H.B. 1095 78(R) BILL ANALYSIS H.B. 1095 By: Capelo Public Health Committee Report (Unamended) BACKGROUND AND PURPOSE Physicians may currently delegate prescriptive authority to Advanced Practice Nurses (APNs) and Physician Assistants (PAs), but Texas limits that authority to dangerous drugs. A "dangerous drug" is a drug or device, other than controlled substances, that pharmacists may only dispense with a prescription from an authorized prescriber. APNs and PAs have safely prescribed these drugs in Texas for over twelve years, and are educated to prescribe controlled substances, just as they are other medications within their scopes of practice. Sometimes a controlled substance may be the safest and most effective medication for a particular patient. It is important to allow a physician to delegate the prescribing of controlled substances because the standard of care for many patients requires treatment with a controlled drug. Controlled substances are divided into five schedules. The most addictive drugs, with no recognized medical use, are in Schedule I, and those with the least abuse potential are in Schedule V. These drugs are controlled because they have an abuse potential, not because they have more serious side effects or adverse effects than dangerous drugs. Texas is one of only seven states that does not permit APNs, and one of only nine states that does not permit PAs to sign prescriptions for controlled substances. Currently, 35 states and the District of Columbia permit APNs to prescribe controlled substances including Schedules II through V. Twenty-seven of the 41 states permitting PAs to prescribe controlled substances include Schedules II through V. Increasing numbers of health care facilities and insurers must credential health care providers. The 77th Legislature directed the Texas Department of Insurance to develop a standardized credentialing form for physicians that must be used by all insurers and hospitals. Physicians are not the only health care professionals that spend a significant amount of time completing credentialing forms. Some APNs and PAs must also go through credentialing processes. APNs and PAs need to spend more time with patients and less time completing forms. Since the form TDI developed is also appropriate for all health care providers, the most efficient way to accomplish this is to require HMOs, PPOs, and hospitals to use that form when credentialing APNs and PAs. RULEMAKING AUTHORITY It is the committee's opinion that rulemaking authority is expressly granted to the Texas Commissioner of Insurance in SECTION 11 (Art. 21.58D Sec. (2), Insurance Code) of this bill. ANALYSIS SECTION 1. Amends Sec. 157.051 of the Occupations Code to add a definition of a controlled substance and dangerous drug. SECTION 2. Amends Subchapter B, Chapter 157 of the Occupations Code to expand the authority of physicians to delegate prescriptive authority to APNs and PAs to include controlled substances, and specifies limitations on that authority as follows: 1. prescriptions for controlled substances are limited to Schedules III - V, 2. the prescription is for a period not to exceed 30 days, 3. refills of those prescriptions require prior consultation with the delegating physician and notation of the consultation in the patient's chart, and 4. prescriptions for children under the age of 2 years require prior consultation with the delegating physician and notation of the consultation in the child's chart. This section also clarifies that the limits on prescribing controlled substances does not effect a registered nurse's or PA's ability to administer or provide a medication under a physician's order, standing medical order, standing delegation order, or protocol. SECTION 3. Amends Sec. 157.052(c) of the Occupations Code to delete the language limiting a physician's ability to delegate only dangerous drugs to an APN or PA practicing at a site serving a medically underserved population. SECTION 4. Amends Sec. 157.053(b) of the Occupations Code to delete the language limiting a physician's ability to delegate only dangerous drugs to an APN or PA practicing in a physician's primary practice site. SECTION 5. Amends Sec. 157.054(b) of the Occupations Code to delete the language limiting a physician's ability to delegate only dangerous drugs to an APN or PA practicing in a facility-based practice. SECTION 6. Amends Sec. 157.0541(b) of the Occupations Code to delete the language limiting a physician's ability to delegate only dangerous drugs to an APN or PA practicing in an alternate site. SECTION 7. Amends Sec. 157.059 (j) of the Occupations Code by adding that the current authority for a physician to delegate the providing of controlled substances to a Certified Nurse Midwife (CNM) or a PA does not limit a physician's ability to delegate to a CNM or PA the prescribing of controlled substances as authorized by this Act. SECTION 8. Amends Sec. 551.003(34) of the Occupations Code to make a conforming amendment to the Pharmacy Act to specify the new section in the Medical Practice Act added by SECTION 2 of this bill under which a physician may delegate prescriptive authority to an APN or PA. SECTION 9. Amends Sec. 481.002(39) of the Health and Safety Code(the Controlled Substances Act) to add APNs and PAs to the definition of practitioner. SECTION 10. Amends Sec. 483.001(12) of the Health and Safety Code to make a conforming amendment to the Dangerous Drug Act to specify the new section in the Medical Practice Act added by SECTION 2 of this bill under which a physician may delegate prescriptive authority to an APN or PA. SECTION 11. Amends Art. 21.58D of the Insurance Code by (1) adding definitions of an APN and PA, (2) requiring the Commissioner by rule to adopt a standardized form for the verification of credentials of APNs and PAs, and require hospitals, HMOs, and PPOs to use that form for verification of credentials, and (3) directing the Commissioner to consider adopting a form currently used by the department. EFFECTIVE DATE On passage, or, if the Act does not receive the necessary vote, the Act takes effect September 1, 2003.