Ontario Medical Association (OMA)
Response in PDF format.
Thank you for the opportunity to provide feedback on the proposed amendments to the Delegation of Controlled Acts policy.As a practicing family physician and the director of a walk-in clinic and an urgent care medical center in a very busy and underserved area in Ontario, while I support the CPSO’s commitment to patient safety and regulatory clarity, I have significant concerns regarding several aspects of the proposed changes—particularly the 48-hour assessment requirement in the context of an “anticipated” physician-patient relationship, and the clarification on OHIP billing requirements. These changes risk disrupting access to care, undermining interdisciplinary collaboration, and narrowing physician discretion in their judgment scope and limits in ways that are not aligned with the practical realities of modern medical practice and safe extension of delivering medical services where it is highly needed and is underserved.Concerns with 48-Hour Assessment Requirement:The proposed requirement that a physician must perform a clinical assessment within 48 hours for the initial patient encounter under an anticipated physician-patient relationship is impractical and overly rigid. It fails to account for high-volume environments, rural/remote care settings, mobile clinics, and transitional or urgent care situations where safe, protocol-based delegation is both necessary and appropriate.Licensed physicians are extensively trained and regulated professionals who are expected to be fully capable of determining when and how delegation is clinically appropriate. Imposing an arbitrary timeline for assessment does not enhance patient safety—it restricts efficiency, introduces delays, and may undermine care in underserved areas.Impact of OHIP Billing and Physician-PA ModelsI also share the concerns raised by others regarding the clarification that assessments must be “personally rendered” by the physician to be eligible for OHIP reimbursement. Many Physician Assistants (PAs) are working in outpatient and primary care settings function under direct physician oversight, with the physician billing for services and using that income to support the PA’s salary. The proposed clarification threatens to destabilize this model and will negatively impact patients' access to extended medical care and likely reduce job opportunities for PAs-especially in community clinics, family practices, and rural health teams where physicians rely on this collaborative structure to meet patient needs.Instead of limiting physician discretion through rigid timelines and billing barriers, I encourage the CPSO to focus on policies that support:• Safe and flexible delegation models that reflect clinical realities;• Sustainable inter-professional collaboration, including physician-PA models;• Expanded licensure pathways for international physicians, PAs, and other allied health providers who are qualified and ready to serve Ontario’s growing patient population.Proposed Policy Language for Delegation Framework:To support clarity and accountability in delegation while preserving professional judgment, I propose that CPSO consider incorporating the following language into the policy:A delegate appointed by a physician to perform controlled acts is considered to be acting under the direct authority and professional responsibility of the delegating physician. The delegate must be formally contracted or authorized to perform such acts within the scope defined by the physician. The physician retains full accountability for the appropriateness of the delegation, the supervision provided, and any clinical consequences arising from the delegate’s actions or omissions.This approach maintains a better accountability while enabling adaptable team-based care models that reflect real-world practice.
I respectfully disagree with several aspects of the proposed policy revisions. While I understand the intention to maintain high standards of care and accountability, I believe these changes may unintentionally hinder access, efficiency, and system sustainability. Here are several points of concern:1. Mandatory Physician Assessment Within 48 Hours for First Encounters:Requiring a physician to assess every new patient within 48 hours, regardless of clinical context or acuity, undercuts the role of Physician Assistants (PAs) and Nurse Practitioners (NPs), who are highly trained to perform comprehensive assessments. In many regions across Canada and internationally, PAs are successfully integrated into primary and acute care settings precisely to extend physician capacity and improve access. This rigid 48-hour requirement undermines this model and may create unnecessary delays in care.2. Removal of the “Patient’s Best Interest” Exception:Clinical care is often complex and context-dependent. Removing flexibility from delegation decisions removes the capacity for physicians and their teams to use clinical judgment to act in the best interest of patients. Delegation decisions made in structured, supervised environments—such as team-based practices—should be supported, not constrained, especially when PAs are already working under supervision and within scope.3. Emphasis on OHIP Billing Over Patient-Centered Care:The focus on OHIP reimbursement criteria, while important from a funding perspective, should not dictate clinical workflow in a way that compromises timely access to care. PAs are not independently billable, yet they contribute significantly to patient throughput, chronic disease management, and preventive care. Using billing rules to restrict their scope diminishes their value and may increase long-term costs by delaying care and increasing ER visits.Conclusion:If implemented, these changes may discourage the integration of PAs and frustrate efforts to build more efficient, team-based models of care. Given the ongoing physician shortages and overwhelming demand in both primary and emergency care, the system should focus on maximizing safe delegation, not limiting it.I urge the College to reconsider these changes with an emphasis on collaborative care models, evidence-based delegation, and efficient system design. Ensuring oversight and quality is critical—but not at the expense of access, innovation, and sustainability.
Note: Some content has been edited in accordance with our posting guidelines.
To whom it may concern,
Attached please find my letter of support for the submission made by the Canadian Association of Physician Assistants (CAPA) regarding the Delegation of Controlled Acts Consultation. This is an important matter, and the changes mentioned will support better care for the citizens of Ontario.
To Whom it May Concern,
I am writing to express my strong support for the submission made by the Canadian Association of Physician Assistants (CAPA) regarding the Delegation of Controlled Acts Consultation.
As a Family Physician I believe the recommendations outlined in the submission are thoughtful, practical, and essential to ensuring safe, effective, and equitable care across Ontario. I support the following key recommendations:
Clarifying the definition of “clinical assessment” by the delegating physician to reduce confusion, reflect real-world clinical workflows and enhance patient care and safety.
Recognizing the beneficial role of PAs in remote and isolated regions by explicitly including PAs as well as RNs in expanded scopes in Appendix B’s exceptional circumstances for the delivery of primary care.
Removing Footnote #10, which introduces billing considerations that may have the unintended outcome of discouraging appropriate delegation.
Considering a distinct approach for delegation to CPSO-registered PAs, acknowledging their unique role and integration within regulated clinical teams.
As registrants of the CPSO, Physician Assistants are now formally accountable to the College’s policies, standards, and expectations. This regulatory status reinforces the importance of ensuring that CPSO policies—such as those governing delegation—accurately reflect the responsibilities, and realities of PA practice. Aligning policy language with the PA role will support safe, collaborative care and uphold public trust in the regulatory framework.
Thank you for the opportunity to provide input on this important matter.
I am writing to provide feedback on the proposed changes to this policy. As a Physician Assistant, I appreciate the College's effort to make updates to this policy however as it is currently structured, I have concerns on a few fronts.
1)48hr Physician Assessment Requirement for 1st Encounters - the way that this is currently structured/crafted is vague and confusing. It does not reflect the current abilities of PAs nor real-world clinical workflows that exist. I am also concerned that it would hamper safe patient care and reduce access by leading to redundant clinical re-assessments by MDs.
2) PAs are missing from Appendix B of roles that could be expanded in remote/rural care primary care delivery. Especially as PAs are now CPSO registrants, this recognition by the CPSO in policy is important and reflects the value that PAs bring to these communities.
3)The policy provides some guidance on OHIP billing for delegated acts that suggests that suggests billing should not occur for acts that are done under appropriate delegation. This suggestion could have negative implications for PAs (e.g. reduce scope, impact compensation), MDs (e.g. disincentivize those who attempt to integrate PAs into team based care because the necessary financial compensation is not clear or support this setup), and the broader system (e.g. creates process and financial inefficiencies as it does not reflect each providers scopes and capabilities by pushing all billable services to MDs).
Has the CPSO considered creating a unique/standalone delegation policy to capture the MD-PA relationship? Especially as both parties are registrants of this college now, this could be the perfect time to move ahead with this and it more accurately reflects the unique aspects of this relationship that are different than other delegation relationships.
Thank you for the consideration in advance.
As a Physician Assistant who has now worked for 11 years in both the USA and Canada, I believe the recommendations outlined in the submission are thoughtful, practical, and essential to ensuring safe, effective, and equitable care across Ontario. I support the following key recommendations:
Thank you for the opportunity to consult on this policy. I have been integrating physician assistants into the team of hospitalists at [redacted] over the past several years. My experience working with the PAs, training PAs, holding physicians accountable for appropriate delegation and supervision inform my opinions below.
I appreciate the need to clarify the expectations of the profession in appropriately delegating and maintaining professional standards.
I believe that delegation is primarily a relational act and not a technical one. It requires trust and communication. I fear that the requirement to have medical directives that outline every detail will erode that relationship.
I believe it is important to clarify that if a physician is delegating, they are immediately available to assess and treat the patient themselves and that they are immediately available to support the delegates questions or concerns.
I believe that the requirement for assessment in 48 hours is problematic. Many times, a delegate is seeing a patient to support the concerns or the patient or the care team that did not warrant an in person assessment in the first place. The role of a delegate can be an important reassurance.
The role of the PA as a “physician extender” is much needed in our system, and ultimately negated in practicality by this proposed stipulation.
It also undermines the physician’s clinical judgement to triage patient needs.
The policy does not reflect the goals of team based care or group based practices clearly enough, particularly in the wording around anticipated patient-physician relationships.
I trust this has been helpful.
Response in PDF format:
As a Physician Assistant I believe the recommendations outlined in the submission are thoughtful, practical, and essential to ensuring safe, effective, and equitable care across Ontario. I support the following key recommendations:
As a Physician Assistant, I believe the recommendations outlined in the submission are thoughtful, practical, and essential to ensuring safe, effective, and equitable care across Ontario. I support the following key recommendations:
Canadian Association of Physician Assistants (CAPA)
Hello,
As a mature member of the public, I am commenting further following having considered the draft and the discussion along with recent observations and examples of delegation, either directly or assumed.
The topic of my concern is the pharmacist:
When my doctor in [redacted] sends a prescription to my usual private (not large franchise pharmacy), she/he expects the drug will be safely dispensed as prescribed.
With many generics and drugs on not available lists due to recall or manufacturing supply reasons, we are fortunate if the drug is dispensed as prescribed.
Further, expanded responsibilities of pharmacists includes diagnosing and prescribing - at a fee, I assume - however can a pharmacist safely diagnose a symptom associated with our vision ? Or other critical symptoms. Does the pharmacist then inform the doctor?
Also, I have observed pharmacists eagerly meeting with patients in public areas - no privacy - where they provide a very superficial $75.00 assessment / review of the client’s medical status. Are these ever shared by report to the prescribing doctor. As a shopper, I have observed these at WalMart and grocery store pharmacies in [redacted], with no privacy and questionable accuracy of diagnosis and advice.
In Ontario, I understand the Shoppers Drug Mart Pharmacist fee of $75.00 has been totalled to cost millions of dollars to Ontario health care costs. Have these been audited to verify? An office practice doctor does not receive $75.00 for similar patient contact.
This is a fairly new area of pharmacy practice open to accuracy of diagnosis, prescription, pharmacist medical advice and billing, auditing, communication with prescribing doctor.
Further, boundaries in access to patient medical records must be maintained with limited access to pharmacists.
My general practice doctor since 2003 and I have had a recent conversation about the decline in professional pharmacy service by my usual private pharmacy since 2006. With owner/pharmacist retiring last year and selling his business in a small established medical clinic in [redacted], pharmacy service and accuracy has declined. I am considering changing my pharmacy if patient services do not improve during 2025.
In addition to the delegation - either directly or assumed - this fairly new delegation requires consideration.
College of Physicians and Surgeons of Ontario,
I am writing to express my concern regarding the current practices surrounding delegation of controlled acts in cosmetic medicine. As a physician with over a decade of experience performing aesthetic procedures in Ontario, I have observed a growing trend of physicians delegating procedures to nurses without being physically present at the time of treatment. While I understand that delegation is permitted within certain policy frameworks, I believe these practices may compromise patient safety and fall short of the standards expected in our profession.
In particular, I am troubled by situations where physicians provide initial consultations—sometimes virtually—and then delegate procedures across multiple locations simultaneously, often without ever having met or assessed the patient in person on the day of treatment. Given the potential for serious adverse events in cosmetic medicine, I believe patients deserve in-person evaluation by the physician who is authorizing the treatment and that physician oversight should not be remote or nominal.
Furthermore, while the training and scope of practice for nurses is ultimately under the purview of the College of Nurses, the decision to delegate to individuals who may have only attended brief commercial training courses—sometimes as short as one or two days—is deeply concerning. This model, in my view, does not reflect responsible medical oversight and is not in alignment with international standards. In fact, in many jurisdictions with lower healthcare standards, I have not encountered such a permissive delegation model.
Finally, I urge the College to consider implementing clearer, stricter guidelines to address situations where physicians are named as medical directors for multiple clinics while being physically absent—even from the province or country. I believe this undermines public trust in the profession and opens the door to unsafe practices.
Thank you for considering this feedback. I share it out of a strong commitment to uphold the integrity of medical practice in Ontario and to protect the safety and well-being of our patients.
A year ago I had a sleep study and it took months for me to see the “sleep doctor” to get the results. According to this he should not have taken my drivers license away g he didn’t see me within 48 hours and this didn’t have a doctor-patient relationship with me!!!! Can I sue him???
Every day thousands of Ontarians have an x-ray interpreted by a radiologist they will never meet; an ECG read by a cardiologist who will not see them for an assessment; blood work or a surgical specimens interpreted by a pathologist whom they will not know. Yet the CPSO considersall these situations to be a doctor-patient relationship for the purposes of licensure and medico-legal risk. To apply the arbitrary requirement for a physician assessment, let alone within the unrealistic time of 48 hours, for one multidisciplinary context and no requirement for so many others is so inconsistent as to be ludicrous. The physician signing a medical directive takes responsibility for the work of the team members, let them also use their medical judgement to determine when a patient needs to be assessed.
The proposed changes to the policy introduce significant challenges that could unintentionally endanger care for new patients and negatively affect Physician Assistants (PAs), including their earning potential:
1. 48-hour Physician Assessment Requirement for First Encounterso Risk to New Patients: Requiring a physician to conduct an in-person clinical assessment within 48 hours for all new patient encounters could lead to delays in care, especially in high-volume or underserved practices where physician availability is limited. New patients with urgent but non-emergent issues might wait longer for evaluation, increasing the risk of disease progression or complications.o Operational Bottleneck: Many practices rely on PAs to perform initial assessments and manage straightforward cases. This rule may create bottlenecks, overload physicians with routine visits, and reduce overall clinic capacity.o Undermines PA Autonomy: Highly skilled PAs are trained to assess new patients and escalate care appropriately. Imposing mandatory physician assessments may undercut their role and devalue their clinical contributions.2. Removal of “Patient’s Best Interest” Exceptiono Loss of Flexibility: The existing “patient’s best interest” exception allows clinicians to exercise judgment in delegating care when timely physician involvement isn’t feasible but safe alternatives exist. Removing it entirely risks rigidity that can compromise patient-centered care. For example, in remote or rural settings, this flexibility is often critical.o Possible Gaps in Care: In scenarios where a PA could safely manage a patient but is prohibited due to strict rules, patients may face unnecessary ER visits or delays in accessing care. 3. Highlighting OHIP Requirements for Physician-Rendered Serviceso Impact on PA Employment & Salaries: Emphasizing that OHIP only reimburses services personally rendered by physicians may incentivize practices to limit PA involvement in billable services. This can reduce the scope of PAs’ practice, lower billable hours, and ultimately decrease their salaries or job opportunities.o Reduced Cost Efficiency: Part of the value PAs bring is cost-effective care delivery. Policies that push all reimbursable services to physicians may increase system costs, contradicting broader health system goals of efficiency and accessibilit
As a practicing dermatologist and clinic owner, I welcome the CPSO’s efforts to clarify and modernize the delegation framework, especially given the well-documented shortage of dermatologists in Ontario and the increasing demand for timely access to dermatologic care.While the updated draft contains several helpful changes — such as clearer definitions, continued support for medical directives, and recognition of delegation as a means to facilitate access and optimize healthcare resources — I believe the policy could go further to meaningfully support access and innovation in team-based models of care.The policy continues to require a physician assessment before or within 48 hours of delegation in most cases. This is too restrictive for chronic or low-risk dermatologic care (e.g., acne, wart treatments, lesion monitoring, cosmetic follow-ups), where protocols, medical directives, and experienced nursing staff can ensure safe and effective delivery. I recommend expanding the list of exceptions or allowing discretion in stable, protocol-based cases.As we work to improve access, especially in underserved regions and for high-demand services, enabling nurse practitioners, registered nurses, and physician assistants to deliver delegated care under medical directives — without redundant reassessments — is essential. This would mirror successful team-based models in other provinces and specialties.The current OHIP billing limitations prevent physicians from being remunerated for services delegated to non-physicians, even when they are responsible for the care and oversight. This discourages appropriate delegation and adds financial strain on practices that are otherwise optimizing care delivery. While this is outside the CPSO’s regulatory scope, the policy could acknowledge this barrier and support ongoing collaboration with the Ministry of Health and OMA to modernize funding models.Lastly, the level of documentation required for medical directives and delegated acts may be overly burdensome, especially in high-volume clinics. Allowing simplified protocols and annual approval processes for stable, evidence-based procedures (e.g., cryotherapy for warts, intralesional steroid injections) would enhance uptake without compromising safety.
I need to express significant concern regarding the proposed 48-hour physician assessment requirement in the context of an "anticipated" physician-patient relationship. This proposal represents an egregious overreach into the practical realities of medical practice and undermines the collaborative role of Physician Assistants (PAs) and other allied health professionals.The CPSO’s mandate, as outlined in the Regulated Health Professions Act, is to protect the public interest and regulate the practice of medicine—not to micromanage how physicians safely and responsibly delegate care within a competent healthcare team. Physicians, by our training and licensure, are entrusted to use our professional judgment in determining when and how to delegate. This draft policy veers dangerously close to dictating clinical workflow rather than ensuring public safety.
At a time when allied health providers are being granted expanded scopes of practice without physician oversight, it is baffling—and frankly insulting—that the CPSO is seeking to restrict physicians' delegation authority. The healthcare system relies on interdisciplinary collaboration to function efficiently. Imposing arbitrary and impractical timelines, such as a mandatory 48-hour assessment for first encounters, will severely hamper access to care, increase bottlenecks, and create unnecessary administrative burdens without evidence of improving patient safety.
Instead of restricting delegation, the CPSO should be advocating for policies that support responsible team-based care, especially in underserved and rural areas where timely physician access is not always feasible.
I urge the CPSO to reconsider this overstep and work with frontline physicians and PAs to develop guidance that protects patients without impairing access or micromanaging clinical discretion.
The proposed changes seem reasonable to me in association with the changes proposed for Appendix B exceptions.
Just want to clarify footnote 2 on "health professionals". By my read, residents and fellows would be exempted from this policy, specifically the requirement that the patient has a pre-existing relationship, or must be seen within 48h by the supervising physician.
I'd like clarification on delegating tasks to Nurse Practitioners - can we bill for these? Outside of a FHT for instance, in a FHO, can we hire our own NP and what are the rules for billing?What about if we are supervising Medical Students or Residents - what are the specific rules regarding billing?
This remains the single biggest barrier to hiring more staff thus seeing more patients, or being open to provide learning opportunities for medical students or residents
Hello, My name is [redacted], a [redacted] PA student at [redacted]. As someone who is passionate about the profession and advocating for it, I am concerned about the proposed changes specifically in relation to the Physician Assistant profession.Clarifying the "anticipated" physician relationship to include a mandatory clinical assessment by the physician within 48 hours (for the first patient encounter), would mean that PAs could not work in many outpatient settings such as the emergency room, walk-in clinic or telemedicine. While we understand that physician oversight is essential to the PA-physician relationship, this change would make the PA's role in these settings redundant. Additionally, the clarification that assessments must be done by the physician directly to bill for OHIP would also significantly impact PA's who work in outpatient settings where the physician bills for their consults and uses that income to supplement the PA's salary. I can see this being a large barrier to job opportunities and PA accessibility for physicians. I understand that these delegation policies are applicable to all allied health professionals and because of that, they should be specific although these changes significantly hinder the PA profession and the physician-PA relationship. Not only on the PA side of things, reducing PA scope with the above changes will negatively impact patient wait times, satisfaction and physician mental health, further exacerbating the stress the Canadian healthcare system is under. A solution to this could be to have a separate delegation policy specific for PA's that does not restrict their ability to provide care and maintain the current physician-PA relationship. I know the CPSO recently spent alot of time and money to have PA's regulated although these changes do not seem to align with this and in a sense nullify the large strides that regulation of PA's in Ontario represented.I appreciate you taking the time to read this feedback. Kindly, [redacted]
