Center for the Future of the Health Professions March 2024 digest
Posted: March 13, 2024
Welcome to the March 2024 op-ed column of the Center for the Future of the Health Professions Digest! Our goal is to provide reliable information and research on the healthcare workforce, helping policymakers and health system stakeholders plan for a sustainable future. This month, we will delve into the physician assistant/associate (PA) profession, which has become an essential component of the American healthcare system in the last 50 years. Currently, there are more than 168,000 PAs across the United States practicing in various specialties and settings. PAs engage in over 500 million patient interactions yearly, showcasing their significant impact. The PA profession consistently ranks among the top healthcare jobs in the U.S. News & World Report. Various studies highlight how PAs enhance healthcare quality and cost efficiency. Given the ever-evolving healthcare landscape, it is valuable to explore the future trajectory of the PA profession.
This article is a compilation of information written by me and two consummate PA educators. The first is Albert F. “Bert” Simon, DHSc, PA-C Emeritus. Dr. Simon is the associate director of the Doctor of Medical Science (DMSc) program at A.T. Still University-Arizona School of Health Sciences (ATSU-ASHS). In 2005, Dr. Simon joined A.T. Still University’s PA program as chair and program director. He later served as the associate dean for Evaluation and Quality Innovation at A.T. Still University’s School of Osteopathic Medicine in Arizona (ATSU-SOMA) from 2006 to 2008 and then as vice dean from 2008 to 2012. In 2012, Dr. Simon returned to ATSU-ASHS as chair and director of the Department of Physician Studies and director of the PA program. In 2019, he took on the role of associate director of the DMSc program, which he designed as a professional doctorate option for PAs. He has authored and co-authored numerous articles and chapters for various journals and publications and served as a co-editor for Appleton and Lange’s Q&A for the Physician Assistant.
Next is Melinda Rawcliffe, DMSc, PA-C. Dr. Rawcliffe is an experienced and highly respected medical professional with more than 16 years of dedicated service as a PA. Throughout her career she has worked tirelessly to improve healthcare access for marginalized populations. Her leadership roles, including her past presidency of the Arizona State Association of Physician Assistants (ASAPA), advisory positions to the ASAPA Board, and chief delegate to the American Academy of Physician Associates (AAPA) House of Delegates, demonstrate her commitment to this cause. Currently, she plays a crucial role on the AAPA Government Relations and Practice Advancement Commission, influencing the PA profession’s future. Additionally, Dr. Rawcliffe serves as an assistant professor and interim director of for Franklin Pierce University’s Hybrid PA program, as well as an adjunct professor for A.T. Still University’s DMSc program. Beyond her academic endeavors, she actively contributes to disaster relief efforts, deploying with the Federal National Disaster Management Services’ AZ-1 DMAT team. Furthermore, she leads the Phoenix chapter of the Flying Samaritans, providing healthcare in remote areas of Baja California Sur, Mexico.
We invite you to share your thoughts on this month’s digest.
Randy Danielsen, PhD, DHL(h), PA-C Emeritus, DFAAPA
Professor and Director
The Center for the Future of the Health Professions
A.T. Still University
Independence v. interdependence: The PA conundrum
After more than 50 years, the physician associate/assistant (PA) profession has solidified its crucial role in the American healthcare system. There are over 168,000 PAs in the United States working in various specialties and practice locations with PAs providing more than 500 million patient interactions per year. There are 306 PA programs nationwide with new applications for additional programs made each year. In addition, the PA profession continues to be listed in the top best healthcare jobs list by the U.S. News & World Report.1 Research consistently shows PAs continue to improve the quality and cost-effectiveness of healthcare.2 PAs are working to meet the challenges of increased demand for healthcare services fueled by an aging population and the implementation of healthcare reform.
Recent data from the Association of American Medical Colleges (AAMC) highlights a projected shortage of 139,000 physicians in the United States by 2033.3 To bridge this gap, PAs are vital in providing high-quality and cost-effective care. The employment outlook for PAs is promising, with a projected 31% increase by 2029.4 Professional association leaders, regulators, and state legislators continue to recognize the need to reform PA state regulations to align with workforce needs and the changing healthcare landscape. PAs are increasingly taking on responsibilities for medically complex patients with chronic conditions. The legislation governing PA practice needs to mature to match these changes with updates of professional practice.
The controversy surrounding the expanded role of PAs, particularly their dependent relationships with physicians, remains a persistent issue. In May 2017, the American Academy of Physician Associates (AAPA) House of Delegates passed an Optimal Team Practice (OTP) policy. This policy encourages state chapters to advocate for changes in state laws eliminating the legal requirement for PAs to maintain a specific collaborating physician relationship to practice. A number of states have already achieved success in implementing these changes.5 For example, Utah implemented a law in 2021 granting PAs the authority to deliver medical services within their expertise and competency. The bill outlined collaboration requirements for PAs with less than 10,000 hours of practice experience to address concerns raised by various stakeholder groups.6 Additionally, the legislation mandated that PAs collaborate with the appropriate healthcare team member based on the patient’s condition, the PA’s education, experience, competencies, and the applicable standard of care.
In a significant move in 2020, Minnesota transitioned from the term “supervision” to “collaboration” to define a PAs practice. This groundbreaking legislation eliminated the need for PAs with over 2,080 practice hours to have formal agreements with physicians. It also removed any references to delegation, the responsibility for care, and delegated prescriptive authority. Instead, PAs are now authorized to prescribe medications based on their qualifications.7 Recently, Arizona passed a law allowing licensed PAs with at least 8,000 clinical hours and certification from the regulatory board to work without supervision. This legislation also changes the requirements for supervision agreements between PAs and their supervising physicians or employers. Previously, PAs were only allowed to perform delegated healthcare tasks from their supervising physician. However, under the new legislation, PAs can provide any legal or medical service they have been educated, trained, and experienced in and are competent to perform. This includes tasks previously outlined in the statute. The law no longer requires specific delegation from a supervising physician for healthcare tasks. However, a supervision agreement that outlines the PA’s scope of practice and prescribing authority is still necessary.8
Physician groups continue to advocate for the formal supervision of PAs, opposing the independent or autonomous practice of PAs. Some physicians view the increasing number of PAs as potentially threatening their profession. The American Medical Association (AMA) strongly opposes legislation allowing PAs to practice medicine independently. They argue physicians must retain the ultimate responsibility for coordinating and managing patient care while incorporating the input of PAs to ensure healthcare quality. The AMA also opposes legislative efforts to establish separate regulatory boards for licensing, regulating, and disciplining physician assistants outside the authority of existing state medical licensing and regulatory bodies.9 The American Osteopathic Association (AOA) also argues PAs must maintain a formal regulated relationship with a specific physician.10
The physician/PA relationship has long been described as a relationship of dependence or interdependence. This means clinicians rely on each other for support and collaboration. State laws often dictate the specifics of this relationship, emphasizing its importance. Since physicians established the PA profession, it is not surprising this relationship has been valued and maintained for so many years. Many PAs believe this relationship should continue and oppose any changes in state legislation. However, in the past few decades, the requirement for a designated supervising physician has become a significant obstacle for PAs. This has resulted in limited job opportunities and a shrinking job market despite the increasing demand for PAs. As a result, potential employers have found hiring nurse practitioners more accessible due to fewer bureaucratic hurdles. Subsequently, to the authors of this article, the problem is not the interdependence relationship but somewhat archaic state rules and regulations.
Allowing PAs to deliver patient care and loosening strict laws and regulations while still prioritizing patient safety is crucial for meeting the demands of patients and the U.S. healthcare system. A study conducted by DePalma and colleagues analyzed data from 2010 to 2019 to evaluate whether states with more flexible PA scope of practice laws had higher rates of medical malpractice payment reports, which are indicators of patient harm. The findings of this study indicate that easing restrictive laws and regulations on PA practice does not raise the overall risks to patients or lead to higher malpractice rates in the U.S. healthcare system.11
Healthcare in this country has undergone significant changes in the past 50 years. Regardless, PAs will continue to work together, seek advice from, and refer patients to other healthcare providers, particularly their physician colleagues, when their condition exceeds their education, training, and experience. Some argue it is time for the profession to take ownership of their role and strive for autonomy. Is that too much to ask? Autonomy implies independence and self-governance, but it is essential to acknowledge that in today’s healthcare landscape, “independent practice” does not exist within team care. With the support of their professional associations, PAs are determined to modernize their state legislation nationwide. According this article’s authors, the PA profession should have acted on the valuable contributions a collaborative effort between physicians and PAs could bring to the table to resolve this issue. The expression “the train has left the station” is frequently used when this matter comes up. However, the main focus of this discussion is indeed patient access to healthcare, quality of healthcare, and practitioner competence. In that case, there may still be an opportunity for a unified solution.
According to the book “(P)luck: Lessons We Learned for Improving Healthcare and the World” by Alfred and Blair Sadler, significant progress can only be achieved when individuals and organizations join forces and pool their resources and abilities toward a shared objective. Successful partnerships involve mutual support, combining complementary skills, leveraging unique resources, and embracing diverse perspectives. Unfortunately, collective efforts are frequently hindered by ego clashes, territorial behavior, or conflicting ideologies. Does that sound familiar? The Sadlers contend that a highly efficient and interdependent medical team is an excellent example of collaboration. Is it too much to expect this level of collaboration?12
In light of projected shortages, the time has come for healthcare professionals, association leaders, and stakeholders to convene and collectively determine the most optimal healthcare model for the citizens of this country. A healthcare system allowing all providers to work at the top of their license is a true team environment.
References
- Information Graphic, January 2024, published by the American Academy of Physician Associates (AAPA) accessed at https://www.aapa.org/download/80021/
- Laurant M, Harmsen M, Wollersheim H, Grol R, Faber M, Sibbald B. The impact of nonphysician clinicians: do they improve the quality and cost-effectiveness of health care services? Med Care Res Rev. 2009;66:36S-89S.
- Kidd, Vasco Deon DHSc, MPH, MS, PA-C; Cawley, James F. MPH, PA-C, DHL (hon); Cloutier, Dagan MS, PA-C; Tankersley, Dennis DMSc, PA-C. Optimal Team Practice: The Way Forward. JBJS Journal of Orthopaedics for Physician Assistants 7(2):p e0010, April-June 2019. | DOI: 10.2106/JBJS.JOPA.19.00010
- AAMC, U.S. physician shortage growing, 2023 accessed at https://www.aamc.org/news/us-physician-shortage-growing#:~:text=A%20new%20AAMC%20study%20projects,older%20patients%20and%20retiring%20doctors.
- Occupational Outlook Handbook, 2023 Accessed at https://www.bls.gov/ooh/healthcare/physician-assistants.htm
- Utah PAs Celebrate Enactment of Major PA Modernization Legislation, AAPA News Central found at https://www.aapa.org/news-central/2021/03/utah-pas-celebrate-enactment-of-major-pa-modernization-legislation/
- PA State Chapters Persevere in 2020 to Achieve Improvements for Profession in News Central, AAPA found at https://www.aapa.org/news-central/2021/01/pa-state-chapters-persevere-in-2020-to-achieve-improvements-for-profession/
- Arizona Medical Board, Letter to Arizona PAs, found at https://azmd.gov/Misc/HB2043/pa-practice-act-hb2043#:~:text=The%20new%20legislation%20allows%20for,Board%20to%20work%20without%20supervision.
- Keeping politics out of the exam room: Protecting the patient-physician relationship, AMA Advocacy Resource Center, accessed at https://www.ama-assn.org/system/files/protecting-patient-physician-relationship-issue-brief.pdf
- AOA News Release. AOA statement on physician-led care, Physician Assistant title change, and nonphysician clinician use of the title ‘Doctor’ accessed at https://osteopathic.org/2021/05/28/aoa-statement-on-physician-led-care-physician-assistant-title-change-and-non-physician-clinician-use-of-the-title-doctor/
- DePalma SM, DePalma M, Kolhoff S, Smith NE. Medical Malpractice Payment Reports of Physician Assistants/Associates Related to State Practice Laws and Regulations. J Med Regul. 2023;109(4):27-37. doi:10.30770/2572-1852-109.4.27.
- Sadler S, Sadler B. (P)luck: Lessons We Learned for Improving Healthcare and the World. Silicon Valley Press; 2023.