Connecticut law recommends that any person or entity seeking to change a health profession’s scope of practice submit a written scope of practice request to the Connecticut Department of Public Health. Executive Director Balasa drafted the following document that was approved by the Connecticut Society of Medical Assistants and submitted to the Department of Public Health on July 16, 2012.

(A) Plain language description of the request

Background: Medical assistants are allied health professionals educated and trained to work in outpatient settings (e.g., medical offices and clinics) under direct physician supervision. Direct physician supervision is defined in the laws of other states as the overseeing/delegating/supervising physician being on the premises and reasonably available, although not necessarily in the same room. Medical assistants do not work under general physician supervision, as do physician assistants and nurse practitioners, and are not educated and trained to work without direct physician supervision.

A scope of practice for medical assistants is not set forth in Connecticut statutes or regulations. (However, the Connecticut Department of Public Health [DPH], pursuant to Public Act 04-82, provides a list of Connecticut registrants who hold a current Certified Medical Assistant [CMA (AAMA)] credential granted by the Certifying Board of the American Association of Medical Assistants [AAMA].) Chapter 370, Section 20-9(a) of the General Statutes of Connecticut states that no person may practice medicine unless licensed under Section 20-10 of the statute. 20-9(b) lists exceptions to this prohibition. Medical assistants are not included in the list of exceptions.

The Connecticut Department of Public Health in a document entitled “Medical Assistant Information” provides informal advice about the duties physicians may delegate to medical assistants. In this document the DPH states that medical assistants may not be delegated “medication administration by any route (including oxygen, immunizations, and tuberculin testing).”

Request: The Connecticut Society of Medical Assistants and the American Association of Medical Assistants request that the Connecticut General Assembly enact legislation that would enable licensed physicians to delegate:

(1) the administration of medication orally or by inhalation; and

(2) the administration of intramuscular, intradermal, and subcutaneous injections (including vaccinations/immunizations) to medical assistants working under their direct supervision (as defined above) in outpatient settings who:

(1) have graduated from an accredited, postsecondary medical assisting program that is accredited by either the Commission on Accreditation of Allied Health Education Programs (CAAHEP) or the Accrediting Bureau of Health Education Schools (ABHES)—the only academic accrediting bodies that are recognized by either the United States Department of Education or the Council for Higher Education Accreditation; and

(2) have a current medical assisting credential acceptable to, and recognized by, the Connecticut Medical Examining Board and the Connecticut Department of Public Health.

Licensure not necessarily required to fulfill this request: Although the above request could be fulfilled by creating a licensure mechanism for medical assistants, licensure is not absolutely required to meet this request. For example, New Jersey has a provision in the regulations of the New Jersey Board of Medical Examiners that permits physicians to delegate certain injections to medical assistants who meet educational and credentialing requirements. However, there is no licensure mechanism for these medical assistants. Rather, the provisions of the New Jersey medical assisting regulation are enforced by requiring licensed physicians to delegate medication administration only to medical assistants meeting the requirements of the regulation. Physicians who do not abide by the provisions of the regulation are subject to discipline by the New Jersey Board of Medical Examiners.

(B) Potential public health and safety benefits, and potential harm to public health and safety, should the request not be implemented

If a law described immediately above were enacted, the people of Connecticut would benefit by having greater access to, and availability of, health care. Under current law, physicians are restricted in the categories of allied health professionals to whom they may delegate medication administration. Allowing physicians to delegate certain types of medication administration to educated and credentialed medical assistants would increase the supply of allied health professionals, and consequently the efficiency of the provision of health care. This would enable physicians to see a greater number of patients in a shorter time, without any diminishment of the quality of care provided to patients.

If the above request for legislation were not granted, the Connecticut health system, delegating physicians, and patients would be deprived of the efficiencies of fully utilizing competent and knowledgeable medical assistants. In other words, the availability of health care involving certain types of medication administration would be less than it would be if educated and credentialed medical assistants were able to use their full range of abilities under direct physician supervision.

(C) The impact on public access to health care

See (B) immediately above.

(D) Summary of state and federal laws regarding medical assisting

There are no federal laws that have a direct bearing on medical assistants and their scope of practice in regard to medication administration.

Most state laws permit physicians to delegate to unlicensed allied health professionals (such as medical assistants) working under their direct supervision in outpatient settings any duties except those which:

(1) constitute the practice of medicine, or require the skill and knowledge of a licensed physician;

(2) are restricted in state law to other health or allied health professionals;

(3) require the medical assistant to exercise independent professional judgment, or to make clinical assessments/evaluations.

Some states require medical assistants to meet educational and/or examinational requirements in order to be delegated certain “advanced” medical assisting duties. The New Jersey medical assisting regulation pertaining to injections has been discussed above. South Dakota requires medical assistants to have graduated from a formal, postsecondary educational program that meets the joint standards of the South Dakota Board of Medical and Osteopathic Examiners and the South Dakota Board of Nursing in order to be registered and to work as a medical assistant.

(E) Connecticut’s current regulatory oversight of medical assisting

As stated above, Connecticut has no oversight of the medical assisting profession other than the Department of Public Health’s position that medical assistants may not be delegated any administration of medication. As also stated above, the DPH makes available a list of Connecticut residents who hold the CMA (AAMA) certification awarded by the Certifying Board of the American Association of Medical Assistants.

(F) Current education, training, and examination requirements

There are no education, training, or examination requirements for medical assistants in Connecticut law, or in the laws of most other states.

(G) Scope of practice requests within the past five (5) years

There have been no scope of practice requests for medical assistants in Connecticut within the past five (5) years.

(H) The extent to which the request directly impacts existing relationships within the health care delivery systems

This request would only have an impact on the relationship of physicians as delegators to medical assistants, and medical assistants as delegatees of physicians. There would be no change in the requirement that medical assistants work under direct physician supervision. If the request were granted, physicians would be permitted to delegate certain types of medication administration to medical assistants meeting the educational and credentialing requirements. If the General Assembly enacts the requested legislation, physicians would continue to be able to delegate to all medical assistants (those who meet the educational and credentialing requirements and those who do not) the limited duties they are now permitted to delegate, such as taking vital signs, rooming patients, administrative tasks, and—as directed by the overseeing physician—entering data into the medical record.

(I) The anticipated economic impact of the request on the health care delivery system

As presented in B above, expanding the scope of delegation of physicians to medical assistants who meet the educational and credentialing requirements would increase the supply of allied health professionals to whom doctors could delegate medication administration. According to basic microeconomic principles, an increase in the supply of allied health professionals would permit the employers/supervisors of these delegatees to increase their output of medical care—especially medical care that involves medication administration.

It is important to note that this increase in supply of allied health professionals would not decrease the quality of health care, and thus would not jeopardize the health, safety, and welfare of Connecticut patients. This is due to the fact that, under the proposed legislative request, only educated and currently credentialed medical assistants would be permitted to be delegated the administration of medication.

(J) National trends in state medical assisting laws

In addition to the aforementioned laws in New Jersey and South Dakota, there are statutory and/or regulatory provisions that establish requirements for medical assisting scope of practice in California, Washington, and Arizona. Legislation was signed into law in Washington in 2012.

(K) Health care professions that may be directly impacted by the request

Physicians would be directly impacted by this scope of practice request. The Connecticut Society of Medical Assistants is working closely with the Connecticut State Medical Society on this request, and therefore no significant opposition from organized medicine is anticipated.

Registered nurses (RNs) and licensed practical nurses (LPNs) sometimes work under physician supervision in outpatient settings and are delegated administration of medication. Consequently, this scope of practice request could have an indirect impact on RNs and LPNs. This request stipulates that medical assistants must graduate from a postsecondary, programmatically accredited (by either CAAHEP or ABHES) medical assisting program and receive either a one-year certificate or diploma or a two-year associate degree in order to be delegated administration of medication. The CAAHEP and ABHES accreditation standards for medical assisting programs are somewhat comparable to the accreditation standards for LPN programs. Once this fact is brought to the attention of the Connecticut Board of Nursing and the nursing societies in this state, it is not anticipated that there will be significant nursing opposition to legislation embodying this scope of practice request.

(L) How this request relates to the ability of educated and suitably credentialed medical assistants to practice to the full extent of the profession’s education and training

There are 23 medical assisting programs in Connecticut that are accredited by either CAAHEP or ABHES. Graduates of these programs have been taught the didactic knowledge necessary to safely perform medication administration, including intramuscular, intradermal, and subcutaneous injections. In addition, they have been required to demonstrate psychomotor competence in these procedures in order to graduate—even though this psychomotor competence can only be demonstrated on mannequins, not live subjects, because of the Connecticut law.

The current state of Connecticut law is preventing these educated and credentialed medical assistants from being delegated duties to the full extent of their education and training. This scope of practice request would remedy this situation, and would provide physicians and other employment decision makers with more options in the hiring of competent and knowledgeable allied health personnel. Most importantly, this scope of practice request would increase the availability of health care for Connecticut residents without lessening the quality of care they would be receiving.

This scope of practice request is being considered by a scope of practice review committee appointed by the Connecticut Department of Public Health. Mr. Balasa will report the outcome of this process in Legal Eye.

Questions? Contact Donald A. Balasa, JD, MBA, at dbalasa@aama-ntl.org or 800/228-2262.