Gen. 173] 173

1 T his opi ni on gen eral l y con cu rswi th ad v i ce prev i ous l y gi v en to t he State Board

of P har macy and t he Board of Physici an Qual ity Assuran ce. Memorandum f

rom Assistant At to rneys Gen eral Geoff rey J.C. Bo yd

and C. Fre der ick Ryland(D ec em b er 9, 1 99 2) . Th

e q ue sti on pos ed to us does not ca ll fo ra d isc us sio n o f fed er al r eg ula t io ns rel ating to contro ll

ed dangerous subst ances.

HEALTH OCCUPAT IONS

P HYSICIANS

) P HYSICIAN A S SISTANTS

) R EGULAT ION OF P RESCRIBING A ND D ISPENSING O F D R UGS B Y P HYSICIAN A SSIS TANTS

February 1, 1995

The Honorable Martin P . Wasserman Secretar y of Healt

h and Mental Hygiene

Your predecess or as S ecret ary of Healt h and Mental Hygiene request ed our opini on on the int erplay be tween t he M aryland Physici an A ssistants A ct and the M arylan d Ph armac y Act. Speci fical ly, Secret ary Sabatini’ s questi on was whether the Board of Physici an Quality A ssurance may adopt reg ulati ons permi tti ng physici an assistan ts to w rite pre scripti ons for, and dispense medication to, pati ents in hospital s and other health care settings.

For the rea s ons stat ed below, we conclude as foll ows: The Board has autho rity to adopt a re gul ation s pecifying the circums tances under which t he job descripti ons of physi cian assistan ts may inclu de p resc ribin g. A regul ation may not authorize physician a ssistants to dispense p rescription medicine s, how ever. 1

We recognize that the State B oard of P harmacy and othe rs have seri ous r eser

vat ions about

the wi sdom o f allowing physici an assistant s, giv en the nat ure of their train ing, to write prescript ions. At the same time, physician assi stant org anizations a nd o thers strongly advocat e the ut ili ty of t his t ype of de legation. W e sho uld not and d o no t enter th is deb ate, w hich th e Board of Physic ian Qu ality Assur ance will res olve in its ru lemakin g proc eedingif t he General Assembly doe s not do so by ame nding the Physi cian Assistan ts Act or t

he Phar macy A ct. This opinion r eflec ts our174 [80 O p. Att’y

inter pretation of cu rrent law ; we le ave the p olicy ju dgmen ts to others.

I

Pre scribing

A. Sco pe of Pra ctice o

f Ph ysician Assis tants

W ith certa in except ions t hat are not rel evant

here, “ an indiv idual shallbe cert ifi ed by the Boa rd before the individua l may practi ce as a phy sician assistant.” §1 5-30 1(b)(1 ) of the He alth Occupations (“HO” ) Art ic le, M arylan d C ode. In genera l, to “prac tice as a phy sician assistant” is to perform “medic al acts deleg atedto a physici an assistant under this title.” HO §15-10 1(i). The scope of pr acti ce of a cer tif ied physi cian ass ist ant is limi ted to:
(i) Serv ices with in the tra in in g or expe rience of the p hysic ian ass istant;
(ii) Serv ices custo mary to the prac tice of the super vis ing phys ician; (iii) Serv ices deleg ated by the superv isi ng physici an; and
(iv) The ap proved job d escription fr o m the Board.

HO §15 -301 (a)(1). A mon g the pa tient service s that a physici an assis tant may perfor

m are “ [i] nterpr eting

and eval uating

patie nt data
as authori zed by the supe r visin g physi cian for the purpos e of determi ning management and treatment of

patie nts,” “ [t] ranscr ibing
or executing specifi c orders at the dir ection of the supervi si n g physician,” and “[o]ther medicalacts p ermi tted to be deleg ated under an approve d job descripti on.” HO §15-301(2)( iii ), (v i)3, and (vii).Gen. 173] 175

A “medi cal act ” unquesti onably inc ludes pr escribing medicat ion. A “medi cal act ” refer s to act s that are w ithin the scope of practice of med icine. See Mashak v. Poelk er , 356 S.W.2d 713, 720 (Mo. Ap p . 1962). Under HO §14-101(k)(2)( i), t he “pra ctic e [of] medici ne” includes “prescrib ing for ... a ny p hysic al, men tal, or emotiona l ailment or s upposed ail ment of an indivi dual .. ..”
Thus, because a physici an may prescribe medi cati on as part of his or her pr acti ce of medic ine, t he physici an may deleg ate th at medi cal act t o a physici an assi stant “under an approved jo b description.” The job descr ipti on must cont ain, amongother things,
a lis t of “ all me dical acts t o be deleg atedto the phys ician assis tant and the su pervision to be pe rforme d,” a s we ll as a descr ipti on of “t he special izedtrai ning pr ovide d to the phys ician assis tant and the superv isi on to be provi ded by the super vis ing phys ician.” HO §15- 302(b)(1)(i)(iii).

The Maryland Pharmacy Act do es not it self

inhibi t the authori ty of

a physici an assi stant

to pres cribe medi cati on under an approved job descr ipti on. Under H O §12-313 (b)(14), a pharmacist who dispense s a drug f

or which a pres cription is requir ed “[w]i thout first havi ng rece ive d a writt en or oralprescr ipti on for the drug f rom an autho rized prescriber” is subject to professio nal discipline. See al so HO §12 -507 (a) (req uiring “auth orized presc riber” to date prescriptions).

The term “au thorize d pre scribe r” is de fined in HO §12-101(b) as follo ws:

“Authorized pr es criber” means any lice nsed dentist, l icensed phys ician, li censed pod iatrist, lice nsed vet erinarian, cer tif ied
nurse mid-w ife to the ex tent pe rmitted in §8- 601 of thi s Art icl e, or other individual authori zed by l aw t o prescribe drugs, med icines, or device s.”176 [80 O p. Att’y

2 For a discu ssio n of t he r elat ionship be t wee n a pr ior ver sion o f the de f i ni ti on of “authori

zed prescri

ber” an d ot her law au t ho r iz i

ng a h ea l th
car e practitioner to write prescri ptions, see 71 Opini

ons o f the Attorne

y General 142 (1 986).

3 Until they were repealed

in 199 1, Bo ar d r egu latio ns pr ohibit ed t he de l eg ati on to a phy sici an as si stant o f the duty to p rescribe or dispense drugs. Former CO MAR 10. 32. 03. 06. The Bo ar d’s e xisting r egu latio ns go ver ning ph y si ci an as sista nts do n ot expr essly add re ss t he ci rcumstances unde r w hich physician ass ista nt s may pre scr ibemedi cation. In

199 1, t he Board ad dr es se d t he mat t er in apo lic y s tatement t hat, not havi ng be en adopted as a

regul ati on, wa s legal

l y une nf orceabl e. §10 -12 5(d

)(3 ) of t he Sta te Gove rnm en t Article, M ar y

l and Code. See78 Opinions of the AttorneyGeneral

8 (1993); 76 Opinions of the Attorney General 3 (199 1); 57 Opinions o

f the Attorney General

478 (1 972 ). Since t hat t ime, t he Board ha s be enpa rt icip at ing in aleg isla t ive r ev iew o f t he t o pic an d work in g on draft r egulations. (Em phas is added .) A physici an assi stant who, under an approv ed job description, has been del egat ed th e auth ority to w rite prescr ipti ons would be an “i ndivi dual authori zed by law to pr escribe drugs, med ic ines , or dev ices. ” The “law” in this case is HO §15- 301, as int erpret ed by the B oard of Physi cian Quali ty Assur ance. Hence, the ph ysician assistan t wo uld be an “authorized presc riber.” 2

B. Rulem aking Au thority of the Bo ard o f Ph ysician Qu ality Assurance
Under HO §15-205(b)(1), “the Board shal l adopt r egul ations to carry out provis ions of this tit le”

)that i s, the Phys ician Assistan ts Act. S hould the Boar d determine that genera lly applic able stan dar ds o r req uire men ts ou gh t to apply to j ob descriptions that de leg ate to phy sician a ssistants th e auth ority to prescr ibe medication, the Board has authority t o adopt those regulat ions. 3

The B oard’s broad, expr ess rul emaki ng authori ty in HO §15- 205(b)(1) is un affect ed by the re cent fa ilur e of leg isl ation spec ifically authorizing pr escribing by physici an assist an ts under
some circumstances. See House Bill 1527 of 1994. The defeat

of this bill might b e attribu table to dissatisfa ction w ith variou s aspe cts of it; its defeat

does not nece ssari ly ref lect a polic y dec isi on that ph ysici an assis tants should hav e not the authori ty to pr es crib e medicat ion. In any e vent, how eve r one might sp ecula te in this regard, the defe at of

leg isl ation of

this kind i s not a r epeal of exist ingGen. 173] 177

4 This def in ition is as follows: (1) “Practice

phar macy” means to en ga ge in any of the foll

owing activi

ties: (i ) Sel ecti

ng, p re par ing, a nd disp ensing drugs, medici

nes, or devices; (ii) Provi di ng i nf orm ati on a nd ex pl an ati on to patien ts an d he al th ca re practitioners a

bout t he
sa fe an d e f f ecti ve us e of dru gs , m edi ci ne s, or dev i ces ; or ( iii) I de nt ifying a ndap pr ais ing p r o ble ms co ncer ning

the us e or moni tori ng of dr ug t he r ap y.

(conti nue d...) s tatu tory authority. See, e.g. , American Trucking Ass’ns v. Atchinson, T. & S.F. Ry. , 387 U.S. 397 (1967) (a gency rulemaking autho rity unaffected by Congress’ fai lure to a men d statute to autho rize the rules); FTC v. Dean Foods C o., 384 U.S. 597 (1966) (agenc y juri sdict ion una ffect ed by Congress ’ fai lure t o enact leg isl ationconferr ing j urisdi ction) ; 79 Opinions of the A ttor ne

y General347 (199 4) (ex isting agenc y auth ority to imple men t “family cap” limi tati on on welfare be nefit s unaffe cted by am end ment deleti ng “family ca p” pr ovision f rom w elfare re form b ill); 7 7 Opinions of the A tt orney General110 (1992) (e xist ing a gency autho rity to impl ement pres cription drug discount progr am unaffect ed by General Ass embly’s failure t o pass departmenta l legislation conferring specific authority).

Shou ld the Board de ci de to adopt regul ations gove rning prescr ibingby physician assistant s, in our opi nion the Boar d is not requir ed to adopt s uch a re gulation j ointly with the S tate Board of Pha rmacy . To be su re, H O § 15-3 01(d )(1) pro vides tha t, “if aduty that i s to be del egat ed under thi s sect ion is a par t of t he pract ice of
a health occu pation that is regu lated u nder this artic le by an other board, any r

ule or r egul ation c oncerning that duty shall be adopted jointly by the Board of Phys ician Qu ality Assurance a nd the bo ard that regul ates t

he other he alth oc c upati on.” A regulati on determi ning the ci rcu m stances under which a physi cian ass ist ant may write a pr escription, however, does not deal with “ a part of the practi ce of a heal th occupat ion that is re gulated .. . by another board ....”

The practice of pharmacy does n o t include prescr ibing medicat ion, how ever. See HO §12-10 1(j). 4 Although a ph armacist’s178 [80 O p. Att’y

4 (...co ntin

ued) (2) “P racticepharm

acy ” does not incl

ude t he o pe ra t io ns o f a

person who holds a permi t issued under §§12-601 and 12-602 of thi s title

. The latter par agraph refers to man ufacturers and distributor s.

5 HO §1 2- 10 2( e) de als wit h t he dis t inc t ac t o f “a dmin is tering a pre scri ption dr ug in t he co ur se o f t r ea t ing a pa t ie nt. ” Our d i scus si on of dis pensi ng by a phy sici an ass is

tant does not appl

y to admi ni sterin g. s cope of pract ice does include an obl igation t o refr ain fr om dispensing drugs on the pres cription of someone who is not an “aut horized prescriber,” phy sician a ssistants w ould be “aut horized prescri b ers” to the e xtent pe rmitted by the Board of Physic ian Qual ity Assurance

. See Part IA above. Cf. 76 Opinions of the AttorneyGeneral3 (1991 ) (when an acti vit y proposed t o be undertaken by physicaltherapi sts f alls within t

he scope of pr acti ce of chiropr acti c, neve rthel ess Physi cal The rapy Board alone has regul atory j urisdi ction t o decide wh ether a ctivity is perm issible for physical therap ists).

II
Dispen sin g
The defini tion of

“prac tice [ of] med icine ” in H O § 14- 101 (k) does not explic itly include the dis pensingof presc ript ion medic ation by a phy sician. W hile the dispe nsing o f med icati on m ight be comprehendedby some of the broad lang uage i n that de fini tion, the physician’s explic it autho rity to dis pense deri ves f rom provisio ns in the Pharma cy Act. H O §1 2-102(c) (d ), (f) , and (g) set forth carefu lly limited circumstances u nder w hich specified h ealth care practiti oners, includ ing phy sic ian s, may personally dispense medicat ion. See also HO §12 -102 (a)(3) (d efinition of “pers onally prepari ng and dispe nsing”). 5 By contrast with the d efini tion of “aut horized prescr iber, ” these pr ovis ions on di spensing do not give autho rity to dispense to “othe r individual[s] authorized b y law.” Particu larly in light of that omission, w e read t hese prov isi ons as intende d to li mit t

he dispens ing of

medicat ion to t

he physici an personal ly. In our opini on, the di spensing of medication may not be delegated to a ph ysician assistant.Gen. 10] 179

III

Con clusion

In summary, i t is our opi nion th at the B oard has a utho rity to adopt a regul ation s pecifying the circums tances unde r which the job descript io ns of physician assistants may includ e prescribing. A regul ation may not authorize physician assi stants to di spense prescription med icines, how ever. J. Joseph C urran, Jr. AttorneyGeneral

Jack Sch wa rtz Chief Counsel Opinions & Advic e