Emily Boyd
Associate Editor
Loyola University Chicago School of Law, JD 2019

Physician Assistants (PAs) have long been recognized as clinicians working under the supervision and guidance of physicians. In recent years, advocacy efforts have shifted to encourage the recognition of PAs as team-based practice clinicians working in collaboration with physicians. State legislation is beginning to reflect those efforts, as one by one, states begin to update the governing rules and regulations. As that future nears, compliance efforts must be able to effectively respond and adjust to these changes in a timely manner. 

The Bureau of Labor Statistics identifies a PA as a person who examines, diagnoses, and treats patients on teams with physicians, surgeons, and other healthcare workers. PAs work in physician offices, hospitals, clinics, and in a variety of other healthcare settings. Licensure is typically dependent on master’s level education, and individual state licensing requirements. As the demand for healthcare services increases, employment projections for PAs predict a forty percent increase in growth from 2016 to 2026 Traditionally, PAs practice under the direct supervision of a licensed “supervising physician.” While the exact definitions vary from state to state, direct supervision is generally satisfied by access to telecommunication and/or a tapered level of supervision with PA tenure.

Advocacy efforts and a push for change

The American Academy of Physician Assistants (AAPA), in its identified effort to “ensure the professional growth, personal excellence and recognition of PAs,” strives to elicit changes in healthcare legislation that they believe will ultimately enhance the ability of PAs to provide quality, cost-effective, and accessible patient-centered healthcare. The AAPA is a strong advocate, even insisting that the term “physician assistant” be eliminated and replaced with “PA.” The AAPA’s “Just say PA” Initiative argues that the use of the word “assistant” does not do justice to the scope of modern PA practice. As an advocacy organization, AAPA endeavors to motivate legislation that broadens the scope of PA practice, while still maintaining PAs as team-based clinicians.

In May 2017, the AAPA adopted its “Optimal Team Practice” policy, which it claims will expand patient access to care and align the PA profession with modern healthcare needs. In the policy, the AAPA advocates for “team practice” between physicians and PAs and the ability for PAs to be directly reimbursed by both public and private payors. This is a departure from the traditional supervisory relationship and billing structure PAs hold with physicians.

AAPA’s “Guidelines for State Regulation”

In its Guidelines for State Regulation, revised in 2017, the AAPA encourages each state to define the regulatory agency responsible for implementation of the law governing PAs. There is a strong preference for separate PA licensing boards, rather than incorporating PAs under medical boards. It is a worthy effort, as there is little consistency between states on the governing body for PA licensure. Only eight states currently have a separate and independent regulatory board, and the codification of rules and regulations varies. Some states have separate PA practice acts, while others have some guidance in administrative code and parts in specific board rules.

With the AAPA’s push for change, the spread of PA scope of practice and supervision or collaboration requirements is increasing and it may prove difficult to remain compliant with disparate and changing rules.

Recent changes at the state level

The advocacy efforts of AAPA are beginning to show results. Illinois Public Act 100-0453, enacted on August 25, 2017, replaced the “supervising” physician relationship and agreements for “collaborative” ones. The state still uses the full title of “physician assistant,” and the PAs scope of practice is determined at the practice site, rather than specific mandates from the board. Under the Act, collaboration with the PA does not require the constant physical presence of the physician, telecommunication consultation is sufficient.

New Mexico House Bill 215, passed on February 19, 2017, does retain the full “physician assistant” title. However, the bill calls for supervision when the PA practices in specialty medicine, and collaboration in primary care practice. Furthermore, a PA’s scope of practice and duties are assigned or delegated by the supervising or collaborating physician rather than dictated by the Medical Board or legislature.

Other gains are even more incremental. Michigan Public Act 379, effective March 22, 2017, uses the term “physician’s assistant,” which is even less preferred than “physician assistant” because of its implication of subservience. Michigan is also the only state in which PAs work in accordance to a practice agreement with a “participating physician.” The term defies both the traditional supervisory role and the newly advocated-for collaborative role.

These recent examples of changing PA legislation illustrate that the AAPA’s efforts may be influencing state legislators to revise the rules and regulations governing PA practice. Presently, no state has fully implemented the Guidelines for State Regulation. However, the AAPA’s efforts are growing, and the Guidelines are being updated with increasing regularity—7 times since 2005.

Compliance in the face of change

Practitioners, and any entity employing PAs, must remain cognizant of the changing face of PA scope of practice and the medical authority. Policies and procedures must be updated to accurately reflect the physician-PA relationship, as well as the PA scope of practice. Supervising/collaborating (and participating) physicians must be provided additional training and education, to ensure that all clinicians are working to the top of their license. With more authority in clinical practice, PAs will need oversight by both the supervising/collaborating/participating physician, as well as the compliance department and officer. If PAs are converted into directly reimbursable providers, compliance efforts must go even further into the billing and reimbursement practices of the employer/entity. Financial auditing and monitoring will also need increased attention with a new reimbursable provider type.

It appears as if change is inevitable, and compliance efforts are especially susceptible to missteps as states gradually elect to incorporate none, some, or all of the AAPA recommendations. As the rules and regulations governing PAs evolve, so too must the compliance efforts of the organizations and physicians employing them.