Are You a Team Leader?

November 15, 2013

There is a direct correlation between laws governing physician assistant scope of practice and their effectiveness as part of the care team.

There is a direct correlation between the regulations and laws governing physician assistant (PA) practice in a state, and the utility of PAs in the modern healthcare system. Essentially, the more the relationship between a physician and a PA is determined at the practice level, the more effective and efficient the care delivered by that team is.

Part of the fall out of the Affordable Care Act (ACA) is the political reality of the dearth of providers available to treat the millions who will suddenly have health insurance, especially in rural and medically underserved areas. Attracting providers such as PAs has been difficult in states like Kentucky, which has significant regions that are rural and medically underserved or even un-served. Recently, Kentucky made a big step forward in relaxing the rules governing PA practice in the state.

In March of 2013, the Kentucky Medical Association and Kentucky Academy of Physician Assistants (KAPA) worked with the state legislature to pass a bill that phased out the requirement for 18 months of direct onsite supervision of new graduate PAs. The next restrictive state is Colorado, with a requirement for 1,000 hours of direct physician supervision for new graduate PAs. These sorts of rules and regulations, with no evidence of enhancement of patient safety, interfere with the development of rational, practice- based relationships between and among physician-PA teams.

This rule has had a profound effect on the supply of PAs in Kentucky. Over 50 percent of PAs trained in Kentucky have left the state to practice in more "PA friendly" states, according to KAPA. This is a stunning loss of providers who are desperately needed to provide patient care especially to rural patients. Not to mention the indirect loss of funding and other resources needed to train healthcare providers who will work in the state.

PAs are a well trained and highly mobile workforce, and the demand for physicians, PAs, and other providers is causing a rethinking on how teams are governed in nearly every state struggling with the fallout of the ACA. The American Academy of Physician Assistants has identified six key elements for truly effective PA practice, and you can see where your state ranks by looking at this map.

Another hurdle facing PAs in Kentucky mentioned in this news story is the requirement that a physician cosign 100 percent of the charts of patients cared for by PAs. This issue is something PAs face in many states. While at face value this provides a "paper trail" documenting oversight, this requirement can increase the administrative workload of already overworked physicians, and take them away from direct patient care.

I'm happy to say that one fallout of the push toward electronic health records, is the ability of physician-PA teams to dispense with this type of administrative overhead with a couple of clicks of a mouse. However, this is not true for the significant percentage of practices that still rely on paper records. Work needs to be done on both ends - making sure that the relationship between physician-PA teams is supported and enhanced, and unnecessary, ill-advised, and overly burdensome rules and regulations are changed to make teams more efficient, safer, and focused on patient care.

I feel blessed to have practiced my entire career in California, which has a good track record of ensuring that physician-PA teams have a supportive regulatory environment. PAs from all over the nation migrate to states like California to practice because the medical associations and state and national PA organizations work together as closely at the legislative level as they do at the clinical level.

We still have a long way to go to enhance the effectiveness and efficiency of these teams in many state jurisdictions across the United States. Let's all work together to keep the regulation of teams of physicians, PAs, and other providers rational and reasonable.