ARC 5133C
MEDICINE BOARD[653]
Notice of Intended Action
Proposing rule making related to physician supervision of physician assistants and providing an opportunity for public comment
The Board of Medicine hereby proposes to amend Chapter 21, “Physician Supervision of a Physician Assistant,” Iowa Administrative Code.
Legal Authority for Rule Making
This rule making is proposed under the authority provided in Iowa Code section 272C.3 and 2020 Iowa Acts, Senate File 2357.
State or Federal Law Implemented
This rule making implements, in whole or in part, 2020 Iowa Acts, Senate File 2357.
Purpose and Summary
In 2020, the Iowa General Assembly passed Senate File 2357, which makes several changes to the regulation of physician assistants in Iowa. Specifically, these proposed amendments address changes to the obligations of supervising physicians and supervisory agreements with physician assistants. 
These proposed amendments also clarify that a supervising physician shall not supervise more than five physician assistants pursuant to Iowa Code section 148C.3(2) as an eligibility criterion for being a supervising physician. 
Fiscal Impact
This rule making has no fiscal impact to the State of Iowa.
Jobs Impact
After analysis and review of this rule making, no impact on jobs has been found.
Waivers
Any person who believes that the application of the discretionary provisions of this rule making would result in hardship or injustice to that person may petition the Board for a waiver of the discretionary provisions, if any, pursuant to 653—Chapter 3.
Public Comment
Any interested person may submit written or oral comments concerning this proposed rule making. Written or oral comments in response to this rule making must be received by the Board no later than 4:30 p.m.	on September 2, 2020. Comments should be directed to:

Joseph Fraioli
Iowa Board of Medicine
400 SW Eighth Street, Suite C
Des Moines, Iowa 50309
Phone: 515.281.3614
Email: joseph.fraioli@iowa.gov	
Public Hearing
A public hearing at which persons may present their views orally or in writing will be held via Google Meet at the link below. Participants may also call in via phone at the following phone number: (US) +1 502.382.4450. When prompted, enter PIN: 756 685 379#. Please mute your phones or microphones upon entering the meeting.

September 2, 2020
2 to 3 p.m.	meet.google.com/zpn-yudi-jvb
Google Meet Location	
Persons who wish to make oral comments at the public hearing may be asked to state their names for the record and to confine their remarks to the subject of this proposed rule making.
Any persons who intend to attend the public hearing and have special requirements, such as those related to hearing or mobility impairments, should contact the Board and advise of specific needs.
Review by Administrative Rules Review Committee
The Administrative Rules Review Committee, a bipartisan legislative committee which oversees rule making by executive branch agencies, may, on its own motion or on written request by any individual or group, review this rule making at its regular monthly meeting or at a special meeting. The Committee’s meetings are open to the public, and interested persons may be heard as provided in Iowa Code section 17A.8(6).
The following rule-making actions are proposed:
	Item 1. Amend rule 653—21.1(148,272C) as follows:
653—21.1(148,272C) Ineligibility determinants. A physician with an active permanent, special, or temporary Iowa license who is actively engaged in the practice of medicine in Iowa may supervise a physician assistant. A physician is ineligible to supervise a physician assistant for any of the following reasons:
	21.1(1) The physician does not hold an active, permanent, special or temporary Iowa medical license.
	21.1(2) The physician is subject to a disciplinary order of the board that restricts or rescinds the physician’s authority to supervise a physician assistant. The physician may supervise a physician assistant to the extent that the order allows.
	21.1(3) The physician does not have a written supervisory agreement in place with each physician assistant supervised by the physician.
	21.1(4) The physician is already supervising five physician assistants.
	Item 2. Amend rule 653—21.4(148,272C) as follows:
653—21.4(148,272C) Supervisory agreements.
	21.4(1) Each A  physician who supervises a physician assistant shall establish a written supervisory agreement prior to supervising a physician assistant. A sample supervisory agreement form is available from the board. The purpose of the supervisory agreement is to define the nature and extent of the supervisory relationship and the expectations of each party. The supervisory agreement shall take into account the physician assistant’s demonstrated skills, training and experience, proximity of the supervising physician to the physician assistant, and the nature and scope of the medical practice. The supervising physician shall maintain a copy of the supervisory agreement and provide a copy of the agreement to the board upon request. The supervisory agreement shall, at a minimum, address the following provisions.
	21.4(1) a.	Review of requirements. The supervisory agreement shall include a provision which ensures that the supervising physician and the physician assistant shall review all of the requirements of physician assistant licensure, practice, supervision, and delegation of medical services as set forth in Iowa Code section 148.13 and chapter 148C, this chapter these rules, and 645—Chapters 326 to 329.
	21.4(2) b.	Assessment of education, training, skills, and experience. The supervisory agreement shall include a provision which ensures that each Each supervising physician assesses shall assess the education, training, skills, and relevant experience of the physician assistant prior to providing supervision. Each supervising physician and physician assistant shall ensure that the other party has the appropriate education, training, skills, and relevant experience necessary to successfully collaborate on patient care delivered by the team. Thereafter, each supervising physician shall regularly evaluate the clinical judgment, skills, performance and patient care of the physician assistant and shall provide appropriate feedback to the physician assistant. The method for assessing and providing feedback regarding the physician assistant’s education, training, skills, and experience shall be reflected in the supervisory agreement.
	21.4(3) 21.4(2) Delegated services. The supervisory agreement shall include a provision which addresses the services the supervising physician delegates to the physician assistant. between the physician assistant and the physician shall address all of the following:
	a.	The medical services the supervising physician delegates to the physician assistant. The medical services and medical tasks delegated to and provided by the physician assistant shall be in compliance with 645—subrule 327.1(1). All delegated medical services shall be within the scope of practice of the supervising physician and the physician assistant. The supervising physician and the physician assistant shall have the education, training, skills, and relevant experience necessary to perform the delegated services prior to delegation.
	21.4(4) Communication. The supervisory agreement shall include a provision which sets forth expectations for communication. Each supervising physician and physician assistant shall communicate about and consult on patient complaints, medical problems, complications, emergencies, and patient referrals as indicated by the clinical condition of the patient. The supervising physician shall be available for timely consultation with the physician assistant, either in person or by telephonic or other electronic means. The supervisory agreement shall also include a provision which ensures that each supervising physician and physician assistant
	b.	Methods for communication between the physician assistant and the physician and whether the physician assistant practices at the same site or a remote site. Each supervising physician and physician assistant shall conduct ongoing discussions and evaluation of the supervisory agreement, including supervision; expectations for both parties; assessment of education, training, skills, and relevant experience; review of delegated services; review of the medical services provided by the physician assistant; and the types of cases and situations when the supervising physician expects to be consulted.
	21.4(5) Chart review. The supervisory agreement shall include a provision which sets forth the plan for completing and documenting chart reviews. Documentation may include, but is not limited to, the supervising physician’s placing the supervising physician’s signature or initials on the charts reviewed. Each supervising physician shall ensure that
	(1)	The plan for completing and documenting chart reviews. A licensed physician within the same facility or health care system as the physician assistant shall conduct an ongoing review of a representative sample of the physician assistant’s patient charts encompassing the scope of the physician assistant’s practice provided under the physician’s supervision occurs and that the findings of the review are discussed with the physician assistant.  The finding of the review shall be discussed with the physician assistant in a manner determined by the practice in consultation with the physician assistant’s primary supervising physician.
	21.4(6) (2)	Remote medical site. Remote medical site. “Remote medical site” means a medical clinic for ambulatory patients which is more than 30 miles away from the main practice location of the supervising physician and in which the supervising physician is present less than 50 percent of the time when the remote medical site is open. “Remote medical site” will not apply to nursing homes, patient homes, hospital outpatient departments, outreach clinics, or any location at which medical care is incidentally provided (e.g., diet center, free clinic, site for athletic physicals, jail facility). The supervisory agreement shall include a provision which ensures that the supervising physician visits the remote medical site, or communicates with a physician assistant at the remote medical site via electronic communications, at least every two weeks to provide additional medical direction, medical services and consultation specific to the medical services provided at the remote medical site. For purposes of this subrule subparagraph, communication may consist of, but shall not be limited to, in-person meetings or two-way, interactive communication directly between the supervising physician and the physician assistant via the telephone, secure messaging, electronic mail, or chart review. The supervisory agreement shall also include a provision which ensures that at least one supervising physician meets in person, and documents the meeting, with the physician assistant at the remote medical site at least once every six months to evaluate and discuss the medical facilities, resources, and medical services provided at the remote medical site. The board shall only grant a waiver or variance of this provision if substantially equal protection of public health, safety, and welfare will be afforded by a means other than that prescribed in this rule subparagraph.
	21.4(7) (3)	Alternate supervision. The expectations and plan for alternate supervision.  The supervisory agreement shall include a provision which sets forth the expectations and plan for alternate supervision. If the supervising physician will not be available for any reason, an alternate supervising physician must be available to ensure continuity of supervision. The supervising physician will ensure that the alternate supervising physician is available for a timely consultation and will ensure that the physician assistant is notified of the means by which to reach the alternate supervising physician. The physician assistant may not practice if supervision is unavailable, except as otherwise provided in Iowa Code chapter 148C or 645—Chapters 326 to 329.