For more than a year, physician assistants (PAs) have engaged in a rich dialogue about our future. As chair of the American Academy of PAs' (AAPA) Joint Task Force on the Future of PA Practice Authority, I have had the honor to be at the center of this dialogue. I want to thank everyone who expressed their opinion and shared their thoughts. This article is a precursor to broader discussions at this year's AAPA conference in Las Vegas.
As a PA for more than two decades, I can tell you from my own experience (and data confirm) that fewer physicians own their practices than did 30 years ago.1 NPs have full practice authority in 22 states (Alaska, Arizona, Colorado, Connecticut, Hawaii, Idaho, Iowa, Maryland, Maine, Minnesota, Montana, North Dakota, Nebraska, New Hampshire, New Mexico, Nevada, Oregon, Rhode Island, South Dakota, Vermont, Washington, Wyoming) and the District of Columbia.
The reality is that, as employees, physicians have less incentive to supervise a PA—and differences in legislation have resulted in hiring practices that sometimes favor NPs over PAs.2
In January, an AAPA survey found that 45% of respondents have experienced NPs being hired over PAs; and those who experienced this were almost twice as likely (78% versus 40%) to support eliminating state laws and regulations that require PAs to have and/or report a supervisory, collaborating, or other relationship with a physician.3
Seventy-two percent of survey respondents supported the Joint Task Force's overall proposal, which has four components:
- team-based practice
- elimination of supervisory agreement requirements in law or regulation
- creation of autonomous state PA boards
- PA eligibility for direct reimbursement.
Along with the survey, which sought feedback on these four components, the Joint Task Force held more than 20 conference calls with PAs and PA students nationwide, met with leaders from the Physician Assistant Education Association, National Commission on Certification of Physician Assistants, and the Accreditation Review Commission on Education for the Physician Assistant, and reviewed feedback from hundreds of individual PAs and AAPA constituent organizations.
After reviewing all of the feedback received, the Joint Task Force decided to keep the proposal's basic tenets while better articulating its intent and practical implications. Rather than standalone policy statements, the Joint Task Force has recommended modifications to AAPA's guidelines for state regulation of PAs.4 This will make it easier to translate the policy into model state legislation and allows us to put the recommendations in context.5 Importantly, the guidelines clearly recognize that a state's unique political and healthcare climate may require modification of some provisions, and offer state constituent organizations the freedom to craft and promote alternative provisions.
The final Joint Task Force proposal for optimal team practice emphasizes the profession's desire to continue to work closely in teams with physicians, while relieving PAs, physicians, and employers from requirements to have or report a physician relationship for the PA to practice. The Joint Task Force is not proposing independent practice. We distinguish between that and optimal team practice as follows:
- Independent practice—practice without the benefit of physicians or other providers for collaboration, consultation, referral, or team-based care.
- Optimal team practice—practice with access to physicians and other qualified medical professionals for collaboration, consultation, and referral, as indicated by the patient's condition and the standard of care, and in accordance with the PA's education, training, and experience.
We refined our recommendation on creating a PA board to oversee PA licensing and discipline to reflect concerns raised about the potential cost of such an autonomous state board. The proposal now expresses a strong preference for an autonomous PA-majority board, but also acknowledges that regulation of PAs may be administered by a multidisciplinary healing arts or medical board, with a strong recommendation that PAs and physicians who practice with PAs be full voting members of the board.
Finally, in keeping with the strong support for PAs being directly reimbursed by both public and private payers, the Joint Task Force has recommended that this be included in the guidelines and subsequent version of the model state legislation. This is consistent with AAPA policy (HP 3600.1.1-HP 3600.1.5) but its inclusion in state laws and regulations will help ensure that PA services are billed under the PA's name and NPI number. This will allow PA services to be measured and attributed to PAs in the key databases used by government agencies, employers, and insurers to conduct policy research, assess quality, and set payment policies.
The Joint Task Force remains steadfast in our view, informed by thousands of you, that we must be strong advocates. The incredible growth that this profession has seen in recent years may soon turn into a measured retreat if we do not advocate for what's best for PAs, healthcare, and the millions of patients who depend on us every day.
I am passionate about this topic, and look forward to a comprehensive discussion of the optimal team practice resolution at the conference. AAPA members can obtain a copy of the Report of the Joint Task Force on the Future of PA Practice Authority at http://news-center.aapa.org/wp-content/uploads/sites/2/2017/04/JTF-on-PA-Practice-Authority-FINAL-REPORT.pdf.
1. Kane CK. Updated data on physician practice arrangements: inching toward hospital ownership. AMA Economic and Health Policy Research, July 2015.
2. Pittman P, Masselink L, Bade L, et al. Factors determining medical staff configurations in community health centers: CEO perspectives. J Healthc Manag
3. American Academy of PAs. Full practice authority and responsibility survey report: a report to the Joint Task Force on the Future of PA Practice Authority. https://news-center.aapa.org/fpar
. Accessed March 29, 2017.
4. American Academy of PAs. Guidelines for state regulation of PAs. https://www.aapa.org/wp-content/uploads/2017/02/Guidelines_for_State_-Regulation_of_-PAs.pdf
. Accessed March 29, 2017.