performance of its responsibilities. SECTION 2. Amends Section 106.025(a), Health and Safety Code, to require the Center for Rural Health Initiatives to encourage the use of advanced communication technology to ensure that rural areas receive the maximum benefits of telemedicine and distance learning by promoting a transmission rate structure and improving telecommunications infrastructure in rural areas, to develop and initiate a study of rural health clinics with certain objectives and a quality assessment program to evaluate the health outcomes of patients treated in rural clinics, and encourage the active participation by physicians and other health care providers in the early periodic diagnosis and treatment program, among other requirements. SECTION 3. Amends Chapter 262.034, Health and Safety Code, as follows: New heading: FACILITIES AND SERVICES FOR ELDERLY AND DISABLED (a)-(d) Authorize a hospital authority to construct, acquire, own, operate, enlarge, improve, furnish, or equip certain facilities or services, including long-term care, elderly housing, assisted living, home health, personal care, special care, continuing care and durable medical equipment for the elderly or disabled. Make conforming changes. (e) Applies this section only to an authority that owns or operates a hospital licensed under Chapter 241 and that is located in a county with a population of 35,000 or less, those portions of extended municipalities that the federal Census Bureau (bureau) has determined to be rural, or an area that is not delineated as an urbanized area by the bureau (rural area). SECTION 4. Amends Chapter 285, Health and Safety Code, by adding Subchapter H, as follows: SUBCHAPTER H. LONG-TERM CARE AND RELATED FACILITIES Sec. 285.101. FACILITIES OR SERVICES FOR ELDERLY OR DISABLED. (a) Applies this subchapter only to a hospital, hospital district, or authority created and operated under Article IX, Texas Constitution, under a special law, or under this title that is located in a rural area. (b) Sets forth authorized actions regarding facilities and services of any hospital, hospital district, or authority covered by this subchapter. (c) Provides that a facility service created under Subsection (a) is considered to be a hospital project under Chapter 223. SECTION 5. Amends Section 483.001(13), Health and Safety Code, to redefine "prescription." SECTION 6. Amends Section 671.001(d), Health and Safety Code, as follows: (d) Authorizes a physician assistant, in addition to a registered nurse, to pronounce a person dead in certain situations if permitted by policies of the facility providing services to that person. Requires those policies to consider assistants who are credentialed or otherwise permitted to practice at the facility. SECTION 7. Amends Section 671.002, Health and Safety Code, to make conforming changes. SECTION 8. Amends Section 51.918(c), Education Code, to require the Center for Rural Health Initiatives to develop relief service programs for rural physicians and allied health personnel to facilitate ready access to practice coverage for purposes other than continuing medical education. SECTION 9. Amends Section 501.059, Government Code, to require the Managed Health Care Advisory Committee to the Texas Department of Criminal Justice to develop a managed health care plan (plan) for all inmates at the institutional division that includes provisions concerning the establishment of criteria for hospitals, home health, or hospice providers, requiring the plan to accept certification by the Medicare program as an alternative to accreditation by the Joint Commission on Accreditation of Healthcare Organizations. Makes conforming changes. SECTION 10. Amends Section 5(42), Article 4542a-1, V.T.C.S. (Texas Pharmacy Act), to make a conforming change. SECTION 11. Amends Section 3.06(d)(5), Article 4495b, V.T.C.S. (Medical Practice Act) to provide that the authority of a physician to delegate the carrying out or signing of prescription drug orders is limited to dangerous drugs. Redefines "carrying out or signing a petition" and "medically underserved area." Makes conforming changes. SECTION 12. Amends Section 3.06, Article 4495b, V.T.C.S., by adding Subsection (d)(6), as follows: (6)(A) Authorizes a physician licensed by the Texas State Board of Medical Examiners (board) to delegate to a physician assistant or an advanced nurse practitioner acting under adequate supervision the acts of administering, providing, carrying out, or signing a prescription drug order for dangerous drugs as authorized through board protocols. Requires providing and carrying out or signing a prescription drug order to be 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 and physician assistant commensurate with their education and experience. Sets forth requirements for protocols used by a reasonable and prudent physician exercising sound medical judgment. (C) Requires supervision of the carrying out and signing of prescriptions to conform to what a reasonable, prudent physician would find consistent with sound medical judgment, but authorizes the judgment to vary with the education and experience of the individuals. Requires a physician to provide continuous supervision, but does not require the physician's constant physical presence. (D) Authorizes an alternate physician to provide appropriate supervision on a temporary basis as defined and established by board rule. (E) Requires the carrying out or signing of petitions to comply with other applicable laws. (F) Sets forth the limits of a physician's responsibility to delegate. (G) Defines "advanced nurse practitioner," "physician assistant," "primary practice site," and "carrying out or signing a prescription drug order." (H) Requires a licensed physician to be authorized to delegate to physician assistant or advanced nurse practitioners acting under physician supervision whose facility is based at a licensed hospital or long-term care facility, the carrying out or signing of prescriptions if the physician is the director or chief of staff of the facility in which the assistant or practitioner practices, the chair of the facility's credentialing committee, or is a department chair of a facility department in which the assistant or practitioner who consents to the delegation practices. Sets forth limits of a physician's authority to delegate under this provision. (I) Authorizes a physician to delegate in a licensed hospital or ambulatory surgical center to a certified registered nurse anesthetist the ordering of drugs and devices necessary to administer an anesthetic or anesthesia related service ordered by the physician. Provides that the physician's order does not have to be drug, dose, or administration-technique specific. Authorizes the nurse anesthetist to select, obtain, and administer those drugs and apply to appropriate devices necessary to accomplish the order and maintain the patient within good status pursuant to the order and in accordance with facility policies or bylaws. (J) Prohibits holding a physician liable for the acts of an assistant or practitioner solely on the basis of having signed certain orders or protocols authorizing the person to perform the acts of administering, providing, carrying out, or signing a prescription unless the physician has reason to believe that the person lacked the competency to perform the acts. (K) Prohibits construing the authority granted to a physician to delegate as limiting the authority of a physician to delegate under any other subdivision of this subsection. SECTION 13. Amends Article 4514, V.T.C.S., by adding Section 8, as follows: (a) Requires the board to adopt rules for approval of a registered nurse as an advanced nurse practitioner or an advanced practice nurse. Defines "advanced nurse practitioner" or "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 prescriptions. Sets forth minimum requirements for the rules to meet. SECTION 14. Amends Section 5, Article 4518, V.T.C.S., to redefine "professional nursing." SECTION 15. Emergency clause. Effective date: upon passage.