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Loosening restrictions on the scope of practice for PAs

Adams, E. Kathleen PhD; Markowitz, Sara PhD

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Journal of the American Academy of Physician Assistants: January 2019 - Volume 32 - Issue 1 - p 8-9
doi: 10.1097/01.JAA.0000550294.83595.b4
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The media recently has raised awareness about the need for increased capacity in the US healthcare system as financially stressed hospitals in rural areas close and healthcare providers' employment levels fall with hospital closures.1 As noted in a commentary in this journal, physician assistants (PAs) could begin to fill gaps in access to primary care for pregnant women and could help ease the current public health crisis of maternal mortality.2,3


As the nation continues to deal with escalating and perhaps unsustainable healthcare costs and federal deficits, making the healthcare system more efficient becomes critical. A recent Hamilton Project report highlights that restrictions on scope of practice for PAs and other clinicians generally reduces flexibility in staffing in healthcare markets. This in turn leads to reduced capacity and higher administrative and other healthcare costs.4 The report calls for loosening restrictions on PAs and advanced practice RNs (APRNs) as a means of addressing healthcare costs through increased productivity.

PAs in particular could reduce capacity constraints. Their shorter length of training means that PAs can respond more quickly to changes in the demand for their services. The growth in the supply of PAs between 2016 and 2026 is projected to exceed that of NPs and indeed, all diagnosing and health-treating practitioners.5 This is important because of ongoing concerns about an inadequate supply of primary care providers. Maximizing PAs' incorporation into the healthcare system is important because they help expand access to healthcare as they work with physician practices, federally qualified health centers and other safety net clinics, hospitals, and other employers.

States unnecessarily limit incorporation of PAs into these practice settings through legal restrictions on their scope of practice. Although states have generally moved to reduce restrictions, southeastern states in particular have lagged behind in loosening restrictions on PAs and APRNs. Ironically, these states have greater healthcare needs because they have higher numbers of uninsured patients, poor patients, and patients with poor health status.6 The choice of these same states not to expand Medicaid under the Affordable Care Act (ACA) has increased financial pressure on their hospitals and increased closure rates.7

The relative restrictiveness of PA scope of practice varies by state and even within states if it is set at the practice level. The least restrictive environment for PAs is one of optimal team practice, which the American Academy of PAs defines as “Practice with access to physicians and other qualified medical professionals for collaboration, consultation, and referral, as indicated by the patient's condition and consistent with the standard of care, and in accordance with the PA's education, training, and experience.” Requiring PAs to have an agreement with a specific physician as a condition of practice imposes an additional restriction on scope of practice that should be eliminated.


Research clearly indicates that reducing scope of practice restrictions on PAs and APRNs leads to lower costs without any discernable negative effects on healthcare outcomes.4 This finding is important to convey to legislators when they are asked to consider changes to scope of practice laws. In turn, as PA organizations become more aware of the arguments for eliminating burdensome scope of practice laws, advocacy organizations must identify the relevant policy issues facing federal and state officials. At the state level, public health infrastructure, access to healthcare, and health status of residents in both urban and especially rural areas should enter into the discussion. At the federal level, fee schedule policies directly affect the discussion—the incident to billing under Medicare allows services provided by PAs and APRNs to be billed under the physicians' identifications. This makes monitoring and analyzing the use and outcomes of PAs and APRNs difficult because the data for these providers are largely unobserved for Medicare and most commercial plans. This reduces researchers' ability to understand how accountable care organizations and other innovations in payment and service delivery alter the mix of labor and potentially improve efficiency in the system.


1. Healy J. It's 4 a.m. The baby's coming. But the hospital is 100 miles away. New York Times, July 17, 2018.
2. Ritsema TS, Klingler AM. Can PAs help address the pressing public health problem of rising maternal mortality. JAAPA. 2018;31(6):11–12.
3. MacDorman MF, Declercq E, Cabral H, Morton C. Recent increases in the U.S. maternal mortality rate: disentangling trends from measurement issues. Obstet Gynecol. 2016;128(3):447–455.
4. Adams EK, Markowitz S. Improving efficiency in the health-care system: removing anticompetitive barriers for advanced practice registered nurses and physician assistants. Policy Proposal. 2018;8. Accessed October 17, 2018.
5. US Department of Labor. Bureau of Labor Statistics. Employment projections program. Washington, DC. 2017. Accessed October 17, 2018.
6. Artiga S, Damico A. Health and Health Coverage in the South: A Data Update. Kaiser Commission on Medicaid and the Uninsured, February 2016. Accessed October 17, 2018.
7. Lindrooth RC, Perraillon MC, Hardy RY, Tung GJ. Understanding the relationship between Medicaid expansions and hospital closures. Health Aff (Millwood). 2018;37(1):111–120.
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