S.F. 2357 Section 1. Section 147.107, subsections 3, 4, and 5, Code 1 2020, are amended to read as follows: 2 3. A physician assistant or registered nurse may supply, 3 when pharmacist services are not reasonably available or when 4 it is in the best interests of the patient, on the direct 5 order of the supervising physician, a quantity of properly 6 packaged and labeled prescription drugs, controlled substances, 7 or contraceptive devices necessary to complete a course of 8 therapy. However, a remote clinic, staffed by a physician 9 assistant or registered nurse, where pharmacy services are 10 not reasonably available, shall secure the regular advice 11 and consultation of a pharmacist regarding the distribution, 12 storage, and appropriate use of such drugs, substances, and 13 devices. 14 4. Notwithstanding subsection 3 , a A physician assistant 15 shall not may prescribe, dispense , order, administer, or 16 procure prescription drugs as an incident to the practice 17 of the supervising physician or the physician assistant, 18 but may supply, when pharmacist services are not reasonably 19 available, or when it is in the best interests of the patient, 20 a quantity of properly packaged and labeled prescription 21 drugs , controlled substances, or medical devices necessary 22 to complete a course of therapy . However, a remote clinic, 23 staffed by a physician assistant, where pharmacy services are 24 not reasonably available, shall secure the regular advice 25 and consultation of a pharmacist regarding the distribution, 26 storage, and appropriate use of such drugs, substances, and 27 devices. Prescription drugs supplied under the provisions 28 of this subsection shall be supplied for the purpose of 29 accommodating the patient and shall not be sold for more than 30 the cost of the drug and reasonable overhead costs, as they 31 relate to supplying prescription drugs to the patient, and 32 not at a profit to the physician or the physician assistant. 33 If prescription drug supplying authority is delegated by a 34 supervising physician to a physician assistant, a nurse or 35 -1- LSB 5646SV (3) 88 pf/rh 1/ 19

S.F. 2357 staff assistant may assist the physician assistant in providing 1 that service. Rules shall be adopted by the board of physician 2 assistants, after consultation with the board of pharmacy, to 3 implement this subsection pursuant to section 148C.4 . 4 5. Notwithstanding subsection 1 and any other provision 5 of this section to the contrary, a physician may delegate 6 the function of prescribing drugs, controlled substances, 7 and medical devices for which the supervising physician has 8 sufficient training or experience to a physician assistant 9 licensed pursuant to chapter 148C after the supervising 10 physician determines the physician assistant’s proficiency 11 and competence . When delegated prescribing occurs, the 12 supervising physician’s name shall be used, recorded, or 13 otherwise indicated in connection with each individual 14 prescription so that the individual who dispenses or 15 administers the prescription knows under whose delegated 16 authority the physician assistant is prescribing. Rules 17 relating to the authority of physician assistants to prescribe 18 drugs, controlled substances, and medical devices pursuant to 19 this subsection shall be adopted by the board of physician 20 assistants, after consultation with the board of medicine and 21 the board of pharmacy. However, the rules shall prohibit the 22 prescribing of schedule II controlled substances which are 23 listed as depressants pursuant to chapter 124 . 24 Sec. 2. Section 147.136, subsection 1, Code 2020, is amended 25 to read as follows: 26 1. Except as otherwise provided in subsection 2 , in an 27 action for damages for personal injury against a physician and 28 surgeon, osteopathic physician and surgeon, dentist, podiatric 29 physician, optometrist, pharmacist, chiropractor, physician 30 assistant, or nurse licensed to practice that profession in 31 this state, or against a hospital licensed for operation in 32 this state, based on the alleged negligence of the practitioner 33 in the practice of the profession or occupation, or upon the 34 alleged negligence of the hospital in patient care, in which 35 -2- LSB 5646SV (3) 88 pf/rh 2/ 19

S.F. 2357 liability is admitted or established, the damages awarded shall 1 not include actual economic losses incurred or to be incurred 2 in the future by the claimant by reason of the personal 3 injury, including but not limited to the cost of reasonable and 4 necessary medical care, rehabilitation services, and custodial 5 care, and the loss of services and loss of earned income, to 6 the extent that those losses are replaced or are indemnified by 7 insurance, or by governmental, employment, or service benefit 8 programs or from any other source. 9 Sec. 3. Section 147.138, Code 2020, is amended to read as 10 follows: 11 147.138 Contingent fee of attorney reviewed by court. 12 In any action for personal injury or wrongful death against 13 any physician and surgeon, osteopathic physician and surgeon, 14 dentist, podiatric physician, optometrist, pharmacist, 15 chiropractor , physician assistant, or nurse licensed under 16 this chapter or against any hospital licensed under chapter 17 135B , based upon the alleged negligence of the licensee in the 18 practice of that profession or occupation, or upon the alleged 19 negligence of the hospital in patient care, the court shall 20 determine the reasonableness of any contingent fee arrangement 21 between the plaintiff and the plaintiff’s attorney. 22 Sec. 4. Section 148C.1, Code 2020, is amended to read as 23 follows: 24 148C.1 Definitions. 25 1. “Approved program” means a program for the education 26 of physician assistants which has been accredited by the 27 American medical association’s committee on allied health 28 education and accreditation or its successor, by the commission 29 on accreditation of allied health educational programs or 30 its successor, or by the accreditation review commission on 31 education for the physician assistant or its successor , or, if 32 accredited prior to 2001, either by the committee on allied 33 health education and accreditation, or the commission on 34 accreditation of allied health education programs . 35 -3- LSB 5646SV (3) 88 pf/rh 3/ 19

S.F. 2357 2. “Board” means the board of physician assistants created 1 under chapter 147 . 2 3. “Collaboration” means consultation with or referral to 3 the appropriate physician or other health care professional by 4 a physician assistant as indicated by the patient’s condition; 5 the education, competencies, and experience of the physician 6 assistant; and the standard of care. 7 3. 4. “Department” means the Iowa department of public 8 health. 9 4. 5. “Licensed physician assistant” or “licensed P.A.” 10 means a person who is licensed by the board to practice as 11 a physician assistant under the supervision of one or more 12 physicians. “Supervision” does not require the personal 13 presence of the supervising physician at the place where 14 medical services are rendered except insofar as the personal 15 presence is expressly required by this chapter or required by 16 rules of the board adopted pursuant to this chapter . 17 5. 6. “Physician” means a person who is currently licensed 18 in Iowa to practice medicine and surgery or osteopathic 19 medicine and surgery. Notwithstanding this subsection , a 20 physician supervising a physician assistant practicing in 21 a federal facility or under federal authority shall not be 22 required to obtain licensure beyond licensure requirements 23 mandated by the federal government for supervising physicians. 24 6. 7. “Physician assistant” or “P.A.” means a person who 25 has successfully completed an approved program and passed an 26 examination approved by the board or is otherwise found by the 27 board to be qualified to perform medical services under the 28 supervision of a physician meets the qualifications under this 29 chapter and is licensed to practice medicine by the board . 30 7. “Trainee” means a person who is currently enrolled in an 31 approved program. 32 8. “Supervising physician” means a physician who supervises 33 the medical services provided by a physician assistant 34 consistent with the physician assistant’s education, training, 35 -4- LSB 5646SV (3) 88 pf/rh 4/ 19

S.F. 2357 or experience and who accepts ultimate responsibility for the 1 medical care provided by the supervising physician-physician 2 assistant team. 3 Sec. 5. Section 148C.3, subsections 1 and 3, Code 2020, are 4 amended to read as follows: 5 1. The board shall adopt rules to govern the licensure of 6 physician assistants. An applicant for licensure shall submit 7 the fee prescribed by the board and shall meet the requirements 8 established by the board with respect to each of the following: 9 a. Academic qualifications, including evidence of graduation 10 from an approved program. A physician assistant who is not a 11 graduate of an approved program, but who passed the national 12 commission on certification of physician assistants’ physician 13 assistant national certifying examination prior to 1986, is 14 exempt from this graduation requirement. 15 b. Evidence of passing the national commission on the 16 certification of physician assistants’ physician assistant 17 national certifying examination or an equivalent examination 18 approved by the board. 19 c. Hours of continuing medical education necessary to become 20 or remain licensed. 21 3. A licensed physician assistant shall perform only 22 those services for which the licensed physician assistant is 23 qualified by training or education and which are not prohibited 24 by the board. 25 Sec. 6. Section 148C.4, subsection 1, Code 2020, is amended 26 to read as follows: 27 1. A physician assistant may perform medical services 28 when the services are rendered under the supervision of a 29 physician. A physician assistant student may perform medical 30 services when the services are rendered within the scope of an 31 approved program provide any legal medical service for which 32 the physician assistant has been prepared by the physician 33 assistant’s education, training, or experience and is competent 34 to perform . For the purposes of this section , “medical 35 -5- LSB 5646SV (3) 88 pf/rh 5/ 19

S.F. 2357 services when the services are rendered under the supervision 1 of a physician” “legal medical service for which the physician 2 assistant has been prepared by the physician assistant’s 3 education, training, or experience and is competent to perform” 4 includes making a pronouncement of death for a patient 5 whose death is anticipated if the death occurs in a licensed 6 hospital, a licensed health care facility, a correctional 7 institution listed in section 904.102 , a Medicare-certified 8 home health agency, or a Medicare-certified hospice program 9 or facility , with notice of the death to a physician and in 10 accordance with the directions of a physician . 11 Sec. 7. Section 148C.4, Code 2020, is amended by adding the 12 following new subsection: 13 NEW SUBSECTION . 3. The degree of collaboration between 14 a physician assistant and the appropriate member of a health 15 care team shall be determined at the practice level, and may 16 involve decisions made by the medical group, hospital service, 17 supervising physician, or employer of the physician assistant, 18 or the credentialing and privileging system of a licensed 19 health care facility. A physician shall be accessible at all 20 times for consultation with a physician assistant unless the 21 physician assistant is providing emergency medical services 22 pursuant to 645 IAC 327.1(1)(n). The supervising physician 23 shall have ultimate responsibility for determining the medical 24 care provided by the supervising physician-physician assistant 25 team. 26 Sec. 8. Section 249A.4, subsection 7, paragraph b, Code 27 2020, is amended to read as follows: 28 b. Advanced registered nurse practitioners licensed pursuant 29 to chapter 152 and physician assistants licensed pursuant to 30 chapter 148C shall be regarded as approved providers of health 31 care services, including primary care, for purposes of managed 32 care or prepaid services contracts under the medical assistance 33 program. This paragraph shall not be construed to expand the 34 scope of practice of an advanced registered nurse practitioner 35 -6- LSB 5646SV (3) 88 pf/rh 6/ 19

S.F. 2357 pursuant to chapter 152 or physician assistants pursuant to 1 chapter 148C . 2 Sec. 9. ADMINISTRATIVE RULEMAKING. 3 1. The board of medicine and the board of physician 4 assistants shall each, at the next meeting of the respective 5 boards held one calendar week or more after the enactment of 6 this Act, approve a notice of intended action to adopt rules to 7 implement this Act for submission to the administrative rules 8 coordinator and the Iowa administrative code editor pursuant to 9 section 17A.4, subsection 1, paragraph “a”. 10 2. Notwithstanding section 148C.5, the board of medicine 11 and the board of physician assistants, in accordance with 12 chapter 17A and this section, and consistent with this Act, 13 shall each amend, rescind, or adopt rules which address all of 14 the following: 15 a. For the board of physician assistants, rules relating to 16 and in substantial conformance with all of the following: 17 (1) Definitions pursuant to 645 IAC 326.1 including all of 18 the following: 19 (a) “Approved program” means a program for the education 20 of physician assistants which has been accredited by the 21 accreditation review commission on education for the physician 22 assistant or its successor, or if accredited prior to 2001, 23 either by the committee on allied health education and 24 accreditation, or the commission on accreditation of allied 25 health education programs. 26 (b) “Collaboration” means consultation with or referral to 27 the appropriate physician or other health care professional by 28 a physician assistant as indicated by the patient’s condition; 29 the education, competencies, and experience of the physician 30 assistant; and the standard of care. 31 (c) “Opioid” means a drug that produces an agonist effect 32 on opioid receptors and is indicated or used for the treatment 33 of pain or opioid use disorder. 34 (d) “Physician assistant” or “P.A.” means a person licensed 35 -7- LSB 5646SV (3) 88 pf/rh 7/ 19

S.F. 2357 as a physician assistant by the board. 1 (e) “Remote medical site” means a medical clinic for 2 ambulatory patients which is more than thirty miles away from 3 the main practice location of a supervising physician and 4 in which a supervising physician is present less than fifty 5 percent of the time the site is open. “Remote medical site” 6 does not apply to nursing homes, patient homes, hospital 7 outpatient departments, outreach clinics, or any location at 8 which medical care is incidentally provided such as a diet 9 center, free clinic, site for athletic physicals, or a jail 10 facility. 11 (f) “Supervising physician” means a physician who 12 supervises the medical services provided by the physician 13 assistant consistent with the physician assistant’s education, 14 training, or experience and who accepts ultimate responsibility 15 for the medical care provided by the physician-physician 16 assistant team. 17 (2) Examination requirements pursuant to 645 IAC 326.6 18 including that the applicant for licensure as a physician 19 assistant shall successfully pass the certifying examination 20 conducted by the national commission on certification of 21 physician assistants or a successor examination approved by the 22 board of physician assistants. 23 (3) Use of title requirements pursuant to 645 IAC 326.15 24 including that a physician assistant licensed under chapter 25 148C may use the words “physician assistant” after the person’s 26 name or signify the same by the use of the letters “P.A.” A 27 person who meets the qualifications for licensure under chapter 28 148C but does not possess a current license may use the title 29 “P.A.” or “physician assistant” but may not act or practice as 30 a physician assistant unless licensed under chapter 148C. 31 (4) Recognition of an approved program pursuant to 645 32 IAC 326.18 including that the board shall recognize a program 33 for education and training of physician assistants if it is 34 accredited by the accreditation review commission on education 35 -8- LSB 5646SV (3) 88 pf/rh 8/ 19

S.F. 2357 for the physician assistant or its successor, or, if accredited 1 prior to 2001, either by the committee on allied health 2 education and accreditation or the commission on accreditation 3 of allied health educational programs. 4 (5) Duties pursuant to 645 IAC 327.1(1), unnumbered 5 paragraph 1, including that the medical services to be 6 provided by the physician assistant are those for which the 7 physician assistant has been prepared by education, training, 8 or experience and is competent to perform. The ultimate 9 role of the physician assistant cannot be rigidly defined 10 because of the variations in practice requirements due to 11 geographic, economic, and sociologic factors. The high degree 12 of responsibility a physician assistant may assume requires 13 that, at the conclusion of formal education, the physician 14 assistant possess the knowledge, skills, and abilities 15 necessary to provide those services appropriate to the practice 16 setting. The physician assistant’s services may be utilized in 17 any clinical settings including but not limited to the office, 18 the ambulatory clinic, the hospital, the patient’s home, 19 extended care facilities, and nursing homes. Diagnostic and 20 therapeutic medical tasks for which the supervising physician 21 has sufficient training or experience may be delegated to the 22 physician assistant after a supervising physician determines 23 the physician assistant’s proficiency and competence. 24 (6) Duties pursuant to 645 IAC 327.1 relating to 25 prescribing, dispensing, ordering, administering, and procuring 26 drugs and medical devices including all of the following: 27 (a) A physician assistant may administer any drug. 28 (b) A physician assistant may prescribe, dispense, 29 order, administer, and procure drugs and medical devices. A 30 physician assistant may plan and initiate a therapeutic regimen 31 that includes ordering and prescribing nonpharmacological 32 interventions, including but not limited to durable medical 33 equipment, nutrition, blood and blood products, and diagnostic 34 support services including but not limited to home health 35 -9- LSB 5646SV (3) 88 pf/rh 9/ 19

S.F. 2357 care, hospice, and physical and occupational therapy. The 1 prescribing and dispensing of drugs may include schedule II 2 through V substances as described in chapter 124 and all legend 3 drugs. 4 (c) A physician assistant may prescribe drugs and medical 5 devices subject to all the following conditions: 6 (i) The physician assistant shall have passed the national 7 certifying examination conducted by the national commission 8 on the certification of physician assistants or its successor 9 examination approved by the board. Physician assistants with a 10 temporary license may order drugs and medical devices only with 11 the prior approval and direction of a supervising physician. 12 Prior approval may include discussion of the specific medical 13 problems with a supervising physician prior to the patient 14 being seen by the physician assistant. 15 (ii) The physician assistant must comply with appropriate 16 federal and state regulations. 17 (iii) If a physician assistant prescribes or dispenses 18 controlled substances, the physician assistant must register 19 with the federal drug enforcement administration. 20 (iv) The physician assistant may prescribe or order 21 schedule II controlled substances which are listed as 22 depressants in chapter 124 only with the prior approval 23 and direction of a supervising physician who has sufficient 24 training or experience. Prior approval may include discussion 25 of the specific medical problems with a supervising physician 26 prior to the patient being seen by the physician assistant. 27 (v) A physician assistant shall not prescribe substances 28 that the supervising physician does not have the authority 29 to prescribe except as allowed in 645 IAC 327.1(1)(n) when 30 providing immediate evaluation, treatment, and institution of 31 procedures essential to providing an appropriate response to 32 emergency medical problems. 33 (vi) The physician assistant may prescribe, supply, and 34 administer drugs and medical devices in all settings including 35 -10- LSB 5646SV (3) 88 pf/rh 10/ 19

S.F. 2357 but not limited to hospitals, health care facilities, health 1 care institutions, clinics, offices, health maintenance 2 organizations, and outpatient and emergency care settings. 3 (vii) A physician assistant may request, receive, and 4 supply sample drugs and medical devices. 5 (viii) The board of physician assistants shall be the only 6 board to regulate the practice of physician assistants relating 7 to prescribing and supplying prescription drugs, controlled 8 substances, and medical devices. 9 (d) A physician assistant may supply properly packaged and 10 labeled prescription drugs, controlled substances, or medical 11 devices when pharmacist services are not reasonably available 12 or when it is in the best interests of the patient. 13 (i) When the physician assistant is the prescriber of the 14 medications supplied, these medications shall be supplied for 15 the purpose of accommodating the patient and shall not be sold 16 for more than the cost of the drug and reasonable overhead 17 costs as they relate to supplying prescription drugs to the 18 patient and not at a profit to the physician or physician 19 assistant. 20 (ii) A nurse or staff assistant may assist the physician 21 assistant in supplying medications. 22 (e) A physician assistant may, at the request of the peace 23 officer, withdraw a specimen of blood from a patient for 24 the purpose of determining the alcohol concentration or the 25 presence of drugs. 26 (f) A physician assistant may direct medical personnel, 27 health professionals, and others involved in caring for 28 patients and the execution of patient care. 29 (g) A physician assistant may authenticate medical forms by 30 signing the form. 31 (h) A physician assistant may perform other duties as 32 appropriate to a physician assistant’s practice. 33 (i) Health care providers shall consider the instructions 34 of a physician assistant to be authoritative. 35 -11- LSB 5646SV (3) 88 pf/rh 11/ 19

S.F. 2357 (7) Remote medical site requirements pursuant to 645 IAC 1 327.4(1) and (2), including all of the following: 2 (a) A physician assistant may provide medical services in a 3 remote medical site if any of the following conditions is met: 4 (i) The physician assistant has a permanent license and at 5 least one year of practice as a physician assistant. 6 (ii) The physician assistant with less than one year of 7 practice has a permanent license and meets all of the following 8 criteria: 9 (A) The physician assistant has practiced as a physician 10 assistant for at least six months. 11 (B) The physician assistant and supervising physician have 12 worked together at the same location for a period of at least 13 three months. 14 (C) The supervising physician reviews patient care provided 15 by the physician assistant as determined to be appropriate by 16 the supervising physician. 17 (D) The supervising physician reviews a representative 18 sample of patient charts unless the medical record documents 19 that direct consultation with the supervising physician 20 occurred for a period the supervising physician determines is 21 appropriate. 22 (iii) The physician assistant and supervising physician 23 provide a written statement sent directly to the board that 24 the physician assistant is qualified to provide the needed 25 medical services and that the medical care will be unavailable 26 at the remote site unless the physician assistant is allowed to 27 practice there. In addition, for three months, the supervising 28 physician must review a representative sample of patient charts 29 for patient care provided by the physician assistant at least 30 weekly. 31 (b) The supervising physician must visit a remote site 32 or communicate with the physician assistant at the remote 33 site via electronic communications to provide additional 34 medical direction, medical services, and consultation at least 35 -12- LSB 5646SV (3) 88 pf/rh 12/ 19

S.F. 2357 every two weeks. For purposes of this rule, communication 1 may consist of, but shall not be limited to, in-person 2 meetings, two-way interactive communication directly between 3 the supervising physician and the physician assistant via 4 telephone, secure messaging, electronic mail, or chart review. 5 (8) Identification as a physician assistant pursuant to 6 645 IAC 327.5 including that the physician assistant shall be 7 identified as a physician assistant to patients and to the 8 public, regardless of their educational degree. 9 (9) Prescription requirements pursuant to 645 IAC 327.6(2) 10 including that each oral prescription drug order issued by a 11 physician assistant shall include the same information required 12 for a written prescription, except for the written signature of 13 the physician assistant and the physician assistant’s practice 14 address. 15 (10) Grounds for discipline pursuant to 645 IAC 329.2(25) 16 including prohibiting a person from representing the person 17 as a physician assistant when the persons’s license has been 18 suspended or revoked, or when the person’s license is on 19 inactive status except as provided by 645 IAC 326.15. 20 b. For the board of medicine rules relating to and in 21 substantial conformance with the following relating to 22 supervisory agreements pursuant to 653 IAC 21.4 including all 23 of the following: 24 (1) A physician who supervises a physician assistant 25 shall establish a written supervisory agreement prior to 26 supervising a physician assistant. A sample supervisory 27 agreement form is available from the board. The purpose of 28 the supervisory agreement is to define the nature and extent 29 of the supervisory relationship and the expectations of each 30 party. The supervisory agreement shall take into account 31 the physician assistant’s demonstrated skills, training and 32 experience, proximity of the supervising physician to the 33 physician assistant, and the nature and scope of the medical 34 practice. The supervising physician shall maintain a copy of 35 -13- LSB 5646SV (3) 88 pf/rh 13/ 19

S.F. 2357 the supervisory agreement and provide a copy of the agreement 1 to the board upon request. The supervisory agreement shall, at 2 a minimum, address all of the following provisions: 3 (a) Review of requirements. The supervising physician and 4 the physician assistant shall review all of the requirements 5 of physician assistant licensure, practice, supervision, and 6 delegation of medical services as set forth in section 148.13 7 and chapter 148C, Iowa administrative code chapter 653, and 645 8 IAC chapters 326 to 329. 9 (b) Assessment of education, training, skills, and 10 experience. Each supervising physician shall assess the 11 education, training, skills, and relevant experience of the 12 physician assistant prior to providing supervision. Each 13 supervising physician and physician assistant shall ensure 14 that the other party has the appropriate education, training, 15 skills, and relevant experience necessary to successfully 16 collaborate on patient care delivered by the team. The method 17 for assessing and providing feedback regarding the physician 18 assistant’s education, training, skills, and experience shall 19 be reflected in the supervision agreement. 20 (2) The supervision agreement between the physician 21 assistant and the physician shall address all of the following: 22 (a) The medical services the supervising physician 23 delegates to the physician assistant. The medical services 24 and medical tasks delegated to and provided by the physician 25 assistant shall be in compliance with 645 IAC 327.1(1). 26 All delegated medical services shall be within the scope 27 of practice of the supervising physician and the physician 28 assistant. 29 (b) Methods for communication between the physician 30 assistant and the physician and whether the physician assistant 31 practices at the same site or a remote site. Each supervising 32 physician and physician assistant shall conduct ongoing 33 discussions and evaluation of the supervisory agreement, 34 including supervision; expectations for both parties; 35 -14- LSB 5646SV (3) 88 pf/rh 14/ 19

S.F. 2357 assessment of education, training, skills, and relevant 1 experience; review of delegated services; review of the medical 2 services provided by the physician assistant; and the types of 3 cases and situations when the supervising physician expects to 4 be consulted. 5 (i) The plan for completing and documenting chart reviews. 6 A licensed physician within the same facility or health care 7 system as the physician assistant shall conduct an ongoing 8 review of a representative sample of the physician assistant’s 9 patient charts encompassing the scope of the physician 10 assistant’s practice. The findings of the review shall be 11 discussed with the physician assistant in a manner determined 12 by the practice in consultation with the physician assistant’s 13 primary supervising physician. 14 (ii) Remote medical site. “Remote medical site” means 15 a medical clinic for ambulatory patients which is more than 16 thirty miles away from the main practice location of the 17 supervising physician and in which the supervising physician 18 is present less than fifty percent of the time when the remote 19 medical site is open. “Remote medical site” does not apply to 20 nursing homes, patient homes, hospital outpatient departments, 21 outreach clinics, or any location at which medical care is 22 incidentally provided, such as a diet center, free clinic, site 23 for athletic physicals, or a jail facility. The supervisory 24 agreement shall include a provision which ensures that the 25 supervising physician visits the remote medical site, or 26 communicates with a physician assistant at the remote medical 27 site via electronic communications, at least every two weeks 28 to provide additional medical direction, medical services, 29 and consultation specific to the medical services provided at 30 the remote medical site. For purposes of this subparagraph 31 subdivision, communication may consist of, but shall not 32 be limited to, in-person meetings or two-way, interactive 33 communication directly between the supervising physician and 34 the physician assistant via telephone, secure messaging, 35 -15- LSB 5646SV (3) 88 pf/rh 15/ 19

S.F. 2357 electronic mail, or chart review. The board shall only 1 grant a waiver or variance of this provision if substantially 2 equal protection of public health, safety, and welfare will 3 be afforded by a means other than that prescribed in this 4 subparagraph subdivision. 5 (iii) The expectations and plan for alternate supervision. 6 The supervising physician shall ensure that the alternate 7 supervising physician is available for a timely consultation 8 and shall ensure that the physician assistant is notified 9 of the means by which to reach the alternate supervising 10 physician. 11 Sec. 10. RESCISSION OF ADMINISTRATIVE RULES. 12 1. The board of physician assistants shall rescind all of 13 the following: 14 a. 645 Iowa administrative code, rule 326.19, subrule (3), 15 paragraph “b”, subparagraph (3). 16 b. 645 Iowa administrative code, rule 327.1, subrule (1), 17 paragraphs “r” through “z”. 18 c. 645 Iowa administrative code, rule 327.4, subrules (1) 19 and (2). 20 2. The board of medicine shall rescind 653 Iowa 21 administrative code, rule 21.4, subrules (3) through (7). 22 Sec. 11. RULEMAKING —— LIMITATION ON AMENDMENTS —— 23 CONSTRUCTION. 24 1. The board of medicine and the board of physician 25 assistants, upon the adoption of rules pursuant to chapter 26 17A as required by sections 9 and 10 of this Act, shall not 27 thereafter approve a notice of intended action pursuant to 28 section 17A.4, subsection 1, paragraph “a”, for the amendment 29 or rescission of such rules for a period of two years from the 30 effective date of this Act. 31 2. Except as provided in subsection 1, the rulemaking 32 requirements provided in sections 9 and 10 of this Act shall 33 not be construed to prohibit the board of medicine or the board 34 of physician assistants from engaging in further rulemaking not 35 -16- LSB 5646SV (3) 88 pf/rh 16/ 19

S.F. 2357 in conflict with sections 9 or 10 of this Act relating to the 1 subject matter of those sections or to otherwise diminish the 2 authority to engage in rulemaking provided to either board by 3 section 147.76 or any other statute. 4 Sec. 12. EFFECTIVE DATE. This Act, being deemed of 5 immediate importance, takes effect upon enactment. 6 EXPLANATION 7 The inclusion of this explanation does not constitute agreement with 8 the explanation’s substance by the members of the general assembly. 9 This bill relates to the practice and licensure of physician 10 assistants. 11 With regard to drug dispensing, supplying, and prescribing, 12 the bill provides that a physician assistant may prescribe, 13 dispense, order, administer, or procure prescription drugs, 14 controlled substances, or medical devices necessary to complete 15 a course of therapy in accordance with Code section 148C.4 16 which provides that the physician assistant may provide any 17 legal medical service for which the physician assistant has 18 been prepared by education, training, or experience and is 19 competent to perform. Additionally, the bill provides that 20 a physician may delegate the function of prescribing drugs, 21 controlled substances, and medical devices for which the 22 supervising physician has sufficient training or experience 23 after the supervising physician determines the physician 24 assistant’s proficiency and competence. Rules relating to 25 the authority of physician assistants to prescribe drugs, 26 controlled substances, and medical devices shall be adopted by 27 the board of physician assistants, after consultation with the 28 board of medicine and the board of pharmacy. 29 The bill includes physician assistants in the listing of 30 health care providers in provisions relating to the scope 31 of recovery in an action for damages for personal injury, 32 limitations on noneconomic damage awards against health care 33 providers, and contingent fees for attorneys in any action 34 for personal injury or wrongful death against a health care 35 -17- LSB 5646SV (3) 88 pf/rh 17/ 19

S.F. 2357 provider. 1 The bill includes definitions for the purposes of Code 2 chapter 148C (physician assistants). The bill amends the 3 definition of “approved program” for the education of physician 4 assistants; includes a definition of “collaboration” and 5 “supervising physician”, and defines “physician assistant” or 6 “P.A.” as a person who meets the qualifications under Code 7 chapter 148C and is licensed to practice medicine by the board 8 of physician assistants. 9 The bill amends the reference to a physician assistant 10 examination that may be completed in lieu of graduation from 11 an approved program, and provides that a licensed physician 12 assistant shall perform only those services for which the 13 licensed physician assistant is qualified by training or 14 education and which are not prohibited by the board. 15 The bill provides with regard to the services that may 16 be performed by a physician assistant, that a physician 17 assistant may provide any legal medical service for which 18 the physician assistant has been prepared by the physician 19 assistant’s education, training, or experience and is competent 20 to perform. The degree of collaboration between a physician 21 assistant and the appropriate member of a health care team 22 shall be determined at the practice level, and may involve 23 decisions made by the medical group, hospital service, 24 supervising physician, or employer of the physician assistant, 25 or the credentialing and privileging system of a licensed 26 health care facility. A physician shall be accessible at all 27 times for consultation with a physician assistant unless the 28 physician assistant is providing emergency medical services. 29 The supervising physician shall have ultimate responsibility 30 for determining the medical care provided by the supervising 31 physician-physician assistant team. 32 The bill also includes physician assistants as approved 33 providers of health care services, including primary care for 34 purposes of managed care or prepaid services contracts under 35 -18- LSB 5646SV (3) 88 pf/rh 18/ 19

S.F. 2357 the Medicaid program and provides that the provision shall not 1 be construed to expand the scope of practice of a physician 2 assistant. 3 The bill also requires the board of medicine and the board 4 of physician assistants to each, at the next meeting of the 5 respective boards held one calendar week or more after the 6 enactment of the bill, to approve a notice of intended action 7 to adopt rules to implement the bill. The bill specifies the 8 rules that the two boards are to address or rescind. The bill 9 provides that the board of medicine and the board of physician 10 assistants, upon the adoption of rules pursuant to Code chapter 11 17A as required by the bill, shall not thereafter approve a 12 notice of intended action for the amendment or rescission of 13 such rules for a period of two years from the effective date 14 of the bill. With the exception of the two-year limitation, 15 the rulemaking requirements provided in the bill shall not be 16 construed to prohibit the board of medicine or the board of 17 physician assistants from engaging in further rulemaking not in 18 conflict with the provisions of the bill relating to rulemaking 19 and to the subject matter of those provisions of the bill or 20 to otherwise diminish the authority to engage in rulemaking 21 provided to either board by Code section 147.76 (rules) or any 22 other statute. 23 The bill takes effect upon enactment. 24 -19- LSB 5646SV (3) 88 pf/rh 19/ 19