Physician assistants move from supervision to collaboration

The role of a physician assistant (PA) has historically been one of a “dependent practitioner” requiring close physician supervision, which included co-signatures, chart review requirements, co-locating physicians on-site where PAs deliver care, and limiting a PA’s scope of practice.

The trend in state regulatory laws, however, has been moving toward more remote supervision of PAs and fewer oversight requirements of PA clinical practice. This trend also includes states transitioning from supervision models to collaboration models. Some states have also eliminated or reduced requirements for chart review and supervision agreements. Several states have eliminated the need for a supervising physician to be physically co-located with the PA (Jones Day, 2020).

While some states have permitted PAs to work more independently to deliver healthcare services, this should not be construed as a blanket endorsement granting PAs licensed independent practitioner (LIP) status. Such status, if recognized by federal guidelines, must also be established by state law and the respective institution. The trend in state laws for expanding the scope of practice (SOP) of advanced practice professionals includes both PAs and nurse practitioners (NP). Many states have enacted some level of reform toward expanding their SOP over the last few decades (Orr, 2020).

Although NPs have historically worked with physicians through a collaborative agreement, 23 states and the District of Columbia have approved full practice status for nurse practitioners, a provision that allows them to assess, diagnose, interpret diagnostic tests, and prescribe medications independently.

Regulatory requirements for PA SOP vary according to state law. A PA’s SOP is determined at the practice site in all states, except for the following (Nadkarni, 2019):

• Alabama
• Georgia
• Iowa
• Kentucky
• Maryland
• Mississippi
• Oklahoma
• Pennsylvania
• South Carolina
• Virginia
• Washington
• West Virginia
• Wisconsin

Although PA program didactic training mirrors medical doctor training programs, PAs receive one year of clinical training and MDs receive five years of clinical training.

The AMA states, “Physicians must maintain the ultimate responsibility for coordinating and managing the care of patients and with the appropriate input of the physician assistant, ensuring the quality of health care provided to patients. PAs should be authorized to provide patient care services only so long as the PA is functioning under the direction and supervision of a physician or group of physicians” (AMA, 2018).

The AMA is opposed to legislation or proposed regulations authorizing PAs to make independent medical judgment regarding such decisions as the drug of choice for an individual patient. The AMA also opposes to the establishment of autonomous regulatory boards meant to license, regulate, and discipline PAs outside of the existing state medical licensing and regulatory bodies' authority and purview.

The AMA provides a summary of PA regulatory requirements throughout the U.S. healthcare system as follows:

• 20 states require a certain percentage or number of PA charts to be co-signed by a physician
• 39 states have established limits on the number of PAs a physician can supervise or collaborate with prescriptive authority
• PAs are authorized to prescribe Schedule II–V medication in most states (44)
• PAs lack the authority to prescribe Schedule II medication in six states (Alabama, Arkansas, Georgia, Hawaii, Iowa, West Virginia)
• PAs lack the authority to prescribe legend drugs in Kentucky
• In 47 states, PAs are supervised by physicians
• In two states, PAs are subject to collaborative agreements with physicians (Alaska, Illinois)

This article summarizes recent developments in the lessening of regulatory restriction for the clinical practice of PAs. It is intended to point out the varying approaches and regulatory requirements being undertaken as this trend continues across the U.S. healthcare system.

Recent state actions

California: On January 1, 2020, the Physician Assistant Practice Act took effect within the jurisdiction of the Medical Board of California. Major points of the act include:

• Requires the Physician Assistant Board to, among other things, make recommendations to the Medical Board of California concerning the formulation of guidelines for the consideration and approval of applications by licensed physicians to supervise PAs
• Requires a practice agreement between a PA and a physician and surgeon to meet specified requirements and would require a practice agreement to establish policies and procedures to identify a physician and surgeon supervising a PA rendering services in a general acute care hospital
• Requires that the practice agreement shall include provisions that address the following:
  
  • The types of medical services a PA is authorized to perform
  • Policies and procedures to ensure adequate supervision of the PA, including, but not limited to, appropriate communication, availability, consultations, and referrals between a physician and surgeon and the PA in the provision of medical services
  • The methods for the continuing evaluation of the competency and qualifications of the PA
  • The furnishing or ordering of drugs or devices by a PA pursuant to Section 3502.1
  • Any additional provisions agreed to by the PA and physician and surgeon

  According to California Senate Bill (SB) 697, “Practice agreement means the writing, developed through collaboration among one or more physicians and surgeons and one or more physician assistants, that defines the medical services the physician assistant is authorized to perform pursuant to Section 3502 and that grants approval for physicians and surgeons on the staff of an organized health care system to supervise one or more physician assistants in the organized health care system. Any reference to a delegation of services agreement relating to physician assistants in any other law shall have the same meaning as a practice agreement” (SB-697, 2019).

  California has also eliminated the requirement that a physician be physically available to the PA for consultation and replaced it with a provision stipulating that availability by telephone or other electronic communication is acceptable. Further, California eliminated requirements for the supervising physician’s review and countersignature for portions of the patient medical records (SB-697, 2019).

  Hawaii: Hawaii's SB 1406, which took effect July 1, 2019, repealed the previous requirement for physicians to review 100% of the medical charts of supervised PAs and replaced it with a much less onerous chart review requirement. PAs with more than one year of professional experience now require no chart review, while PAs with less than six months experience require 50% of their charts to be reviewed and those with six months to one year of experience require 25% chart review.

  Hawaii’s PAs fall under a category designation. Category 1 PAs are those who are newly licensed in Hawaii, have new employment, or started a new practice specialty.

  Category 2 PAs in Hawaii are those PAs who have completed Category 1. Physicians supervising Category 2 PAs are to review and sign 10% of the PA’s medical records within thirty days of the patient visit; or, for at least 30 minutes each month, perform an audit and review and sign medical records.

  On February 22, 2019, Jonathan E. Sobel, president and chair of the board of directors of American Academy of PAs, sent a letter to members of the Hawaii Senate Committee on Commerce, Consumer Protection, and Health as well as the Senate Judiciary Committee. His letter cited a federal report issued December 2018 by the U.S. Departments of Health and Human Services (HHS), Treasury, and Labor titled Reforming America’s Healthcare System Through Choice and Competition. The report warns of the danger inherent in having a board composed entirely of physicians regulating PA practice, stating, “The risk of anti-competitive harm may be even greater when the regulatory board that imposes [scope of practice] restrictions on one occupation is controlled by members of another, overlapping occupation that provides complementary or substitute services, and the board members are themselves active market participants with a financial stake in the outcome” (HHS et al., 2018).

  Illinois: Illinois limited physicians to supervising no more than two PAs and required the supervising physician to be within a "reasonable travel distance" to the PA at all times. In January 2020, revisions to the law (Physician Assistant Practice Act of 1987) permitted physicians to supervise up to seven PAs and no longer imposed any physical geographic proximity requirement on the supervising physician. However, supervising physicians must now be available at all times through telecommunications or other electronic communications.

  The revisions described the association between PAs and physicians as a collaborative relationship rather than supervisory. Previously, physicians could not work with more than five PAs in non-hospital settings. Under the new law, it was clarified that five PAs means five full-time equivalent PAs. This increased the flexibility of providers to staff practices to fit local needs.

  The newly revised Illinois regulations noted a collaborating supervising physician may, but is not required to, delegate prescriptive authority to a PA as part of a written collaborative supervision agreement, and the delegation of prescriptive authority must conform to the requirements of the Act.

  Missouri: Missouri’s revised law became effective in August 2019. Missouri also transitioned from a supervision-based model to a collaboration-based model. The bill, Missouri SB 514, eliminated the requirement that a supervising physician practice at the same facility as the PA for four of every 14 days. The new law also eliminated the requirement that a PA practice at a location where the physician routinely sees patients. While the revised collaborative practice arrangements provide delegated authority to the PA, the term supervision agreement is included in the regulations. The supervision agreement must:

  • Be a written agreement, jointly agreed upon protocols, or standing orders between a supervising physician and a licensed PA that provide for the delegation of healthcare services from a supervising physician to a licensed PA and the review of such services
  • Outline the method and frequency of review of the licensed PA’s practice activities
  • Be reviewed at least annually and revised as the supervising physician and licensed PA deem necessary
  • Be maintained by the supervising physician and licensed PA for a minimum of eight years after the termination of the agreement
  • Be signed and dated by the supervising physician, alternate supervising physician(s), and licensed PA prior to its implementation
  • Contain the mechanisms for input for serious or significant changes to a patient

  In addition to administering and dispensing controlled substances, a PA in Missouri who meets the requirements of 20 CSR 2150-7.130 may be delegated the authority to prescribe controlled substances listed in Schedules II (hydrocodone), III, IV, and V of section 195.017, Missouri Revisor of Statutes (RSMo), in a written supervision agreement, except that the supervision agreement shall not delegate the authority to administer any controlled substances listed in those schedules.

  It is the responsibility of the supervising physician to determine and document the completion of a one-month period of time during which the licensed PA shall practice with a supervising physician continuously present before practicing in a setting where a supervising physician is not continuously present. A one-month period shall consist of a minimum of 100 hours in a consecutive 30-day period (Missouri Secretary of State, 2019).

  Rhode Island: On July 15, 2019, Rhode Island Governor Gina Raimondo signed into law “An Act Relating to Businesses and Professions – Physician Assistants” (H5572/S0443), revising the supervision requirements and expanding aspects of the SOP for PAs in Rhode Island (O’Duffy, 2019).

  This act removed the supervision requirements for PAs, changed the nature of the relationship between PAs and physicians to a collaborative arrangement, and eliminated the requirement that hospitals and other healthcare providers have written PA supervision agreements on file for PAs (Jones Day, 2020).

  Conclusion

  When you look at the PA SOP regulatory requirements in each of the 50 states, as well as the District of Columbia, some offer better practice regulations and more autonomy than others. The question becomes, what have we learned from our experience? What approaches are worthy of replication?

  The shift in regulatory requirements for the clinical practice of PAs from one of physician supervision to one of physician collaboration is unmistakable. One study noted, “International research has demonstrated that PAs perform comparably to physicians on measures of quality and patient satisfaction, make positive contributions to productivity, and, in settings where they have been evaluated, provide cost benefits owing to their ability to substitute for physician services at lower cost” (Bowen et al., 2016).

  At a time when primary care providers are sorely needed, PAs represent a viable cost-effective option for meeting unmet patient care needs. Advanced practice professionals are the only providers other than physicians who can offer primary care services. It is most important that we study the data during this national trend toward increasing autonomy for them. The results can bring our success stories to the forefront, allowing a more informed approach for future refinements and implementation.