Stephen Hanson, PA-C

s blog features contributions from members of the medical community. These blogs are an opportunity for professionals to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions are that of the writers and do not necessarily reflect the opinions of 

Having worked for many years as a PA, my experience in emergency medicine, urgent care, and surgery has put me on the front lines of acute and chronic pain treatment. Like all providers, I struggle to balance adequate pain control against potential patient addiction to pain medications. I am reminded daily of the inadequate resources available to effectively treat pain and the potential side effects of opioids and other pain medications.

Every day over 60 Americans die from an opioid-related overdose

. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), in 2014, nearly 2 million Americans were addicted to prescription painkillers and nearly 600,000 people were addicted to heroin. Unfortunately, treatment programs offering assistance with things like medication, proven to increase patient survival and program retention, have no where near enough capacity to treat all of these people suffering from substance abuse.

We who are on the front lines of patient care all too often deal with the problem of addicted patients or patients in chronic pain by referring them to pain management specialists. These patients consume an inordinate amount of time-time that harried providers don’t have. Chronic pain and addiction are just two of many problems these patients suffer from. The only effective solution is one that is comprehensive and addresses a patient’s physical, psychological, and emotional problems in an all-encompassing approach. This vision of addiction and chronic pain care is a pipe dream in this era of such limited resources. Time is not the only limiting factor. The lack of medical treatment for addiction, outpatient treatment programs, and providers who can prescribe addiction medication are all limited. 

Federal, state, and local government agencies must work together to provide the multi-disciplinary resources needed to effectively support physicians, PAs, and other providers in better treating addiction and chronic pain, or real progress will not be made. 

I realize that PAs represent just one piece of a very complex puzzle, but effective deployment of PAs can help to address the addiction and chronic pain problem by taking these national, state, and local policy steps:

1. Continue to streamline legislation that allows PAs and other providers to prescribe buprenorphine for the treatment of opioid addiction. Legislation signed by President Obama in 2016 enabled PAs and NPs-after completing appropriate training-to apply for waivers to prescribe buprenorphine until 2021. Two years later, after a lot of legislative wrangling, Congress is poised to pass a bill that will make the waiver provision permanent. Removing the 2021 end date will eliminate one barrier to the critical shortage of healthcare providers who are willing and able to provide medication-assisted treatment for patients with opioid use disorder. But it would have been a lot simpler and efficient if the original law had done that.

2. Support legislation that increases access to treatment for opioid addiction and strengthen provider training in the areas of pain management, safe prescribing practices, and treatment of patients who are struggling with drug addiction.

PAs are committed to serving our patients, who give purpose to our lives. Like all providers, we do best when we can make a meaningful difference. We need more research, better medications, expansion of treatment programs, and access to tools that can effectively address the problem of chronic pain and addiction. From a societal standpoint, if we are not part of a comprehensive solution, we are a part of an intractable problem.

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This vision of addiction and chronic pain care is a pipe dream in this era of such limited resources.

More resources, support needed to address addiction and chronic pain

I have been concerned with the maldistribution of rural health provider assets for decades. The situation is dire. The sad reality is that the number of physicians practicing in rural and medically underserved areas has been declining for decades. The reasons for this are complex. Practice in these areas is challenging from financial and quality of life perspectives. Many clinicians I know choose to work in metropolitan areas to find a “better life,” more opportunities, and more professional support.

The PAs I know who practice in rural and medically underserved areas tell me how much they love their work and their patients. They also express concerns about the isolation and the fatigue that comes with being the only provider in a small community with little professional support. It takes a special kind of clinician to work in this environment.

, the National Rural Health Association (NRHA) recognized the substantial resource that PAs represent in solving the crisis of rural healthcare and outlined steps to better utilize PAs to do so.  

Approximately 15 percent of PAs practicing in 2017 (17,280 out of 115,200 total) practiced in rural or frontier counties, as opposed to 11 percent of practicing physicians. The NRHA also found that at least in Iowa, Texas, California, and Washington state, PAs practiced in rural areas in higher percentages than other providers.

PAs are uniquely qualified to fill an expanded healthcare role in rural and medically underserved areas due to their broad generalist education and a 50-year track record demonstrating competence and skill. One issue that stands in the way of PAs practicing at the top of their experience and training is overly restrictive state laws and regulations governing PA practice. The NRHA recommends, in addition to changing state laws, that scope of practice for PAs be determined at the practice level by the teams they work with.

The NRHA policy brief supports the tenets found in the 

American Academy of PAs’ Optimal Team Practice (OTP) policy

Emphasize PAs’ commitment to team practice;

Authorize PAs to practice without an agreement with a specific physician-enabling practice-level decisions about collaboration;

Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and

Authorize PAs to be paid directly by all public and private insurers.

The simple fact of the matter is that physicians who work in rural areas need PAs to practice to the full extent of their training and experience. It is a quality of life issue, and PAs have shown over their long history to be competent, safe, and efficient providers in rural and all other areas of medicine and surgery. PAs have also shown since the inception of the PA profession to be part of solution and not part of the problem when it comes to healthcare delivery.

I have lived in a lot of rural areas in my life, and I have practiced in medically underserved areas. Some of the reasons that physicians and PAs choose rural practice are obvious-the outdoors, clean air, simple living, low crime, low traffic, and other characteristics of rural areas appeal to folks looking for a better, simpler life. The reasons that some folks choose not to live in more isolated areas are a lack of professional support, a lack of resources, fewer opportunities for relationships, and fewer cultural amenities, among other barriers.

I have thought a lot about this problem from a policy standpoint. If we want clinicians to consider rural practice, we have to reduce some of the barriers and incentivize people to work there. It would also be helpful to remove some of rules and regulations that get in the way of team practice of medicine and the practice of medicine in general.I’ve already mentioned OTP, which would help PAs in rural practice, but things like easier implementation of telemedicine would make rural practice much more appealing by increasing providers access to specialty care in remote areas. Tax credits and loan forgiveness for physicians and PAs who commit to rural practice are other possible incentives.

This is a massive problem that will only get worse as the rural population ages and the ratio of rural patients to physicians and PAs gets more upside down. Reversing this trend will require a comprehensive policy solution that includes PAs front and center in ensuring that rural Americans have access to quality, affordable healthcare.

Since the inception of the PA profession, PAs have been shown to be part of solution when it comes to healthcare delivery. Physicians who work in rural areas need PAs to practice to the full extent of their training and experience.

Physician assistants improve healthcare in rural areas

’s blog features contributions from members of the medical community. These blogs are an opportunity for professionals to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions are that of the writers and do not necessarily reflect the opinions of 

The dream of every provider is to have an EHR that is easy and fast to use, creates an accurate record, and gives the provider access to all the patient’s previous health and diagnostic data in real time. We are not there yet.

While nearly every organization and facility has a least a rudimentary EHR, we are far from the point where I, the patient’s provider, can gather needed information from one place to safely and efficiently develop a treatment plan and prescribe necessary medications and care with confidence. All too often in the hospital environment in which I work, we get snippets of information and have to rely on the patient to give us an accurate picture of past care.  

This leads to a fragmentation of care at best, and medical errors at worst, all of which can harm the patient. Part of the problem is “interoperability” of EHRs, or, rather, the lack thereof. This is too complex a problem to deal with in this blog, but suffice it to say that with at least 16 big vendors nationwide developing their product in a “silo,” there is no real interest or incentive for these organization to talk to each other in any meaningful way. It is a significant road block to what providers need the care for patients. But there is hope.

, a meaningful, real-time connection has been achieved at the ED level so that patient health plans, patient registries, and patient prescribing data are on a single network. This is the first state to accomplish this. They are able to avoid repeated and unnecessary diagnostic testing and prescribing, and they have access to patient information at a higher level of confidence than patient memory or paper records.

Virginia aims to expand this network to include other downstream providers, including primary care physicians, case managers, nursing homes, private behavioral health providers, and Federally Qualified Health Centers, who will have the ability to use the technology to receive alerts and contribute to patients' care guidelines.

I believe Virginia is on the cutting edge of EHR change and advancement. Other entities, organizations, and states will get with the program and implement systems such as this. You would think that with so much digital data available, it would be easy, right? This has not been the case as EHR vendors have developed proprietary systems, so they protect their data and technology as they have much time, energy, and money invested in their product.

The interoperability of the EHR is a critical public health matter, and the government should have a more active role in mandating that folks work together, in my opinion. There is an interoperability “road map,” and strategic plan at 

. But it is unclear what is the current role of the government in getting all players together to get on the same page by 2020.

For now, when I see patients and consults from outside of my facility, I have access to electronic patient data and diagnostics only if they were seen within my hospital system. While this does cover a broad geographic area, there are manyfacilities gathering digital patient information in the same area. My system can’t “talk” to their system, so I am forced to rely on phone calls, faxes, hand carried diagnostic data on digital media, and hand-carried paper to develop an effective and real-time treatment plan for the patients under the care of our team. So much of our time is consumed by this process, and I believe that it results in a high level of frustration, leading to a significant reduction of quality of life for all health care providers.

In California, we have a long way to go to follow the path being blazed in Virginia. It is everyone’s goal to get there. In the past ten years, we have come so far with the EHR, and these systems have improved patient care and reduced errors. To be fair, they have also created a new source of medical errors, of which I have written in the past. The potential for the EHR far outweighs the risks and challenges. It is such a monumental project and will lead to a fundamental change in the delivery of healthcare in the U.S. and the world. It is worth doing, and worth doing right.

We are far from the point where providers can gather needed information from one place to safely and efficiently develop a treatment plan. But there is hope. 

The promise of the EHR 

As a long time physician assistant, I have had the privilege of watching firsthand the evolution of the PA profession. From four Navy corpsmen, trained in 1967 to help address the looming shortage of physicians in America, to the present day count of around 123,000 PAs, the profession now works in every specialty, subspecialty, and health care setting you can imagine.

I would have never predicted the present day growth and diversity of the PA profession when I started in 1981. Part of that growth, and what represents a big step forward, took place in May 2017, when the PA profession adopted policy on a broad vision of the profession’s future, called “Optimal Team Practice” (OTP).

Optimal Team Practice calls for laws and regulations that:

• Emphasize PA commitment to team practice;

• Authorize PAs to practice without an agreement with a specific physician-enabling practice level decisions about collaboration;

• Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and

• Authorize PAs to be directly reimbursed by all public and private insurers.

As the American Academy of PAs (AAPA) liaison to the American Medical Association, I have witnessed confusion about this policy and its evolution. I and members of the leadership and staff of the AAPA continue to work hard to address common misperceptions about what this policy means for the PA role.

PAs are committed to working with our physician partners to address concerns and renew our commitment to the team practice of medicine. I’ve included a list below of six things PAs want physicians to know about the new policy.

PAs value a sustained partnership with physicians, have great respect for the depth of physician training, and rely on the PA-physician team in clinical practice. Indeed, the profession is deeply committed to team practice. PAs simply want to remove the requirement for a PA to have an agreement with a specific physician in order to practice. This also removes physician liability for the care that PAs provide and reduces physician risk of disciplinary action for administrative reasons unrelated to patient care outcomes. This makes perfect sense if you look at the change in the practice of medicine over the past 50 years. Working arrangements of physicians and PAs have evolved, and the tradition of a PA being employed by a physician is no longer the norm.

The PA role is well established. PAs will continue to be legally and ethically obligated to consult with and refer patients to physicians based on the patient’s condition, the standard of care, and the PA’s education and experience. This is how I practice day-to-day right now with my surgeon partner. Our relationship and trust have evolved to the point where he knows that I will care for patients in the same manner as he would and knows that I will consult with any questions. This collaboration should be determined at the practice/team level.

3. PAs want to strengthen health care teams.

Optimal Team Practice will make health care teams stronger by reducing administrative burdens and enabling practice-level decision making. State laws should not dictate to physicians how many PAs they may collaborate with or which charts must be co-signed. Those decisions should be made at the practice level where the care is being provided.

4. PAs want to have meaningful input into the regulation of their profession.

PAs want what physicians and nurses already have: regulatory boards that have current knowledge of their profession. Whether that requires a separate PA board-or just the addition of PAs and physicians who work with PAs as members of a medical or healing arts board-this should be determined on a state-by-state basis. In California, we already have a PA board, as do a handful of other states. But in most states, PAs are regulated by the medical boards, the minority of which have PAs as members. Why should PAs be the only health care profession in the nation to not govern and discipline members of their own profession?

5. PAs want a level playing field with nurse practitioners.

In a 2017 survey, 45 percent of PAs said they have personally experienced NPs being hired over PAs due to the administrative burdens imposed on employers and physicians requiring that PAs have an agreement with a specific physician.

PAs want to remain viable in the changing health care marketplace.

Unlike physicians and advance practice nurses, PAs are not eligible for direct reimbursement under Medicare. This means that PAs cannot work with certain staffing companies or in some corporate medical structures because PAs cannot reassign their insurance payment to their employers. This puts PAs at a disadvantage in the health care marketplace.

In many ways, when you look at the way in which long time, experienced PAs like me practice, our team already is committed to the concepts of OTP. When you actually look at what OTP means for PAs, physicians, and the health care system, it makes sense for physicians and others to support OTP. Patient care, safety, and quality of life for all members of the heath care team can be expected to improve with this new policy.



Stephen Hanson, MPA, PA-C, practices in general surgery as well as plastic and reconstructive surgery in Bakersfield, Calif.  He is a past president and speaker of the American Academy of Physician Assistants.

The Optimal Team Practice policy defines the evolution of the PA profession. Here are things every doctor should know about these laws and regulations.