Synergy - January/February 2015 - 13

industry feature

These categories are the same as those
included in the definition of "physician"
contained in Section 1861(r) of the Social
Security Act (Act).6
The Other Practitioners who may be
appointed to the medical staff under the
Revised CoP are not set forth in the CoPs.
However, in an appendix to its State
Operations Manual, CMS explained that
Section 1842(b)(18)(C) of the Act defines
these Other Practitioners to include:
* Physician assistants (PAs);
* Nurse practitioners;
* Clinical nurse specialists;
* Certified registered nurse anesthetists;
* Certified nurse-midwives;
* Clinical social workers;
* Clinical psychologists;7 and
* Registered dieticians (RDs) or nutrition
Importantly, however, the Revised CoP limits
the Other Physicians and Other Practitioners
who may be part of the medical staff to
those whose appointment would be "[i]
n accordance with State law, including
scope-of-practice laws," and further limits
Other Practitioners to those "determined to
be eligible for appointment by the governing
body."9 Thus, it is necessary to consult state
law to determine which Other Practitioners
a hospital may appoint to its medical staff.
For example, in California, MDs and DOs,
dentists, and podiatrists are eligible for
medical staff membership as a matter of law,
and clinical psychologists may be eligible
for medical staff membership at the option
of the hospital.10 California law makes no
affirmative provision for the appointment
of doctors of optometry, chiropractors, or
any Other Practitioners to the medical staff
while, interestingly, among others, marriage
and family therapists, professional clinical
counselors, and PAs are treated like medical

See 42 U.S.C. § 1395x.


Note that, under the Social Security Act, clinical psychologists
may be either "physicians" or "other practitioners," depending on
classification by the medical staff and the hospital's governing body,
and in accordance with state law.


42 U.S.C. § 1395u. Cited in State Operations Manual, Appendix
A-Survey Protocol, Regulations, and Interpretive Guidelines for
Hospitals, CMS, Rev. 116, 06-06-14, at p. 174, available at: www.


42 C.F.R. § 482.22(a), effective July 11, 2014.


CAL. CODE REGS., tit. 22, § 70703(a).

staff members for purposes of reporting and
hearing rights under CAL. BUS. & PROF.
CODE §§ 805 and 809. Thus, even though the
Revised CoP expands the range of practitioners
who may be eligible for medical staff
membership to include certain non-physician
practitioners, state law still controls.

Balancing the Benefits/Risks
of Appointing Non-Physician
Practitioners to Medical Staff
The main benefits of appointing Other
Practitioners to the medical staff appear to
be time savings, flexibility, and efficiency
while the burdens include increased
potential costs of oversight and peer review.
In a number of situations, Other
Practitioners are the professionals best
qualified to assess and develop plans of
care for the patient in a timely manner
to realize improved patient outcomes
at the most efficient cost. For example,
many times RDs are the professionals best
qualified to assess a patient's nutritional
status and to design and implement a
nutritional treatment plan in consultation
with the patient's interdisciplinary care
team. On the other hand, some argue that
in certain cases, such as post-abdominal
surgery care, the physician is best suited to
determine patient diet, and the RD must
defer to or consult with the responsible
physician for the care of the patient.
Therefore, medical staffs must determine
which specific practitioners are qualified for
which specific privileges consistent with the
medical staff bylaws and state law.
The extent of required MD/DO supervision
or oversight is another factor that should be
considered. For example, if a medical staff
includes a dentist as an Other Physician
on the medical staff, that dentist still can
only provide care and treatment within the
scope of practice allowed by state law. For
instance, one question that may arise is the
extent of that dentist's privileges to admit
a patient or perform a history and physical
examination. A dentist may be able to admit
a patient or perform a history and physical
on a patient who only has dental issues
where no medical issues of significance
exist. If the patient has a clear medical
condition (poorly controlled diabetes, a
bleeding disorder, etc.), however, the dentist

could still potentially admit the patient, but
a physician would still need to be involved
for both a complete history and physical and
to manage the medical condition.
Requirements of the hospital's accrediting
body also must be considered in appointing
Other Practitioners to the medical staff. For
example, The Joint Commission's (TJC's)
Standard MS.03.01.03 requires that "[t]
he management and coordination of each
patient's care, treatment, and services is
the responsibility of a practitioner with
appropriate privileges," but one of the
elements of performance of that standard
requires that "a patient's general medical
condition is managed and coordinated
by a doctor of medicine or osteopathy."11
Similarly, although TJC's Standards
provide that a hospital "may choose to
allow individuals who are not licensed
independent practitioners to perform part or
all of a patient's medical history and physical
examination," TJC requires that such
examination be "under the supervision of, or
through appropriate delegation by, a specific
qualified doctor of medicine or osteopathy
who is accountable for the patient's medical
history and physical examination."12 Thus,
even if an Other Practitioner may be
privileged as part of the medical staff, an
MD or DO still must manage and coordinate
patient care provided by that Other
Practitioner if TJC accredited the hospital.13
Before deciding whether to appoint Other
Practitioners to the medical staff, it is
important to weigh the increased burden on
the medical staff to credential and privilege
the Other Practitioners where the hospital's
human resources department traditionally
may have been responsible for oversight
of such Other Practitioners. For example,
while TJC's Standards already require PAs
and Advanced Practice Registered Nurses
to be credentialed through the medical

The Joint Commission, Comprehensive Accreditation Manual for
Hospitals, Update 2, September 2012, at p. MS-17, Standard
MS.03.01.03 and Elements of Performance for MS.03.01.03, no. 3.


Id. at p. MS-16, Elements of Performance for MS.03.01.01, no. 9.
The Joint Commission defines "licensed independent practitioners"
to include physicians, oral and maxillofacial surgeons, dentists,
podiatrists, and some advanced practice registered nurses. Id. at p.
MS-15, Rationale for MS.03.01.01.


In light of the Final Rule's various Revisions, TJC issued revisions to
its Comprehensive Accreditation Manual for Hospitals on August 21,
2014. However, none of these revisions address the Revised CoP or
the appointment of Other Physicians and Other Practitioners to the
medical staff. See The Joint Commission, Prepublication Requirements,
August 21, 2014, available at:




Synergy - January/February 2015

Table of Contents for the Digital Edition of Synergy - January/February 2015

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Synergy - January/February 2015 - 1
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