SALT LAKE CITY — As Utah and the entire nation grapple with a health and mental health care shortage in rural and underserved communities, one group of medical providers say they’re uniquely poised to respond — physician assistants.
But they contend antiquated laws requiring them to work under the supervision of a physician are holding them back.
Often confused with nurse practitioners, P.A.s get trained in general medicine while nurse practitioners receive training for a specific health care focus like pediatrics or women’s health.
A P.A.’s training lasts about three years and includes 2,000 hours of clinical rotations, according to the American Academy of Physician Assistants. They can diagnose and treat illnesses, prescribe medication, conduct physical exams and perform many of the other tasks of general practice physicians. Most states, including Utah, require them to work under a physician and get paid through a physician rather than directly from the patient’s private or public insurance.
Recently, several states have either passed or are weighing laws to broaden physician assistants’ scope as the pandemic has exacerbated health care shortages. In 2019, North Dakota became the first state to eliminate the physician supervision requirement.
But efforts to do so have come up against staunch opposition from members of the physician community spearheaded by groups like the American Medical Association, which says that expanding the scope of P.A.s threatens patient safety because the assistants don’t have as much education and training.
National leaders are also taking measures to reduce barriers for P.A.s to practice. Under the latest coronavirus relief bill signed late in December, P.A.s for the first time can get paid directly for services rendered to Medicare patients — a change that will remain in place permanently beginning January 2022, according to the Academy of American Physician Assistants.
Addressing a shortage
Two bills that would broaden the abilities of P.A.s are being proposed this upcoming legislative session in Utah: SB27 would allow them to work independently of a physician, while SB28 would add them to the state’s Mental Health Professional Practice Act and allow them to independently offer mental health care if they receive certain training and experience.
“When you look at COVID, it has been a real challenge for everyone throughout the world, but it’s given us a new chance to look at different ways to deliver goods and services,” said Sen. Curt Bramble, R-Provo, sponsor of SB27 and SB28.
The state needs more accessible health care, he said, and “these bills go in that direction.”
“For the most part today, when you go into a doctor who has a practicing P.A. with him, you may not see the doctor at all. The only one you may be interacting with is the P.A.,” Bramble said.
Current law limits physician assistants with “a layer of bureaucracy,” he said.
“This has been the trend. Nurse practitioners historically have been overseen by doctors. They gained autonomy in their practice several years ago. And when you look at the data of outcomes, you look at pain clinics and you look, across the board, you’ll see that nurse practitioners, they don’t have a higher incidence of misdiagnoses or malpractice or other things, and we expect the same thing with P.A.s,” Bramble said.
Tim McCreary, president of the Utah Academy of Physician Assistants, says SB27 would “modernize” the Physician Assistant Practice Act and help address the shortage of health care resources in rural communities.
At least 15 rural and low-income counties in Utah are designated as Health Professional Shortage Areas by the U.S. Health Resources and Services Administration for having too few primary care providers, while at least 27 counties have a shortage of mental health care providers.
Matt Pierce became a P.A. because of his love for working with underserved communities.
“I’ve always been interested really since I was in high school, I had this real drive to spend my time serving other people. And when I went to my undergraduate degree, I studied public health. That was the path I started taking in order to serve others,” Pierce said.
After finishing his undergraduate studies, Pierce went to Haiti and the Caribbean to work on public health projects, where he helped vulnerable youth and worked with public health. He later decided to return to school. A P.A. certification appealed to him because he saw it as the best path for him to continue helping the most at-risk communities.
“For me, medicine is really a vehicle to access vulnerable individuals who need someone to access them and to help them with things that are going on with their life situation,” Pierce said.
After graduating in August from the University of Utah’s program, Pierce continued working at the Hope Clinic, a free clinic in Midvale where he mostly works with Spanish speakers.
He works with a physician there.
“And I love practicing with him. But does it matter that he’s a physician? Not really ... this guy is just really good at taking care of patients and providing really good social medicine,” Pierce said.
He believes those mentorship relationships can happen between health care providers regardless of whether one of them is a physician.
“It doesn’t matter so much anymore what your license is as it is your ability to practice medicine and take care of patients well,” Pierce said.
The Utah Academy of Physician Assistants hopes the bill will reduce barriers for health care systems to hire P.A.s. As of now, it’s difficult for rural communities to hire and retain enough physicians. Employers should be able to decide how to best use P.A.s to meet needs, according to McCreary.
“That’s important for maybe a rural community that can’t afford a physician or can’t manage to recruit a physician, they would be able to continue to operate,” McCreary said.
A change to Utah’s law would reflect the way P.A.s already work, rather than allow them to provide health care services they don’t already provide, according to McCreary.
For example, at some hospitals, P.A.s work overnight on trauma teams. Although paperwork shows that a physician is supervising the P.A., the physician isn’t actually on site or available. If a patient comes into the hospital with an issue outside of the physician assistant’s expertise, the P.A. will reach out to a specialist on shift, McCreary said.
“This is how we practice now, this is how things work. The law just hasn’t caught up,” McCreary said.
Because current law also requires physician assistants to receive payment by public and private payers through a physician, McCreary says it’s difficult to gather data on the work P.A.s do in the state.
Like SB27, SB28 also seeks to give P.A.s more independence and would allow them to provide mental health therapy. Although those with the requisite training can already provide therapy while employed by a mental health professional, “this is the first time that P.A.s have had the chance to introduce the (physician assistant) profession into the Mental Health Practice Act,” McCreary said.
Under the bill, P.A.s would need to receive a Certification of Added Qualification in psychiatry issued by the National Commission on Certification of Physician Assistant and an accredited doctorate level academic program for physician assistants; complete a postgraduate residency in psychiatry; finish additional clinical practice or coursework in accordance with requirements; and complete the clinical practice requirement established by the division in collaboration with the board.
Michelle McOmber, Utah Medical Association chief executive officer, says the bills would give P.A.s more scope than those in any other state.
The group especially takes issue with a part of the bill that states a physician assistant would be able to provide any medical services that are within the P.A.’s “skills and scope of competence.” The bill as written does not require the P.A. to show proof of those skills or competence.
The Utah Medical Association isn’t concerned with how that would affect those practicing under physicians or in health care systems that already decide the scope of P.A.s’ practice, but it is worried about those who would go into independent practice, McOmber said.
She said her group fears P.A.s will simply be able to say they’re trained in whatever they choose.
“These bills in a sense make P.A.s super-providers even above physicians in what they can and can’t do in the way they’re drafted,” according to McOmber.
There’s a difference between health care providers based on their education and experience, she said — one that should be seen in what they can legally do.
“It’s a matter of education and training,” McOmber said. “There is a difference, and there should be a difference, and there should continue to be a difference.”
She said the medical association has “great respect” for physician assistants and that they make up an important part of medical teams. Utah Medical Association helped start the first P.A. program in the state, she noted. But the relationship with physicians is important because of the education and training differences, as physicians receive several years more, McOmber said.
But McCreary said the active physician-P.A. relationship has become less prominent over time.
When the P.A. profession started about 50 years ago, they were only able to work with the close supervision of physicians. But over the past five decades, the profession has evolved as training has become validated and proven as safe, according to McCreary.
He said P.A.s are trained to recognize when something is outside of their expertise and defer to a physician.
“They’re very conscientious and want to deliver the very best care,” McCreary said.