These are 5 of the important details about becoming a Utah Medical Cannabis doctor, PA, or NP. If you are a patient looking to find a qualified medical provider, here is what it takes to be great.
Physicians, Advanced Practice Registered Nurses, and Physician Assistants who are licensed to prescribe a controlled substance will be allowed to recommend medical cannabis treatment for their patients. Providers must register as a qualified medical provider through an Electronic Verification System (EVS) established by the UDOH.
PAs, NPs, and physicians are the medical professionals who can legally write recommendations for cannabis medical cards in Utah. Some states, like Montana, only allow physicians to write the letters. Luckily (especially for me) PAs are qualified here.
This is an interesting field of medicine because it is almost entirely "self-taught," for medical providers. This means that it likely does not matter whether a patient sees a PA, NP, or physician because it is that provider's personal level of education, not the degree that matters. The fact is, none of us had any medical training on the endocannabinoid system in medical school.
Providers must take a 4-hour course on the endocannabinoid system, Utah law, and cannabis medicine best practice to be allowed to register as a qualified provider. There are currently at least three approved courses. Two online courses are:
There is also an IHC in-person course that is taught by Dr. Jeremiah West, a pain specialist in Layton, Utah. His course page can be found through this link. The cost of the online course is $250, while the in-person IHC course is $120 for outside providers, and $90 for IHC employed providers.
I have completed the Answer Page course and give it a very good recommendation. It covers the law in Utah and the basics of the endocannabinoid system. It has a lot of reference material, is very thorough in its approach to safety, and is straightforward. The course has a slight negative bias toward cannabis medicine, in my opinion.
My critique of the course is basically my standard critique of cannabis science. The evidence presented is not specific enough, it uses smoked cannabis and recreational cannabis studies where we need more truly medical research. The safety education is decent, but more research needs to be done on plant-based dosing (not synthetic) and on medical dosing protocols vs recreational use, again in my opinion.
I will leave a comment below after I attend the IHC course later this week. I anticipate a better discussion will take place in person and so I am looking forward to that session.
Yes, PAs and NPs (Advanced Practice Clinicians) can indeed recommend Medical Cannabis in Utah. They must complete the same education and registration as the MDs / DOs do, pay our $300.00 registration fee with the Utah Department of Health, and register.
PAs must also have a delegation of services agreement with their supervising physician that explicitly states they can evaluate and recommend Medical Cannabis. This is not the case for NPs, but all providers regardless of title must have explicit permission from their employer and practice group to evaluate and recommend cannabis. There are reasons why that I discuss below.
This brings up an important point. To date, the University of Utah and Intermountain Health Care do allow for providers to evaluate and recommend cannabis to established patients who meet the criteria. Each has its own set of criteria and, in addition, each provider will determine if additional requirements exist for their patients to obtain a recommendation.
Other private health care networks in Utah have been clear with their providers and not allowed them to recommend Medical Cannabis. The two larger private groups, Steward Health and HCA (MountainStar) have national reach, crossing state lines, and may be slow to allow providers to recommend the federally illegal plant. Please comment below if you know of another group's policies.
In addition to the Utah law requirements for Medical Cannabis, many PAs, Docs, and NPs have additional requirements. Some IHC providers require a long-standing relationship (greater than 6 months) and require patients to attend a clinical education seminar about Medical Cannabis, led by a clinical pharmacist before the recommendation is given. We should require that for narcotics and Xanax!
Most patients know that insurance will not pay for the medical visit to have an evaluation or recommendation for Medical Cannabis. This is because the DEA still considers Cannabis a Schedule I drug, without any therapeutic benefit and a high risk of abuse. New York is the only state in which patients might expect to have insurance cover the cost, because of a 2018 legal win for patients there.
But there’s more. Providers billing insurance for visits where cannabis, even as a secondary issue, is discussed might be placing themselves and the patient visit at risk. This documentation in the chart can trigger a denial of the claim for payment, just as if the office visit was solely for a Medical Cannabis evaluation and recommendation.
Recommending cannabis during a normal visit that bills insurance may get rejected by the insurance. This may be putting yourself and the patient at risk of being dropped by the insurance.
Many providers ask the patient to pay a separate cash fee for the cannabis evaluation and document that visit separately. This might allow better protection for the patient from the claim being denied. But this brings up another issue…
Does your malpractice insurance even cover you for Medical Cannabis recommendations? If you don’t know then it is likely not covered. This was my experience and it took two months for me to obtain good coverage due to the lack of policies written in Utah as of 2019. The insurance in Florida, for example, for a sole provider Medical Cannabis doctor, PA, or NP is between $1,000 and $2,000, but in Utah, all I have found is triple that amount.
There are 15 conditions in the Utah Medical Cannabis Act that a patient may qualify for a cannabis card. Of those conditions, pain will be the most common complaint. Of course, you want your patients to reduce opioids and there is quality evidence that cannabis is a safer and reasonably effective alternative or additive to their pain meds. But what about all of the other diagnoses?
My practice is to contact the referring provider directly for most of the other diagnoses, such as seizures, Alzheimer's, and Terminal Illness. This creates an open dialogue between the entire care team and is better for the patient. Direct communication is the safest and most effective way to keep the patient safe.
But if this is too much to ask or your practice is very busy and the time commitment to learn cannabis medicine is daunting, maybe seeing patients with pain and or nausea alone is the best option.
Patients who have longstanding pain and who are already utilizing cannabis in the shadows will mostly know what they like to take, what works, at what doses. These patients tend to teach me more than I offer them. But patients who have never tried cannabis, or who did not have a good experience need guidance... and time.
It is not enough to evaluate patients and give them a recommendation for medical cannabis if you are not familiar enough to discuss the risks and benefits alongside some best practices on delivery and dosing. You might even want to discuss strain types, cannabinoid ratios, and terpene profiles to best treat their specific condition.
Too much information? You are not alone. I realized early in this project that “plant-based” medicine is very different than the allopathic method we use in western medicine. It requires a broad discussion of symptoms, more like a rheumatology visit, and treatment with cannabis can positively (or negatively) affect a wide range of symptoms sometimes not related to their chief complaint.
Utah requires that either you know this stuff and discuss it with the patient, decide on dosing, and enter your recommendations into the dispensary system. If you do not, then you must make available enough clinical data for a state-employed physician or pharmacist to consult the patient themselves and recommend dosing. So far, every single one of my patients has preferred me to a state-run cannabis dosing person.
Add that to the fact that you can only recommend cannabis to 175 patients in total unless you are a specialist in anesthesiology, neurology, gastroenterology, oncology, pain, hospice and palliative care, physical medicine and rehabilitation, rheumatology, or psychiatry. This may be too much for many providers and they may choose not to deal with this at all, just focus on what they are already good at.
Despite this, you may be concerned about referring your patients to an outside clinic specializing in cannabis. Patients trust you, they have come to you in health and sickness and that trust is important. Furthermore, you want them to have a good outcome and a safe outcome.
I see two options. One is to establish a relationship with a provider who specializes in cannabis medicine as you specialize in _____. Reach out and talk to them and get a feel for what type of provider they are. Heck, go see their clinic and make sure it meets the standards of your referral.
Expect communication and feedback from your patients about the experience. Treat the referral like any other; one where you expect the highest quality care because this is a high-quality patient.
Another alternative is to franchise your visit out to a provider or group that has the infrastructure, insurance, and quality education you demand. This brings the outside services to you. You still see the patient and do the recommendations, but the visit fee is paid through the outside group and covered with separate insurance by the outside group.
You keep the patient in-house, but they are willing to support the patient’s education and questions throughout the process. There are plusses and minuses to this option, but if done with a reputable group, I can see how this could work nicely.
There are many items in this bill that are up for discussion in and modification during the current 2020 legislative session in Utah. I am sure that pop-up clinics will be discussed on one side, as well as numbers of patients allowed on another. Qualifying conditions will be argued, and we may inch closer to proposition 2’s original language. Even blister-packed flower will likely return to the discussion. Either way, there will certainly be modifications to the law so stay up to date with our newsletter by signing up for free below.
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