HB 509-FN - AS INTRODUCED
HOUSE BILL 509-FN
SPONSORS: Rep. Marsh, Carr. 8; Rep. Knirk, Carr. 3; Rep. Kotowski, Merr. 24; Rep. Fothergill, Coos 1; Rep. DesMarais, Carr. 6; Rep. Edwards, Rock. 4; Rep. MacKay, Merr. 14; Sen. Bradley, Dist 3; Sen. Gray, Dist 6
COMMITTEE: Health, Human Services and Elderly Affairs
This bill establishes a pilot program for the regulation and licensure of graduate physicians each year by the board of medicine. Practice of a graduate physician is limited to medically underserved areas and rural health clinics.
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Explanation: Matter added to current law appears in bold italics.
Matter removed from current law appears [in brackets and struckthrough.]
Matter which is either (a) all new or (b) repealed and reenacted appears in regular type.
STATE OF NEW HAMPSHIRE
In the Year of Our Lord Two Thousand Nineteen
Be it Enacted by the Senate and House of Representatives in General Court convened:
GRADUATE PHYSICIAN PILOT PROGRAM
328-K:1 Definitions. In this chapter:
I. “Board” means the board of medicine established in RSA 329.
II. “Department” means the department of health and human services.
III. "Graduate physician" or “GP” means a person who fulfills the requirements for physician licensure established by RSA 329:12 except for RSA 329:12, I(d)(5) and RSA 329:12 I, (d)(6), and:
(a) Has successfully completed Step 1 and Step 2 of the United States Medical Licensing Examination or the equivalent of such steps of any other board-approved medical licensing examination; and
(b) Has proficiency in the English language.
IV. "Graduate physician collaborative practice arrangement" means an agreement between a physician licensed under RSA 329 and a graduate physician that meets the requirements of RSA 328-K:16.
V. "Medical school graduate" means any person who has graduated from a medical college or osteopathic medical college described in RSA 329:12, I(d)(4).
VI. "Medically underserved area" means an area designated by the department as a designated Health Professional Shortage Area (HPSA), a Medically Underserved Area (MUA), or a Governor-Designated and Secretary-Certified (GDSC) shortage area.
VII. "Primary care" means physician services in family practice, general practice, internal medicine, pediatrics, and obstetrics. It shall also include gynecology if paired with obstetrics.
328-K:2 License Required.
I. No person shall practice as or hold himself or herself out to be a graduate physician or use any letters designating himself or herself as a graduate physician unless the person is licensed in accordance with this chapter.
II. The board shall license the first 5 applicants per year who satisfies the requirements under RSA 328-K:3. The board may license additional applicants who are graduates of a medical school located in New Hampshire. Upon payment of a license fee, the board shall issue to such person a license, which shall be prima facie evidence of the right to practice as a graduate physician in and only in a medically underserved area. A licensed graduate physician may use the letters "G.P.'' in connection with his or her name to denote licensure under this chapter.
III. Except as provided in RSA 328-K:15, persons licensed under this chapter shall be authorized to receive reimbursement from the Centers for Medicare and Medicaid Services (CMS) and other insurers as if they were licensed under RSA 329. If necessary to establish reimbursement for graduate physicians under Medicare or Medicaid, the commissioner of the department of health and human services shall apply for a Title XIX and/or a Title XXI state plan amendment to establish such coverage.
328-K:3 Conditions for Licensure.
I. To apply for licensure by the board as a graduate physician, an applicant shall file a written application on forms provided by the board and pay an application fee. The applicant to be licensed shall:
(a) Fulfill the requirements for physician licensure established by RSA 329:12 except for RSA 329:12, I(d)(5) and RSA 329:12, I(d)(6);
(b) Have successfully completed Step 1 and Step 2 of the United States Medical Licensing Examination or the equivalent of such steps of any other board-approved medical licensing examination;
(c) Have proficiency in the English language; and
(d) Submit a complete set of fingerprints and a notarized criminal history record release form pursuant to RSA 328-K:4.
II. Circumstances that exist which would be grounds for disciplinary action under RSA 328-K:7 may be grounds for denial of a license.
328-K:4 Criminal History Record Checks.
I. Every applicant for initial licensure or reinstatement shall submit to the board a notarized criminal history record release form, as provided by the New Hampshire division of state police, which authorizes the release of his or her criminal history record, if any, to the board.
II. The applicant shall submit with the release form a complete set of fingerprints taken by a qualified law enforcement agency or an authorized employee of the department of safety. In the event that the first set of fingerprints is invalid due to insufficient pattern, a second set of fingerprints shall be necessary in order to complete the criminal history records check. If, after 2 attempts, a set of fingerprints is invalid due to insufficient pattern, the board may, in lieu of the criminal history records check, accept police clearances from every city, town, or county where the person has lived during the past 5 years.
III. The board shall submit the criminal history records release form and fingerprint form to the division of state police which shall conduct a criminal history records check through its records and through the Federal Bureau of Investigation. Upon completion of the records check, the division of state police shall release copies of the criminal history records to the board.
IV. The board shall review the criminal record information prior to making a licensing decision and shall maintain the confidentiality of all criminal history records received pursuant to this section.
V. The applicant shall bear the cost of a criminal history record check.
328-K:5 Renewal of Licenses. Every person licensed to practice under this chapter shall apply to the board for annual renewal of license on forms provided by the board and shall pay a renewal fee as established by the board. A license issued under this chapter shall not expire until the board has taken final action upon the application for renewal.
328-K:6 Failure to Renew; Lapse.
I. Any licensee who fails to apply for renewal under RSA 328-K:5 shall pay double the renewal fee, provided the licensee applies and pays the renewal fee no later than 90 days after the expiration date. Any licensee who fails to apply for renewal of his or her license within the 90-day period after expiration, shall have his or her license lapse. A lapsed license shall be reinstated only upon payment of a reinstatement fee as established by the board, and upon showing evidence of professional competence as the board may reasonably require.
II. If a license expires or lapses as a result of a licensee being ordered to active duty with the armed services, the licensee shall have 90 days from the date of discharge or release from the armed service to apply for renewal and all late fees shall be waived.
328-K:7 Grounds for Discipline. The board, after hearing under RSA 329:18-a, may take action against any person licensed under this chapter upon finding that the licensee:
I. Has knowingly provided false information on any application for professional licensure, whether by making any affirmative statement which was false at the time it was made or by failing to disclose any fact material to the application.
II. Is a habitual user of drugs or intoxicants or is afflicted with a physical disability, insanity, psychiatric disorder, or other disease deemed dangerous to the public health.
III. Has displayed a pattern of behavior which is incompatible with the basic knowledge and competence expected of persons in the practice of his or her profession.
IV. Has engaged in dishonest or unprofessional conduct or has been grossly or repeatedly negligent in practicing his or her profession or in performing activities ancillary to the practice of his or her profession or any particular aspect or specialty thereof, or has intentionally injured a patient while practicing his or her profession or performing such ancillary activities.
V. Has undertaken to practice independent of the referral or prescription, direction, or supervision of a physician licensed under RSA 329 or has undertaken to practice other than in a medically underserved area.
VI. Has failed to provide adequate safeguards with regard to aseptic techniques or radiation techniques.
VII. Has included in advertising any statement of a character tending to deceive or mislead the public or any statement claiming professional superiority.
VIII. Has advertised the use of any drug or medicine of an unknown formula or any system of anesthetic that is unnamed, misnamed, misrepresented, or not in reality used.
IX. Has willfully or repeatedly violated any provision of this chapter or any substantive rule of the board.
X. Has been convicted of a felony under the laws of the United States or any state.
XI. Has failed to maintain adequate medical record documentation on diagnostic and therapeutic treatment provided or has unreasonably delayed medical record transfer, or violated RSA 332-I.
328-K:8 Disciplinary Action. The board, upon making an affirmative finding under RSA 328-K:7, may take disciplinary action in any one or more of the following ways:
I. Administer a public or private reprimand.
II. Revoke, suspend, limit, or otherwise restrict a license.
III. Require the graduate physician to submit to the care, counseling, or treatment of a physician, counseling service, health care facility, professional assistance program under RSA 329:13-a, or any combination thereof which is acceptable to the board.
IV. Place the graduate physician on probation.
V. Require the graduate physician to participate in a program of continuing education in the area or areas in which he or she has been found deficient.
VI. Assess administrative fines in amounts established by the board which shall not exceed $3,000 per offense, or, in the case of continuing offenses, $300 for each day that the violation continues, whichever is greater.
328-K:9 Appeals. Disciplinary action taken by the board under RSA 328-K:8 may be appealed to the supreme court under RSA 541.
I. The board shall adopt rules under RSA 541-A relative to:
(a) The scope of practice for a licensed graduate physician.
(b) Form and content of the application for licensure.
(c) Application procedures.
(d) Conduct of hearings under RSA 328-K:7.
(e) Standards for graduate physician education and training.
(f) Supervision of graduate physicians.
(g) Notification of changes in employment.
(h) Definition of supervision.
(i) Manner of recordkeeping under RSA 328-K:11.
(j) Except as provided in paragraph II, any other matter which is consistent with the legislative intent of this chapter and which is necessary to the administration of this chapter.
II. The board, in consultation with the New Hampshire pharmacy board, shall adopt rules under RSA 541-A relative to the prescriptions which may be issued by a graduate physician.
328-K:11 Recordkeeping. The board shall keep a record of its proceedings under this chapter and a register of all persons licensed under it. The register shall list the name, last known business address, and last known residence address of each living licensee, and the date and number of the license of each licensed graduate physician. The board shall maintain and publish a list of licensed graduate physicians once a year.
328-K:12 Physician Liability. This chapter shall not be construed to relieve the responsible physician of professional or legal responsibility for the care and treatment of his or her patients.
I. Any person who, not being licensed or otherwise authorized according to the law of this state, shall advertise oneself or hold oneself out as a graduate physician, or any person who does such act after receiving notice that such person's license has been revoked, shall be guilty of a misdemeanor.
II. Any person who shall practice or attempt to practice as a graduate physician in this state without a license shall be guilty of a class A misdemeanor if a natural person or guilty of a felony if any other person.
328-K:14 Limitation on Action. A person, licensed or authorized to practice as a graduate physician under this chapter or under the laws of any other state, who, in good faith, renders emergency care at the scene of an emergency, shall not be liable for any civil damages as a result of acts or omissions by such person in rendering such emergency care, or as a result of any act or failure to act to provide or arrange for further medical treatment or care, as long as such person receives no direct compensation for the care from or on behalf of the person cared for.
328-K:15 Rural Health Clinics. When working in a rural health clinic under the federal Rural Health Clinic Services Act of 1977, Public Law 95-210, as amended:
I. A graduate physician shall be considered a physician assistant for purposes of regulations of the Centers for Medicare and Medicaid Services (CMS); and
II. As provided in RSA 328-K:16, II(e)(2), no supervision requirements in addition to the minimum federal law shall be required.
328-K:16 Graduate Physician Collaborative Practice Arrangements.
I. A physician may enter into collaborative practice arrangements with graduate physicians. Collaborative practice arrangements shall be in the form of written agreements, jointly agreed-upon protocols, or standing orders for the delivery of health care services. Collaborative practice arrangements, which shall be in writing, may delegate to a graduate physician the authority to administer or dispense drugs and provide treatment as long as the delivery of such health care services is within the scope of practice of the graduate physician and is consistent with that graduate physician's skill, training, and competence and the skill and training of the collaborating physician. Collaborative practice arrangements shall provide for graduate physicians to practice in medically underserved areas.
II. The written collaborative practice arrangement shall contain at least the following provisions:
(a) Complete names, home and business addresses, zip codes, and telephone numbers of the collaborating physician and the graduate physician;
(b) A list of all other offices or locations besides those listed in subparagraph (a) where the collaborating physician authorized the graduate physician to prescribe;
(c) A requirement that there shall be posted at every office where the graduate physician is authorized to prescribe, in collaboration with a physician, a prominently displayed disclosure statement informing patients that they may be seen by a graduate physician and have the right to see the collaborating physician;
(d) All specialty or board certifications of the collaborating physician and all certifications of the graduate physician;
(e) The manner of collaboration between the collaborating physician and the graduate physician, including how the collaborating physician and the graduate physician shall:
(1) Engage in collaborative practice consistent with each professional's skill, training, education, and competence;
(2) Maintain geographic proximity; except, the collaborative practice arrangement may allow for geographic proximity to be waived for a maximum of 28 days per calendar year for rural health clinics under RSA 328-K:15, as long as the collaborative practice arrangement includes alternative plans as required in subparagraph (3). Such exception to geographic proximity shall apply only to independent rural health clinics, provider-based rural health clinics if the provider is a critical access hospital as provided in 42 U.S.C. section 1395i-4, and provider-based rural health clinics if the main location of the hospital sponsor is greater than 50 miles from the clinic. The collaborating physician shall maintain documentation related to such requirement and present it to the board of medicine when requested; and
(3) Provide coverage during absence, incapacity, infirmity, or emergency by the collaborating physician;
(f) A description of the graduate physician's controlled substance prescriptive authority in collaboration with the physician, including a list of the controlled substances the physician authorizes the graduate physician to prescribe and documentation that it is consistent with each professional's education, knowledge, skill, and competence;
(g) A list of all other written practice agreements of the collaborating physician and the graduate physician;
(h) The duration of the written practice agreement between the collaborating physician and the graduate physician; and
(i) A description of the time and manner of the collaborating physician's review of the graduate physician's delivery of health care services. The description shall include provisions that the graduate physician shall submit a minimum of 10 percent of the charts documenting the graduate physician's delivery of health care services to the collaborating physician for review by the collaborating physician, or any other physician designated in the collaborative practice arrangement, every 14 days.
III. The collaborating physician, or any other physician designated in the collaborative practice arrangement, shall review every 14 days a minimum of 20 percent of the charts in which the graduate physician prescribes controlled substances. The charts reviewed under this paragraph may be counted in the number of charts required to be reviewed under subparagraph II(i).
IV. The board under RSA 541-A shall adopt rules regulating the use of collaborative practice arrangements for graduate physicians. Such rules shall specify:
(a) Geographic areas to be covered;
(b) The methods of treatment that may be covered by collaborative practice arrangements;
(c) The requirements for review of services provided under collaborative practice arrangements, including delegating authority to prescribe controlled substances. Any rules relating to dispensing or distribution of medications or devices or controlled substances by prescription or prescription drug orders under this section shall be subject to the approval of the state board of pharmacy. The board shall adopt rules applicable to graduate physicians that shall be consistent with guidelines for federally funded clinics.
V. The board shall not deny, revoke, suspend, or otherwise take disciplinary action against a collaborating physician for health care services delegated to a graduate physician provided the provisions of this section and the rules adopted thereunder are satisfied.
VI. Within 30 days of any change and on each renewal, the board shall require every physician to identify whether the physician is engaged in any collaborative practice arrangement, including collaborative practice arrangements delegating the authority to prescribe controlled substances, and also report to the board the name of each graduate physician with whom the physician has entered into such arrangement. The board may make such information available to the public. The board shall track the reported information and may routinely conduct random reviews of such arrangements to ensure that arrangements are carried out for compliance under this chapter.
VII. A collaborating physician shall not enter into a collaborative practice arrangement with more than 3 full-time equivalent graduate physicians.
VIII. The collaborating physician shall determine and document the completion of at least a one-month period of time during which the graduate physician shall practice with the collaborating physician continuously present before practicing in a setting where the collaborating physician is not continuously present.
IX. An agreement made under this section may govern hospital medication orders under protocols and standing orders for the purpose of delivering inpatient or emergency care within a hospital if such protocols or standing orders have been approved by the hospital's medical staff and pharmaceutical therapeutics committee.
X. No contract or other agreement shall require a physician to act as a collaborating physician for a graduate physician against the physician's will. A physician shall have the right to refuse to act as a collaborating physician, without penalty, for a particular graduate physician. No contract or other agreement shall limit the collaborating physician's ultimate authority over any protocols or standing orders or in the delegation of the physician's authority to any graduate physician, but such requirement shall not authorize a physician in implementing such protocols, standing orders, or delegation to violate applicable standards for safe medical practice established by a hospital's medical staff.
XI. No contract or other agreement shall require any graduate physician to serve as a collaborating graduate physician for any collaborating physician against the graduate physician's will. A graduate physician shall have the right to refuse to collaborate, without penalty, with a particular physician.
XII. All collaborating physicians and graduate physicians in collaborative practice arrangements shall wear identification badges while acting within the scope of their collaborative practice arrangement. The identification badges shall prominently display the licensure status of such collaborating physicians and graduate physicians.
XIII. A graduate physician may prescribe any controlled substance listed in Drug Enforcement Administration (DEA) schedule III, IV, or V and may have restricted authority in schedule II, when delegated the authority to prescribe controlled substances in a collaborative practice arrangement. Prescriptions for schedule II medications prescribed by a graduate physician are restricted to only those medications containing hydrocodone. Such authority shall be filed with the board. The collaborating physician shall maintain the right to limit a specific scheduled drug or scheduled drug category that the graduate physician is permitted to prescribe. Any limitations shall be listed in the collaborative practice arrangement. Graduate physicians shall not prescribe controlled substances for themselves or members of their families. Schedule III controlled substances and schedule II hydrocodone prescriptions shall be limited use in an inpatient hospital setting or to a 5-day supply without refill. Graduate physicians who are authorized to prescribe controlled substances under this section shall register with the federal Drug Enforcement Administration and shall include the Drug Enforcement Administration registration number on prescriptions for controlled substances.
XIV. The collaborating physician shall be responsible to determine and document the completion of at least 124 hours in a 4-month period by the graduate physician during which the graduate physician shall practice with the collaborating physician onsite prior to prescribing controlled substances when the collaborating physician is not onsite. Such limitation shall not apply to graduate physicians of population-based public health services.
328-K:17 Graduate Physician Oversight Committee. There shall be established a graduate physician oversight commission to study whether graduate physicians have expanded access to health care in medically underserved areas in both a safe and a cost effective manner.
I. The commission shall be composed of 9 members, as follows:
(a) The commissioner of the department of health and human services, or designee.
(b) A representative of the board of medicine, appointed by the board.
(c) A representative of the Commission on Primary Care Workforce Issues appointed by such commission.
(d) A primary care physician, currently practicing in a medically underserved area, appointed by the New Hampshire Medical Society.
(e) An APRN, currently practicing in a medically underserved area, appointed by the New Hampshire Nurse Practitioner Association.
(f) Three members of the house of representatives, appointed by the speaker of the house of representatives, at least one of whom shall be a member of the house health, human services and elderly affairs committee and one of whom shall be a member of the executive departments and administration committee.
(g) One member of the senate, appointed by the president of the senate.
II. Legislative members of the commission shall receive mileage at the legislative rate when attending to the duties of the commission.
III. The commission's study shall include, but not be limited to, whether the graduate physician pilot program has expanded access to health care in medically underserved areas, whether it has been cost effective, and whether public safety is adequately ensured. The commission shall solicit information from any person or entity the commission deems relevant to its study.
IV. The members of the commission shall elect a chairperson from among the members. The first meeting of the commission shall be called by the first-named house member. The first meeting of the commission shall be held within 45 days of the effective date of this section. Five members of the commission shall constitute a quorum.
V. The commission shall make an interim report annually on or before October 1 of each year, and make a final report of its findings and any recommendations for proposed legislation to the speaker of the house of representatives, the president of the senate, the house clerk, the senate clerk, the governor, and the state library on or before October 1, 2024.
I. RSA 328-K:1 through RSA 328-K:16, relative to the graduate physician pilot program, established in section 1 of this act, is repealed.
II. RSA 328-K:17, relative to graduate physician oversight commission established in section 1 of this act, is repealed.
I. Paragraph I of section 2 of this act shall take effect July 1, 2024.
II. Paragraph II of section 2 of this act shall take effect October 1, 2024.
III. The remainder of this act shall take effect July 1, 2019.
HB 509-FN- FISCAL NOTE
FISCAL IMPACT: [ X ] State [ X ] County [ X ] Local [ ] None
Estimated Increase / (Decrease)
[ X ] General [ ] Education [ ] Highway [ X ] Other - Office of Professional Licensure and Certification Fund (RSA 310-A:1-e, I(b))
This bill establishes a pilot program for the licensing of graduate physicians overseen by the Board of Medicine. The Office of Professional Licensure is unable to estimate the number of applicants that would apply for a license and how much additional staffing may be required to provide administrative support to this new group of licensees.
This bill contains penalties that may have an impact on the New Hampshire judicial and correctional systems. There is no method to determine how many charges would be brought as a result of the changes contained in this bill to determine the fiscal impact on expenditures. However, the entities impacted have provided the potential costs associated with these penalties below.
Class B Misdemeanor
Class A Misdemeanor
Routine Criminal Felony Case
Department of Corrections
FY 2018 Average Cost of Incarcerating an Individual
FY 2018 Annual Marginal Cost of a General Population Inmate
FY 2018 Average Cost of Supervising an Individual on Parole/Probation
NH Association of Counties
County Prosecution Costs
Estimated Average Daily Cost of Incarcerating an Individual
$105 to $120
$105 to $120
Many offenses are prosecuted by local and county prosecutors. When the Department of Justice has investigative and prosecutorial responsibility or is involved in an appeal, the Department would likely absorb the cost within its existing budget. If the Department needs to prosecute significantly more cases or handle more appeals, then costs may increase by an indeterminable amount.
Office of Professional Licensure and Certification, Judicial Branch, Departments of Corrections and Justice, and New Hampshire Association of Counties
|Jan. 24, 2019||House||Hearing|
|Jan. 29, 2019||House||Exec Session|
|Feb. 14, 2019||House||Floor Vote|
|Jan. 3, 2019||Introduced 01/03/2019 and referred to Health, Human Services and Elderly Affairs HJ 3 P. 17|
|Jan. 24, 2019||Public Hearing: 01/24/2019 01:00 pm LOB 205|
|Jan. 29, 2019||Division II Subcommittee Work Session: 01/29/2019 10:00 am LOB 205|
|Jan. 29, 2019||Executive Session: 01/29/2019 01:00 pm LOB 205|
|Committee Report: Inexpedient to Legislate (Vote 17-2; CC)|
|Feb. 14, 2019||Committee Report: Inexpedient to Legislate for 02/14/2019 (Vote 17-2; CC) HC 11 P. 7|
|Feb. 14, 2019||Inexpedient to Legislate: MA VV 02/14/2019 HJ 5 P. 17|