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Understanding the Regulatory Process

Posted By Administration, Friday, September 19, 2014

The Devil Is In the Details

By Brian Bowles, MAOPS Executive Director


The saying, “The devil is in the details,” is especially true in the regulatory process. This process is often a misunderstood component of lawmaking, because either we forget about it or we don’t know enough about it.

When the legislature passes a law, it often stipulates that the rules will be promulgated by a specific regulatory board. This could be the Board of Healing Arts, the Board of Nursing or any of the scores of others that exist. These regulatory bodies are usually appointed by the governor, and meetings occur largely unpublicized. This is where a good law can become a bad one or vice versa! Possibly one of the most well-known regulatory bodies, at least to our outdoors-oriented members, is the Missouri Department of Conservation (MDC). On an annual basis, MDC proposes rules on a host of different topics, like deer harvest limits or the quantity of crappie one can keep.  

Not only does the Missouri Association of Osteopathic Physicians and Surgeons (MAOPS) keep a close watch on the regulatory process involving healthcare issues, but MAOPS also frequently participates in regulatory meetings, including the Board of Healing Arts (the regulatory body responsible for licensing physicians).

MAOPS lobbyist Brad Bates and I recently sat in on deliberations between the Board of Healing Arts and the Board of Nursing, as they jointly promulgated rules for House Bill 315, which passed in 2013. This bill established the ability for physicians and collaborating nurse practitioners to use telemedicine for follow-up visits. Current law requires that the collaborating physician (or other physician designated in the collaborative agreement) examine and evaluate the patient and approve or formulate a plan of treatment for new or significantly changed conditions no more than two weeks after the patient has been seen by the collaborating APRN. The law tasked the Board of Healing Arts and the Board of Nursing to jointly promulgate rules for implementation of the telemedicine component. The two boards had previously been unable to agree on the rules. Rep. Kathy Swan (Cape Girardeau) and Sen. Jay Wasson (Nixa) were present, and they warned the groups that if agreement could not be reached at the meeting, the legislature would determine the rules for them, noting that would likely be something both parties would not want to happen.

As background, a Board of Healing Arts task force met in the summer of 2013 to work on the rules and MAOPS was present for those discussions. During this time, the Board felt strongly that telemedicine should use the best technology available in order to treat and protect patients. The Board of Healing Arts supported live, interactive video as alternative to an onsite visit. However, the Board of Nursing disagreed, and supported conducting follow-up visits via telephone, email or eliminating follow-up visits completely.

During deliberations, the major sticking point seemed to be the requirement of having a two-week follow-up visit with a physician for patients with newly diagnosed conditions. The Board of Nursing supported the elimination of that rule. The issue, though, was that the two-week follow-up component was not the one that was supposed to be debated during the promulgation of these rules. The nurses were trying to use the new law as a way to eliminate an aspect of the law with which they did not agree. The nurses lost focus on the main objective, which should’ve been on examining how telemedicine should be used in the collaborative arrangement between a physician, APRN and patient. Board of Healing Arts member David Tannehill, D.O., said as much when he stated that “the two week follow-up requirement was irrelevant to the conversation.” He noted that the two groups needed to focus on their original charge of determining how telemedicine would be used.

The Board of Healing Arts continued to hold firm in their position on live, interactive video, and that the two week follow-up deadline was essential. The Board of Nursing capitulated, and by the end of the day, agreement was reached on the rules for House Bill 315.

What does this mean moving forward?

  • Telemedicine can now be used to conduct the follow-up visits mandated in current law.
  • It should be much easier for the physician, the APRN and the patient, because technology can be used to determine what is best for the patient.

The way I see it, feedback could now be immediate, as an APRN could video conference with a collaborating physician to provide expertise for patients. Of course, patient consent must be obtained before telemedicine services commence. Yet, I imagine most patients will gladly consent rather than having to wait or travel.

By law, the proposed rule must be published in the Missouri Register for a 30-day comment period. Both the Board of Healing Arts and the Board of Nursing will take comments under consideration before finalizing the rule. I expect that the nursing association will have plenty to say about this topic. MAOPS, on the other hand, is pleased that the rules agreed upon by the two boards actually match the spirit of the original law.


As I alluded to in my comments at the meeting, it’s discouraging when we support a bill that we feel is mutually beneficial to the collaborative arrangement and the patient, only to have to sit through more than an entire year of meetings, because the nurses are using the opportunity to try and gain additional scope of practice. However, by keeping an eye on this important process, MAOPS is helping to ensure that “any devil in the details” is as physician and patient friendly as possible.

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C. L. Parks DO says...
Posted Sunday, September 28, 2014
MAOPS supports medicine with an evidence base. It also supports the patient having the best care team available, using the best technological support available. We try not to get into turf battles, feeling that this does not serve the profession or our patients well, but we have the duty and the privilege of working
to prevent fragmentation of care and ensure that patients know the physician who is ultimately responsible for their care is leading the team rather than a lesser-trained individual, no matter how friendly and well meaning.

Lee Parks, DO
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