Waivers of Delegation of Prescriptive Authority are Hard to Come By

Under TMB rules, a physician can delegate prescriptive authority under a set of somewhat complex rules (See Board Rule 193.6). The TMB does have the authority to waive these rules in certain limited situations. Specifically, the rule states: “The TMB may waive or modify any of the site or supervision requirements for a physician to delegate the carrying out or signing of prescription drug orders to an advanced practice nurse of physician assistant at facilities serving medically underserved populations, at physician primary and alternate practice sites, and at facility-based practice sites.” 22 Texas Administrative Code §193.6(i)(1). To get this waiver, there is an application and review process and there is also an appearance before the Standing Orders Committee of the TMB.

This Committee met on August 28th. Two requests were submitted and both were denied. Denials of requests have been standard from the meetings we have observed over the last several months. The Committee did provide some insight into why these denials have been made. Some members of the Committee expressed the thought that waivers are not just there for the asking. The TMB wants to make sure those asking for waivers fully understand the reason for the standing orders is protecting the public by providing physician oversight. Waivers will not be granted just because someone feels they do not have the time to drive down the road.

In response to these concerns at the last meeting, the Committee directed staff to create a new application form that does go into far more detail that explains the rationale for waivers from the TMB rules concerning standing delegation orders. The form expresses that waivers are only granted if good reason exists. The chief question for the TMB is: would the patient population be better served from the request? If the answer is no, then it will be denied. The Committee directed staff to start using this new form immediately.

My Take: Anything that the TMB and TMB staff can to make these rules more direct and clear would benefit everyone. This rule is complex and difficult to understand unless you deal in this area on a regular basis. As mid-level providers are becoming more the norm and physicians are delegating more and more authority to them, it is critical that both physicians and mid-levels review the delegation rules and fully understand what can and cannot be done. From the many clinics and even hospitals that I have visited over the year, many do not meet the requirements set forth by the TMB. The health care community and the TMB should work together to revisit these rules to make them more user-friendly so that everyone understands these rules.