I support the petition to amend 18VAC85-50-110(1) as noted. Every practice situation is unique and appropriate consultation and collaboration standards as determined at the practice level will allow the medical team to practice with the highest efficiency and maximize the ability to care for the most patients.

I petition to remove the language specifying that the patient care team physician review the clinical course and treatment plan by a patient care physician for a patient that presents for the same acute complaint twice in a single episode of care- I feel that as a PA if we have concerns as a provider regarding a patient case we would be willing to discuss with the supervising physician- but should not be a requirement to discuss all cases that fall into that category- can be cumbersome for the patient which can also lead to distrust from the patient regarding the PA. 

Please amend 18VAC85-50-110(1) to not have specific verbiage requiring a physician be involved in patient care after presenting twice in a single episode of care. I work in psychiatry and patients frequently don't improve after 2 visits, especially when finding the medication that works for them.  It does not benefit my patient to have them involved at this point in their care and would waste the valuable time of my collaborating psychiatrist. We are severely short-staffed in mental health and removing these barriers is essential to getting more patients seen. PAs are trained to ask our collaborator for assistance when needed and PAs work as a part of a healthcare team. Please know that we will do as we are trained and remove these unnecessary barriers to patient care.  

Each PA is required to have a written Practice Agreement with their team physician.  My understanding is that unless the physician is directly involved in the patient's care, they are not liable for that patient's outcome.  

As a physician assistant who is licensed by the Commonwealth of Virginia and credentialed to practice medicine, I understand my own limitations and in all cases ensure I have a practice agreement in place to protect patient safety and ensure I am practice within my scope of care.   As a collaborating member of the healthcare team, each PA has the responsibility and accountability to the patient.   

If a patient fails to improve as expected, it is incumbent upon the PA (or any health practitioner for that matter) to ensure the patient is referred in a timely matter.  I have issues with "fails to improve as expected".  Who determines "improve as expected".   PAs and all medical professionals have a duty to the patient and this petition to change the wording in 18VAC85-50-110 will in no way affect patient outcomes and will ensure physicians are available for complex cases.   

I would reiterate that PAs are licensed medical professionals who by training and education are aware, as should any provider, of their scope of practice and limitations.   In my mind, the Practice Agreement should determine the conditions for which a patient is re-evaluated.  

To provide the best and safest possible care, PAs are trained and educated to practice within their scope of practice and in accordance with their Practice Agreement.  Standard of Care does not change regardless of the level of care and it is incumbent upon each practitioner to ensure they are meeting the standard of care.   

Changing the wording to remove ambiguity will serve to ensure PAs continue to practice within their scope of care and ensure the standard of care is provided to provide the best possible outcomes for patients entrusted to their care. 

I agree that the phrasing of 18VAC85-50-110(1) should be changed as stated.  This change is more in line with the nature of the supervising physician- PA relationship.  This relationship is built on collaboration and trust.  The new phrasing strengthens that trust.  It says to the PA, "I trust that you will collaborate when necessary, on any patient, whether the patient is presenting for the first or the third time."  

PAs are required to have an established practice agreement with their collaborating physician.  Therefore, their scope of practice is clear, and they should be aware of their own limitations (just as physicians are).  If a patient fails to improve as expected, it should be the responsibility of the PA to assess the situation and change treatment, speak with the collaborating physician, and/or refer.  Just because a patient returns for follow-up does not mean that something was done wrong initially, nor does it mean that the situation is complex.  To mandate via law that a patient be seen just because they returned does not make much sense.

I support the proposed regulatory change to language regarding physician/PA appropriate consultation rather than require review after the same complaint twice for the following reasons:

• PAs provide professional, team-based medical care. When a consultation or referral is needed, it will be sought. As a team member, the PA will assess the patient and provide the best care, including consultation as needed. The second visit rule is too restrictive.
• PAs have practice agreements. The practice level agreement is discussed with the PA/physician. Both providers have an understanding of the consultation process and when it is needed for that practice setting.
• There are many patients that may require an expected second visit with the same complaint. I work in pediatrics. I do not often prescribe medication for the initial visit runny nose and cough and recommend follow up-for the ‘same acute complaint’ if there is not improvement. Then the patient returns with the same complaint in three weeks. Do I need to have this case reviewed by a physician when seeing this patient? Right now, by regulation, I do. Is this a waste of time and resources for the physician? Absolutely! Does this patient truly need to be seen by a physician? Not likely, but if I thought they did, I would for best patient care.

I speak in favor of the proposed regulatory change.

PAs are medical professionals and have a long history of providing team-based health care.  The current language implies that a PA would not seek out consultation when a patient fails to improve.  Being trained in the medical model, a PA would of course seek out consultation when indicated, as would any other clinician who follows the standard of care.

I support the amendment to 18VAC 85-50-110.  PAs are trained to provide team-based care and to recognize their limitations within their scope of practice.  The nature of collaborative team practice is to determine when the needs of a patient exceed the knowledge and skillset of a provider and to seek further opinion.  This could occur on an initial visit with a patient or at a later follow-up.  The prescribed content of the current legislative language is not reflective of patient needs.  For example, significant improvement in a patient's condition may not be expected and continued care on subsequent follow-up by a PA may not be out of line with the training and scope of the PA.  A dictated determination for follow-up with a physician could be appropriately determined at the practice level to meet the practice and patient needs, but it should not be dictated at a legislative level.  

I support the change in this regulation. In the event, that patient was not improving it would be standard of care to consult the collaborating team, whether that was your direct collaborating physician or perhaps a specialists who is also caring for the patient. 

This would help remove barrier to care, especially in more rural settings where providers are limited and work load heavy. 

I support removing this barrier to patient care and allowing more time spent with patient care.

I support the amendment to 18VAC 85-50-110.  PAs are trained to provide collaborative team-based care within their scope of practice. The foundations of a collaborative  practice is to determie when the needs of a patient exceed the knowledge and skillset of a provider and to seek further opinion.  This could occur on an initial visit with a patient or at a later follow-up.  The prescribed content of the current legislative language is not reflective of patient needs.  For example, significant improvement in a patient's condition may not be expected and continued care on subsequent follow-up by a PA may not be out of line with the training and scope of the PA.  A dictated determination for follow-up with a physician could be appropriately determined at the practice level to meet the practice and patient needs, but it should not be dictated at a legislative level.  

 I support the amendment to 18VAC 85-50-110.

I support the proposed amendment of 18VAC85-50-110(1) to better reflect the collaborative nature of physicians and PA's working at the top of their licenses to provide access to quality care for patients.  The new phrasing reinforces the trust between and imperative upon all medical providers to recognize their knowledge and limitations, and to collaborate/refer/seek consultation when it would benefit the patient, regardless of when in the course of treatment that is.

Agree

I agree with the proposed amendment as written, and I second the opinions of my colleagues below. Additionally, I am in favor of removing unnecessarily restrictive language like what we have now that hinders patient care and access to care,  language that shows a profound misunderstanding of the training of a PA and the patient care delivered by a PA, a profound misunderstanding of the dynamic PA-MD collaborative relationship, and poorly worded language with legal bias. As written,  a prosecuting attorney is handed a clear and objective timetable of two visits to pin against a medical team, yet leaves the medical team with vague and subjective language to try and interpret in every patient encounter. A PA could also misinterpret the two visit rule and delay appropriate consultation on the first visit believing the standard of care only requires escalation of care if needed after a second visit. I would argue that standard of care for PAs is a national requirement of practice since a PA’s training is nationally accredited, and nationally certified by one certification body. The definition of two visits with a patient regardless of circumstance, chief complaint and practice setting is not standard of care. What IS standard of care, as my colleagues have already mentioned, is that the PA would use his or her clinical judgement to determine when care needs to be brought to a physician, or a referral to a specialist made, at ANY point in the management of that patient, regardless of which visit it is. Thank you. 

Agree to strike the specific 2 visit from legal documents. It is impossible to legislate when care should be collaborative. The detail of 1, 2, 10 etc is antiquated and the number of visits is irrelevant to providing appropriate, safe patient care. This should be determined by the collaborating physician and PA and will vary widely among experience and speciality. Recommend this be an advisory comment for physician-PAs to consider during hiring and collaborative agreement formation, but not included in regulatory statutes.

Agree

PA's are trained to understand their abilities and limits.  We practice team-based care and always seek consultation when necessary.  This regulation puts unnecessary red tape on patient care, and increases administrative burden unnecessarily.  I fully support the proposed change

I support this proposed change.

Agree to proposed change

I speak in favor of the proposed regulatory change.

PAs are trained in the medical model and are adept at providing team-based health care. PAs follow the standards of care and will consult with a collaborating physician when needed. The current regulation implies that practicing PAs would not seek consultation, and the language should be removed.

Agree with the proposed change.

1. PAs are trained medical professionals who practice team-based care and follow standards of care. They consult a physician(s) as indicated. 

2. PAs have a DEA license, and should not require oversight by physicians to prescribe controlled medications. 

3. Eliminating both regulations (physician review and signature) will allow PAs to practice at the top of their license and training, reduces unnecessary redundancies and therefore increases pt access.

4. Please remove the current regulation redundancies that impede access to care for patients within the commonwealth.

I agree with the proposed change. PAs are nationally certified, licensed providers in the state of Virginia and this rule is a barrier to care for patients and undermines PAs ability to practice medicine at the top of their scope and license. 

PAs are trained medical professionals and consult with physicians when indicated. By removing both regulations, it would lead more access to patient care. 

I support the proposal to remove the need to have supervising physician name on prescriptions for controlled substances prescribed by physician assistants. 

I agree with the proposal.  Let PAs practice according to their training! The most dangerous person in medicine is someone who doesn't know what they don't know- this is regardless of the degree or letters behind your name.  The expectation is that anyone practicing in the medical field will be responsible enough to consult when necessary.  Kept how it is the law hinder access to medical care for patients and causes further confusion & divide between MDs, DOs, PAs, and NPs.