Optimal team practice (OTP) has been defined as “PAs, physicians, and other health care professionals working together to provide quality care without burdensome administrative constraints.” The goal of this chapter is to introduce the components that make up OTP and document its evolving history. OTP is the American Academy of Physician Assistants’ (AAPA) policy for establishing future physician assistant (PA) practice. Despite the recommendation, however, individual state law dictates how a PA functions. The information included herein is up to date at the time of this writing; nonetheless, OTP continues to be an iterative process, and as such, is ever-changing.
Meet PA Smith
PA Smith has practiced family medicine in rural, northwest Colorado for 25 years. The physician supervisor with whom she had a great working relationship abruptly retired because of a serious illness, resulting in the PA not meeting the state’s legislated physician supervisor requirement. As a result, PA Smith is no longer able to see patients. Some of the county’s patients have been left without a health care provider and have had to travel great distances to seek care. PA Smith remains in the area but has been unable to practice for the past 5 months because the rural community has had difficulty recruiting a new physician to the area who could serve as her supervisor. Colorado allows an advanced practice registered nurse (APRN) to see patients independent of a physician relationship, thereby allowing an APRN colleague with less experience to continue practicing. Although thankful some patients are getting the care they need from the APRN colleague, the lack of parity is frustrating to PA Smith.
This is a fictitious story, but the consequences are real for PAs and the patients they serve. As the PA profession has evolved and matured, it has recognized the need to explore options to address issues that may limit a PA’s ability to practice at the top of their license. This chapter describes the profession’s evolution toward OTP.
History in the making
AAPA House of delegates
The AAPA is the national professional membership organization for PAs. Within the AAPA, the House of Delegates (HOD) is responsible for establishing policies, principles, and position statements for the AAPA about PAs and the profession. The HOD consists of voting delegates who represent the different components that make up the AAPA, including the 50 state constituent chapters, the District of Columbia, U.S. Virgin Islands, five federal services, officially recognized specialty organizations, caucuses, the Student Academy, and the current and immediate past House Officers. These elected delegates may submit formal resolutions to the HOD for consideration. All matters are run through defined parliamentary processes.
2016 House of delegates
An officially recognized specialty organization, the Association of Family Practice PAs (AFPPA), submitted a resolution called “2016-A-08 PA Full Practice Responsibility” to be considered at the May 2016 HOD. The AFPPA asked the House to consider a definition of full practice responsibility to allow a PA “to function more autonomously by removing the currently imposed practice barrier of physician supervision.” Full practice responsibility would be an alternative option to supervision in states that seek autonomous PA practice. Within the HOD, considerable opposing testimony was offered regarding full practice responsibility. Concern was expressed over vague language in the resolution and the potential implications it might have on the legislative and regulatory environments within individual states; however, positive testimony was provided and support was garnered, with an insistence on a more unified approach to national policy regarding PA practice. As such, delegates voted to refer resolution 2016-A-08 to an appropriate body to develop recommendations regarding full practice responsibility to the 2017 HOD.
Developing a Unified, National Approach
AAPA’s Joint Task Force
The referral of resolution 2016-A-08 from the HOD focused the Academy’s attention on full practice authority. In July 2016, an 11-member Joint Task Force on the Future of PA Practice Authority (the AAPA Joint Task Force) was formed by the AAPA BOD and House Officers. The AAPA Joint Task Force was charged to put forward recommendations and a policy for the “BOD to consider prior to the May 2017 HOD meeting and for consideration at the May 2017 HOD meeting.” A 1-year timeline, although short, is customary of most actions arising out of the HOD. In developing its report and recommendations, the AAPA Joint Task Force was asked to:
Understand and document the current federal, state, and employer context of the practice authority of PAs, APRNs, and other relevant health care providers.
Obtain input and/or feedback from PA stakeholders.
Develop or select appropriate terms and definitions for different types of PA practice authority.
Consider and describe what, if any, limitations or requirements should be established for PAs under the Task Force’s recommended PA practice authority (e.g., differences for primary care PAs vs. surgical PAs, contingent upon number of years practicing or number of years practicing in a specialty, etc.).
Consider and describe the potential benefits of its recommendations for PAs, patients, and PA employers, as well as any potential risks and obstacles that should be taken into account (e.g., malpractice insurance).
The task force was charged to help the AAPA better understand the range of issues involved, the changes in the marketplace, and the potential impact of those changes on PA practice.
Full practice authority and responsibility
The AAPA’s Joint Task Force went to work to meet the charges. In November 2016, the committee released initial recommendations for full practice authority and responsibility (FPAR) that included four components :
Emphasize the PA profession’s continued commitment to team-based practice.
Support the elimination of provisions in laws and regulations that require a PA to have and/or report a supervisory, collaborating, or other specific relationship with a physician in order to practice.
Advocate for the establishment of autonomous state boards, with a voting membership comprised of a majority of PAs, to license, regulate, and discipline PAs.
Ensure that PAs are eligible to be reimbursed directly by public and private insurance.
In January 2017, the AAPA sent a survey to elicit feedback from active PAs, retired PAs, and students. The survey was sent to 102,101 individuals, and a total of 12,485 people, having completed at least some portion of the survey, responded (12.6% response rate). The response rate included 1827 students. A majority of the survey respondents (72%) expressed overall support for the proposed components of FPAR, with 13% opposed and 16% undecided. The components “Emphasize the PA profession’s continued commitment to team-based practice” and “Ensure that PAs are eligible to be reimbursed directly” were overwhelmingly supported (each component was supported by >90% of survey respondents). A small majority, 63% of the respondents (with 17% undecided), supported the elimination of a supervisory, collaborative, or specific relationship with the physician.
As a result of the input and feedback received, the AAPA Joint Task Force tweaked the components and modified its proposal to also incorporate changes to the AAPA’s Guidelines for State Regulation of PA Practice (See Chapter X ).
Guidelines for State Regulation of PA Practice
The AAPA’s Guidelines for State Regulation of PA Practice describe the collective values, philosophies, and principles of the PA profession as they relate to the state regulation of PAs. The 2015 revisions to the Model State Legislation and the 2016 revisions to the Guidelines for State Regulation of PA Practice were progressive and supported the Six Key Elements of a Modern PA Practice Act (See Ballweg Chapter X ). Nevertheless, the Joint Task Force on the Future of PA Practice Authority believed these policies did not sufficiently address all of the issues for two reasons. First, the AAPA Joint Task Force insisted research showed PAs provided high-quality care. Therefore provisions included in early PA state laws to assure quality—such as specific physician oversight and responsibility requirements—were unnecessary. Second, the Joint Task Force believed the Six Key Elements of a Modern PA Practice Act were no longer sufficient because the health care marketplace had evolved. The AAPA Joint Task Force believed the PA profession, and the rules that govern it, should also evolve.
The AAPA Joint Task Force identified several marketplace changes that affected PAs and the delivery of health care that influenced the recommendation. , One marketplace change observed by the Joint Task Force was that health care providers were being employed in larger group practices owned by hospitals or other agencies. Physicians no longer saw direct economic benefit from hiring PAs. As such, physicians had become more reticent in assuming responsibility/liability for “supervising” or “collaborating with” PAs. A second marketplace change observed by the Joint Task Force was that PAs were reporting to the AAPA that hospitals and health systems were preferentially hiring APRNs because they were perceived as being easier to hire because of less administrative burden or oversight requirements. Twenty-two states and the District of Columbia grant APRNs full practice authority. This permits APRNs to evaluate patients, diagnose, initiate, and manage treatments under the exclusive licensure authority of the state board of nursing and without a requirement for physician supervision or collaboration. As of April 2019, only North Dakota, under defined circumstances, allows a PA to work without a specific, legally required supervisory or collaborative relationship with a physician. Finally, there was a perception that recruiting physicians was not needed to collaborate in states where APRNs have full practice authority. In states where PAs are legislated/regulated to be supervised by physicians, PAs may be overlooked for clinical positions in deference to APRNs. This is a result of needing to hire a physician to supervise the PA. In some rural and underserved areas, it is easier to hire one provider than to hire two.
PAEA’s initial response
The Physician Assistant Education Association (PAEA)’s Board of Directors established an initial Task Force in early 2017 in response to the AAPA Joint Task Force’s FPAR proposal. The PAEA FPAR Task Force was composed of members of the Board of Directors and PAEA staff. It was within this timeframe that the AAPA Joint Task Force changed the terminology from the original “full practice authority and responsibility” (FPAR) to “optimal team practice” (OTP). The PAEA Task Force was charged to:
Identify the implications of OTP (as defined by the AAPA) for PA education.
Prepare a formal response to the AAPA’s Joint Task Force on the Future of PA Practice Authority detailing these implications.
The report published by PAEA was called “Optimal Team Practice: The Right Prescription for All PAs?” and was largely based on a March 2017 survey of PA program directors (N = 218) and medical directors (N = 218) from all programs and PAEA past presidents (N = 28) regarding FPAR. Response rates were 78% (n = 170) for program directors, 34% (n = 77) for medical directors, and 61% (n = 17) for PAEA past presidents. In the report, 86% of PA program directors, 89% of PA program medical directors, and 100% of PAEA past president respondents answered “no” to the statement, “Does your program’s current curriculum already prepare your graduates to practice without ‘a supervisory, collaborating, or other specific relationship with a physician’ in order to practice?”
PAEA supported three of the four components of the AAPA’s Joint Task Force on the Future of PA Practice Authority resolution: team practice, autonomous state boards, and direct reimbursement for PAs. Based on the perception of those responding to the survey, however, PAEA did not support the elimination of the legal provisions that require a collaborating physician for PAs. The final characteristic was opposed because of the unknown implications for PA education and for new PA graduates.
2017 House of delegates
The AAPA Joint Task Force proposal for FPAR was submitted as a resolution known as “2017-A-07-HO Optimal Team Practice” to the May 2017 HOD. This resolution called for states to update their laws and regulations and implement four components:
Emphasize a commitment to team practice.
Remove supervisory agreement laws from a specific relationship between the PA and physician in order to practice.
Create separate or majority-PA boards to oversee PA licensure, regulation, and discipline.
Authorize PAs to be directly reimbursed by public and private insurers.
The resolution also called for the OTP modifications to be incorporated into the AAPA’s Guidelines for State Regulation of PA Practice. , Within the HOD, vigorous debate resulted in amendments that changed the second component of the resolution to state that the specific relationship between the PA and physician should “be determined at the practice level.”