in-20250716-IR-844240435FRA: DIGEST PHYSICIAN ASSISTANT PRACTICE AND COLLABORATION AGREEMENTS

Final Rule LSA Document #24-435 DIGEST Sec. 3. "Board" refers to the medical licensing board of Indiana has the meaning set forth in IC 25-27.5-2-3. Sec 3.1. "Collaborating physician" has the meaning set forth in IC 25-27.5-2-4.7. Sec. 3.2. "Collaboration" has the meaning set forth in IC 25-27.5-2-4.9. Sec. 3.5. " Collaboration agreement" means a written document signed by the collaborating physician or physicians and the physician assistant that: Sec. 4. "Committee" refers to the physician assistant committee established by IC 25-27.5-3-1 has the meaning set forth in IC 25-27.5-2-5. Sec. 6. (a) For purposes of IC 25-27.5, "deep sedation/analgesia" means a drug-induced depression of consciousness during which patients cannot be easily aroused, but respond purposefully following after repeated or painful stimulation. For purposes of this rule, reflex withdrawal from a painful stimulus is not considered a purposeful response. (b) The following are conditions that a patient under deep sedation/analgesia may experience: Sec. 12. "NCCPA" refers to the National Commission on Certification of Physician Assistants has the meaning set forth in IC 25-27.5-2-8. Sec. 13. "Physician assistant" means an individual who has: has the meaning set forth in IC 25-27.5-2-10. Sec. 15. (a) For purposes of IC 25-27.5, "regional anesthesia" means the administration of anesthetic agents to a patient to interrupt nerve impulses without the loss of consciousness and includes the following: (b) A superficial nerve block or application of a local anesthetic agent in which where the total dosage administered exceeds the recommended maximum dosage per body weight described in the manufacturer's package insert shall be is considered regional anesthesia for purposes of this rule. Sec. 1. (a) The application for licensure of a physician assistant must be made upon on forms supplied by the committee. (b) Each An application for licensure as a physician assistant or for a temporary permit shall must include all of the following information: (c) All The information in the an application shall be submitted under oath or affirmation, subject to the penalties of perjury. (d) Each An applicant for licensure as a physician assistant shall submit an executed authorization and release form supplied provided by the committee that: (e) Application forms submitted to the committee must be complete. All Supporting documents required by the application must be submitted with the application. (f) Applicants for a temporary permit to practice as a physician assistant while waiting to take the examination or awaiting results of the examination must shall submit all the requirements of subsection (b), except for subsection (b)(2)(B) and (b)(2)(C), in order to apply for a temporary permit. (g) A temporary permit becomes invalid if the temporary permit holder fails to sit or fails to register for the next available examination. (h) Prior to Before beginning practice as a physician assistant, the physician assistant must shall submit a supervisory collaboration agreement to the committee, which must be approved by the board. The supervisory collaboration agreement must: Sec. 2. (a) A physician licensed under IC 25-22.5 who intends to supervise collaborate with a physician assistant shall register his or her their intent to do so with the board, on a form approved by the board, prior to commencing supervision of a before collaboration begins with the physician assistant. The supervising collaborating physician shall include the following information on the form supplied provided by the board: (b) The supervising physician may not: (c) (b) The designated supervising collaborating physician is to accept the responsibility of supervising collaborating with the physician assistant in the absence of the primary supervising collaborating physician of record. Protocol is to be established by the physician practice. (d) (c) The supervising collaborating physician shall, within fifteen (15) days, notify both the board and the committee that the supervising collaborating relationship with the physician assistant is terminated. The notification shall must state the reason for the termination. Sec. 3. (a) Every A physician assistant holding a license issued by the committee shall renew his or her their license every two (2) years, in even-numbered years, and pay the fee required by section 8 of this rule. (b) On or Before April 30 May 1 of a renewal year, the committee, or its duly authorized agent, shall notify each license holder that the license holder is required to renew with the committee. The committee, or its agent, shall furnish a provide the license holder with a form to be completed for renewal. (c) Applications for all renewals must be made under oath or affirmation. (d) Each A license holder shall do the following: (e) A license holder's failure to receive notification of renewal due to failure because they failed to notify the committee of a change of address or name shall does not: (f) A physician assistant who is less than three (3) years delinquent in renewing a license may be reinstated upon receipt of after the committee receives the: (g) If more than three (3) years have elapsed since the expiration of a license to practice as a physician assistant, prior to before reinstatement, the applicant may be required by the committee to take and pass the examination approved by the committee. Sec. 4. If for any reason a physician assistant discontinues working at the direction or under the supervision collaboration, or both, of the physician under which the physician assistant is registered with the board, the physician assistant shall inform both the board and the committee, in writing, within fifteen (15) days of after the event. The physician assistant shall may not commence begin practice under a new supervising collaborating physician until that physician registers his or her their intent to supervise collaborate with the physician assistant to the board under section 2 of this rule. The physician assistant, in the written report, shall state the specific reason for the discontinuation of supervision collaboration. Sec. 5. (a) When engaged in the physician assistant's professional activities, a physician assistant shall: (b) A physician assistant shall make available for inspection at his or her their primary place of business: (c) The physician assistant may perform, under the supervision of the supervising collaborating physician, such those duties and responsibilities that are: Sec. 6. It shall be deemed is considered willful misconduct or the incompetent practice as a physician assistant under IC 25-27.5 if a physician assistant licensed by the committee has committed any of the following acts: Sec. 8. (a) A nonrefundable fee of one hundred dollars ($100) shall must accompany the initial application for certification. (b) A nonrefundable fee of fifty dollars ($50) shall must accompany an application for changing supervising collaborating physicians. (c) A fee of fifty dollars ($50) shall must accompany each biennial application for renewal of the physician assistant certificate. A fee of fifty dollars ($50) shall must accompany each request for a temporary permit in addition to the fee for initial certification. (d) A fee of ten dollars ($10) shall must accompany each request for verification of licensure to another state. (e) All such The fees under this section are nonrefundable. Sec. 2. (a) The definitions in this section apply throughout this rule. (b) "Abuse deterrent formulation" means an opioid formulation that has properties shown to meaningfully deter the intentional, nontherapeutic use, even once, to achieve a desirable psychological or physiological effect, even if such the formulation does not fully prevent such those intentional, nontherapeutic uses. (c) "Chronic pain" means a state in which pain persists beyond the usual course of an acute disease or healing of an injury, or that may or may not be associated with an acute or chronic pathologic process that causes continuous or intermittent pain over months or years. (d) "Controlled substances" has the meaning set forth in IC 35-48-1-9. (e) "Morphine equivalent dose" means a conversion of various opioids to a standardized dose of morphine by the use of accepted conversion tables. (f) "Opioid" means any of various narcotics containing opium or at least one (1) or more of its natural or synthetic derivatives. However, if such a narcotic is not a controlled substance, it shall is not be an opioid for the purposes of this rule. (g) "Outset of an opioid treatment plan" means that a patient has been prescribed opioids as described in section 3(c) of this rule, and, therefore, the provisions stated in section 3(a) of this rule become applicable apply to that patient. (h) "Terminal" means a condition caused by injury, disease, or illness from which, to a reasonable degree of medical certainty: Sec. 3. (a) This section and sections 4 through 9 of this rule establish requirements concerning the use of opioids for chronic pain management for patients. (b) Notwithstanding subsection (a), this section and sections 4 through 9 of this rule shall do not apply to the use of opioids for chronic pain management for the following: (c) The requirements in the sections identified in subsection (a) only apply if a patient has been prescribed: (d) Because the requirements in the sections identified in subsection (a) do not apply until the time stated in subsection (c), the initial evaluation of the patient for the purposes of sections 4, 7, and 8(a) of this rule shall is not be required to take place until that time. (e) Notwithstanding subsection (d), the physician assistant may undertake those actions earlier than required if the physician assistant deems [sic] it medically appropriate and, if those actions meet the requirements, a further initial evaluation is not required. If the physician assistant conducts actions earlier than required under this subsection, any subsequent requirements are determined by when the initial evaluation would have been required and not at the earlier date it actually was conducted. Sec. 4. (a) The A physician assistant shall do the physician assistant's own evaluation and risk stratification of the a patient by doing the following in the initial evaluation of the patient: (b) Where medically appropriate, the physician assistant shall utilize use nonopioid options instead of, or in addition to, prescribing opioids. Sec. 5. The A physician assistant shall discuss with the a patient the potential risks and benefits of opioid treatment for chronic pain, as well as expectations related to prescription requests and proper medication use. In doing so, the physician assistant shall do the following: Sec. 6. (a) Physician assistants shall may not prescribe opioids for patients without periodic scheduled visits. Visits for patients with a stable medication regimen and treatment plan shall occur face-to-face at least once every four (4) months. More frequent visits may be appropriate for patients working with the physician assistant to achieve optimal management. For patients requiring changes to the medication and treatment plan, if changes are prescribed by the physician assistant, the visits required by this subsection shall be are scheduled at least once every two (2) months until the medication and treatment has been stabilized. (b) During the visits required by subsection (a), the physician assistant shall evaluate patient progress and compliance with the patient's treatment plan regularly and set clear expectations along the way, such as attending physical therapy, counseling, or other treatment options. Sec. 7. At the outset of an opioid treatment plan, and at least annually thereafter, a physician assistant prescribing opioids for a patient shall run an INSPECT report on that patient under IC 35-48-7-11.1(d)(4) IC 25-26-24-19 and document in the patient's chart whether the INSPECT report is consistent with the physician assistant's knowledge of the patient's controlled substance use history. Sec. 8. (a) At any time the physician assistant determines that it is medically necessary, whether at the outset of an opioid treatment plan, or any time thereafter, a physician assistant prescribing opioids for a patient shall perform or order a drug monitoring test, which must include a confirmatory test using a method selective enough to differentiate individual drugs within a drug class, on the patient. (b) In determining whether a drug monitoring test under subsection (a) is medically necessary, the physician assistant shall consider, subject to the provisions of subsection (c), each of the following factors where applicable and reasonably feasible: (c) It shall is not be considered a violation of this section for a physician assistant to fail to conduct a review of all the eighteen (18) factors listed in subsection (b) if the physician assistant reasonably determines, following after a review of less than all of the factors listed in subsection (b), that a drug monitoring test is medically necessary. (d) Nothing about subsection (b) shall may be construed to prohibit the physician assistant from performing or ordering a drug monitoring test at any other time the physician assistant considers appropriate. (e) If a test performed under subsection (a), or conducted under subsection (d), reveals inconsistent medication use patterns or the presence of illicit substances, a review of the current treatment plan shall be is required. Documentation of the revised treatment plan and discussion with the patient must be recorded in the patient's chart. Sec. 10. IC 25-27.5-5 addresses the scope of practice of physician assistants in their dependent practice under supervising collaborating physicians, including limiting the duties and responsibilities of physician assistants to those that are delegated by the supervising collaborating physician and that are within the supervising collaborating physician's scope of practice. IC 25-27.5-6 addresses supervisory responsibilities of the supervising collaborating physician, or when applicable, a physician designee. The Prescribing of opioids for chronic pain management as regulated by this rule falls within the requirements on supervising collaborating physicians, or when applicable, on physician designees, under IC 25-27.5-5 and IC 25-27.5-6, including appropriate delegating of duties and responsibilities to physician assistants and appropriate supervision of physician assistants.