Individual Responsibilities

As a PA, you have a personal responsibility to understand the political process and to use that knowledge to advance the interests of patients. There are many levels of involvement. At a minimum, you should stay abreast of current issues and trends in health care by reading journals, newspapers, and professional publications, and you should vote. You can also provide moral or financial support for the efforts of others who work on your behalf by becoming a member of a PA organization or advocacy group. You can become one of those workers yourself, participating in the government-related activities of PA and other health care organizations. You can seek appointment to a licensing board or run for public office at the local, state, or national level.

If running for public office is not for you, consider supporting a candidate whose positions on health care and other issues are compatible with your own. There are dozens of ways to support a candidate: becoming a campaign manager or an issues coordinator, hosting a fundraiser, canvassing for votes, working on a phone bank to solicit supporters, organizing a committee of “Physician Assistants for Candidate N,” speaking at community functions in support of the candidate, distributing campaign materials, working to “get out the vote” on election day, and, of course, voting.

If campaign work is not attractive or feasible, consider volunteering your services to individuals already elected to federal or state office. One valuable function you can perform is to advise elected officials about health care issues affecting your community. All legislators are called on to make decisions on a wide variety of topics. Having a constituent health care expert as a resource is a great asset.

It is hard to overstate the value of having ongoing contact with elected and appointed officials. If legislators and others in government know you and understand the valuable role that PAs play in health care delivery, they will be more likely to come to your assistance when you need help. Your credibility will have been enhanced if, in the past, you were involved with issues that were not self-serving, such as bicycle safety measures, support for prevention programs, or health care for the homeless. If you know someone has introduced legislation in these or similar areas, offer your personal support. Historically, PAs have been interested in the broader health care issues because resolving these issues has benefited patients. If you maintain a genuine interest in patient welfare, rather than speaking up only when someone threatens your professional “turf,” you will earn genuine respect.

You can do several things to influence the legislative and regulatory processes, even when no issues in which you are interested are awaiting legislation. In fact, if you do these things routinely, you will enhance your visibility and credibility.

The first is to maintain contact with your elected representatives. You want them to know who you are and to smile when they see you coming. When you meet with an elected official, it is best to make an appointment and be prepared to discuss a specific issue. Of course, you will not wait until the busiest days of the legislative session, when everything is in turmoil, to make your visit. Personal contact with legislators when they are at home in the district or between sessions is most productive.

A personal visit is not the only option. You may read something about your representative’s pet project and contact him or her to voice your support (if, in fact, you are in support). Such support is often remembered. If you receive an interesting piece of information on health care that you think might be useful, pass it along.

You may also do this with regulators. Remember, regulators are all people who are trying to develop or maintain a level of expertise. They need information, so provide it. A good relationship with a legislator, a legislator’s staff person, or a regulator is invaluable.

Finally, support your state and national PA organizations. This suggestion is not just another pitch for membership; it is a tactical imperative. When any organization testifies before a governmental body, one of the first questions asked is, “How many people does your society represent?” The larger the number, the more credibility the organization is given. It is also important to know where your professional organizations stand on an issue before you go to your representative’s office to voice your opinion. If you are an active member, you may have already influenced the organization’s policy-making process. Even if you disagree with the group’s final determination, at least you will understand how and why it reached its decision, and you may choose to remain silent rather than undercut its efforts.

There is value in belonging to a professional organization. Organizations and their members have a symbiotic relationship. Organizations need you, and you need them. They know the legislative and regulatory processes, as well as what issues are under consideration, and they most likely have a professional staff. You know the issues from a personal perspective because you confront them daily. Your personal professional perspective as a PA is essential and should be conveyed to lawmakers or regulators, particularly when your association says it is time to call, write, or visit them.

One of the first things you must know about government is that it regulates almost every aspect of your professional life. The most important law affecting you as an individual PA is one passed by the state and implemented by a state licensing board or agency—the PA practice act.

Practice Laws

Occupational regulation is the prerogative of the state rather than the federal government. Each state licenses, certifies, or registers a number of different professions and occupations, everyone from physicians and architects to barbers and plumbers. The goal of occupational regulation is to protect public health and safety. This is done by granting licenses only to individuals who meet minimum standards of education and skill, by defining a scope of practice, and by disciplining those who break the law or fail to uphold certain professional standards. A licensing or regulatory agency can seek an injunction and ultimately revoke a license to prevent the public from being harmed by a negligent or incompetent practitioner. Lawbreakers may also face civil or criminal penalties.

Physician assistants belong to a regulated profession. In broad terms, this means that an individual seeking to work as a PA must first obtain permission from the state (for the purposes this chapter, the term state shall mean all 50 states, the District of Columbia, and the U.S. territories with the exception of Puerto Rico, which does not yet license PAs) and then abide by any conditions of practice that the state has established. For a time, as with other professions and occupations, the term that described the process by which states authorized PA practice varied across the country and included designations such as licensure , certification , or registration . (On October 15, 2015, Senate Bill 110 became effective in Ohio, thus making licensure the official regulatory term for PAs in all states.) However, all states now appropriately use the term licensure for PAs—the highest form of state professional regulation—thereby eliminating patient confusion and assuring the inclusion of PAs in important state laws that are applicable to licensed health professionals such as participation in loan repayment programs, the provision of care during natural disasters, and the reporting of specified patient injuries to law enforcement, among numerous others. The requirements for securing this permission vary from state to state. However, as a result of efforts by American Academy of Physician Assistants (AAPA) and state PA associations, there is growing uniformity in the laws that govern PAs. Total uniformity is an unrealistic goal because each state writes its laws slightly differently and cherishes its prerogative to do so. The differences in style and content are problems with which every regulated occupation and profession must cope.

The basis for regulation of PAs is found in the language of the PA practice act. The law may be included in the medical practice act, which governs doctors, or it may be a separate section of the state statutes. The law is further amplified by regulations issued by the licensing board. Every PA should have a copy of the current state law and regulations governing his or her practice, which may be obtained from the licensing board or found on the licensing board’s website. Ignorance is no excuse if you are ever accused of breaking the law.

Who is responsible for licensing and regulating PAs? In most cases, the regulatory agency is the Board of Medical Examiners, the same entity that licenses physicians. Fewer states have separate PA boards. A handful of states have departments of education or professional regulation that regulate all health practitioners. A list of PA state regulatory agencies is available on the AAPA’s website.

In the law and regulations, you will find details about qualifications, applications and fees for licensure, scope of practice, requirements for PA–physician team practice, prescribing and dispensing privileges, criteria for license renewals, protection of the title “physician assistant,” and what constitutes a violation of the law and the disciplinary measures that can be invoked, as well as information about administrative procedures and due process. You may also find information on the composition, terms of appointment, and other powers of the regulatory board, allowing you to determine what role PAs play in the state’s regulatory system. Most medical boards have PA advisory committees that provide PAs with a way to participate in and contribute to the regulatory process, and a growing number of states include PAs as medical board members.

The two universal requirements for obtaining licensure as a PA are

• 1.
  

  Graduation from an accredited PA educational program

  
  
• 2.
  

  Passage of the Physician Assistant National Certifying Examination (PANCE), administered by the National Commission on Certification of Physician Assistants (NCCPA)

The NCCPA examination, although part of a voluntary, private sector certification process, functions as the national licensing examination for PAs. Every state requires that potential licensees have passed it. Although a few states may test PAs on their familiarity with state law, no state administers its own examination to test clinical knowledge.

Your state license must be renewed on a regular cycle, every 1, 2, or 3 years. Some jurisdictions require that you provide evidence that you have maintained your NCCPA certification or that you have completed a minimum number of continuing medical education (CME) credits, and you will need to pay a renewal fee. Keep in mind that the NCCPA certification system must be dealt with separately; do not confuse it with your state license. To maintain certification by the NCCPA, you must pay NCCPA a fee and register 100 hours of CME every 2 years. It is also necessary to recertify every 10 years by taking an examination. You may use the letters “PA-C” after your name only if you are currently certified by the NCCPA.

The PA law and regulations also include criteria for the formulation and function of the PA–physician patient care team. All state laws require the ready availability of the physician for consultation and, with rare exception, authorize availability via telecommunication. Although no state allows a PA to work without a physician, no state requires that a physician must always be on site while a PA is providing care. Some states do, however, have on-site physician requirements when the PA is performing certain procedures. More details may also be specified if the PA will be practicing in an office or clinic separate from the physician. Ideally, the most effective state laws neither restrict patient access to care nor the PA’s access to the physician. This is best achieved when the laws and regulations authorize collaborative relationships, PA scope of practice and prescriptive authority, the ratio of PAs to physicians, and the necessity (if any) for the review of PA-generated charts, orders, or prescriptions to be determined at the practice level.

All U.S. states permit those PAs who have prescriptive authority to sign prescriptions. The law or regulations may place restrictions on the kinds of medications a PA may prescribe. The authority to dispense medications is also regulated by the state. Pharmacists vigorously protect this privilege and make good arguments for a separation of the prescribing and dispensing functions. Therefore, a physician’s or PA’s ability to provide patients with medications from a supply maintained in the office or clinic is often more easily justified in rural areas or other locations without pharmacy services. Some states do not permit anyone other than a pharmacist to dispense drugs. In nearly all jurisdictions, giving patients drug samples that have been supplied by a pharmaceutical company is not the same as dispensing and is not subject to the same restrictions.

Regulation of the PA profession has been evolving since the first practice act was passed in the late 1960s. The founders of the profession made a conscious political decision to establish a system in which PAs were recognized under the licenses of their supervising physicians. Changes in health care delivery and greater numbers of PAs, as well as the need for administrative efficiency, have persuaded most states to modify this approach. The more modern system, advocated by the AAPA, is one in which licensure is granted to a PA on the basis of his or her credentials (i.e., on proof of meeting the educational and examination requirements of the law). A licensed PA can practice after he or she has established a collaborative relationship with one or more licensed physicians. Such systems greatly facilitate the rapid deployment of the PA workforce and diminish administrative burdens for licensees and for the state.

Regulation of the profession continues to evolve based in part on the availability of data and studies that confirm PA quality, changes in medical education that place greater emphasis on interprofessional training among medicine, nursing, pharmacy, and so on; the transition of health care systems to “team” practice; and adjustments in the expectations of both physicians and PAs with regard to liability and the belief that PAs should no longer be considered the “agent” of the physician. These developments (and many more) have ultimately resulted in a more modernized approach to the regulation of the profession as evidenced by (1) the largest employer of PAs in the country, the Veterans Health Administration (VHA), enacting new utilization guidelines for PAs practicing in Veterans Affairs (VA) medical facilities; (2) adoption of new policy of the AAPA House of Delegates (HOD) on the role of PAs within the health care team; and (3) revision of the Academy’s Model State Legislation for PAs, which describes best practices in the regulation of the profession.

On December 24, 2013, the VHA enacted a directive updating its policy on PA utilization, which included a new definition for PA practice. Among other things, VHA Directive 1063 defines a PA as a credentialed health care professional who provides patient-centered medical care to assigned patients as a member of a health care team. It also states that PAs practice with clinical oversight, consultation, and input by a designated collaborating physician. Last, it also recognizes that although PAs are not licensed independent providers, they are authorized to practice with defined levels of autonomy and exercise independent medical decision making within their scope of practice. Thus, the VA acknowledged that “supervision” does not define the role of the PA accurately. In a historical shift, the relationship as between PAs and physicians is one of “collaboration” in which each member of the medical team works together jointly.

The AAPA HOD has sole authority on behalf of AAPA to enact policies establishing the collective values, philosophies, and principles of the PA profession. It consists of voting delegates from 56 chapters representing 50 states, the District of Columbia and five federal services, 25 officially recognized specialty organizations, eight caucuses composed of individuals sharing a common goal or interest related to health care access or delivery, and the Student Academy. In addition, the current and immediate past House officers are delegates at large and also vote. Elected delegates have an effective voice in AAPA activities by making recommendations to the AAPA Board of Directors, submitting formal resolutions through the procedures outlined by the House officers, participating in open reference committee hearings conducted at the HOD meeting held during AAPA’s Annual Conference and volunteering as a member of a reference committee, and researching and reporting on the resolutions and testimony received. In the year following the enactment of the VHA Directive, the AAPA HOD amended its policy on the role of PAs to reflect that PAs are health professionals licensed or, in the case of those employed by the federal government, credentialed to practice medicine in collaboration with physicians. This significant policy change was made partly to guide PAs, AAPA leaders, and professional staff in their navigation of the rapidly evolving team-focused, value-based health care landscape but also to more precisely define the way in which modern PA–physician teams practice medicine. It thus illustrates the progression of PAs’ abilities as medical providers, which was previously believed to be absent within the realm of the “supervision” structure. The change was also embraced in order to overcome the misconception held by some legislators, health policymakers, physicians, and patients that given their need for supervision PAs were less safe or provided inferior care in contrast to their physician counterparts despite numerous studies to the contrary.

When the AAPA HOD adopted its new policy on the PA role in 2014, the Academy’s Commission on Advocacy was also charged with the important task of updating the AAPA’s Model State Legislation for PAs (Model Law). First drafted in 1991, the Model Law was adopted by the AAPA to describe best practices in regulation of the profession, achieve regulatory efficiency, and promote consistency across states. Although it had undergone several revisions over time in order to incorporate changes in program accrediting agencies and to reflect the evolution of PAs practice, it has always reflected two hallmark concepts: that PAs should be licensed to practice medicine and that PA scope of practice should be based on the PA’s skills, education, and experience. As of 2015, the updated model state legislation recommends an administrative process in which a PA presents his or her credentials to a state regulatory agency and receives a license in return. The license is renewable, based on meeting state requirements. The model legislation does not propose that the regulatory authority approve or register collaborating physicians. Any licensed physician or group of physicians (MD or DO) may collaborate with a PA unless the physician’s ability to collaborate has been limited by disciplinary action. Under the updated Model Law, a PA’s scope of practice is established by what is within the PA’s skills, education, and experience. Language describing the PA scope of practice being determined by physician delegation has been deleted. Since its first draft more than 20 years ago, the model legislation authorizes PA prescriptive authority, including controlled substances in Schedules II through V, as well as limited dispensing authority. This authority has been retained. However, language requiring the collaborating physician to assume responsibility for care provided by PAs has been removed. Instead, PAs are responsible for their professional actions. The new model also deletes the concept that a PA should be considered the “agent” of a physician. In the past, rather than amending health law outside the PA practice act, PAs sought to be able to perform specific regulated medical and surgical tasks as the “agent” of a physician. Current advocacy efforts seek to have PAs specifically named in all relevant health law, removing the need for “agency” language. It is stated quite clearly in the model legislation that a physician need not be physically present as long as the PA and physician can contact one another easily. The details of collaboration are left to the PA–physician team.

Augmenting the current language that removes the requirement that PAs practice with physician collaboration when responding to a disaster situation, the new model state legislation extends the same authorization to PAs who are participating in volunteer activities. The new model legislation presents a list of options for regulatory models, with the preferred option being a separate and independent PA Board. The improved Model Law will serve as a guide for states looking to update PA laws and regulations.

Thus, a good state law is one that allows a PA’s scope of practice to be determined by what is within his or her skills, education, and experience. It should neither limit a PA’s scope via a law, a regulation, or a licensure application that contains a list of permissible tasks that physicians may delegate nor narrow it by a system in which licensing board members are allowed, when reviewing PA practice descriptions, to arbitrarily delete certain procedures on the basis of their personal biases. Last, it should not be restricted by legislators who do not understand the depth and breadth of PA education and training. The AAPA has distilled the aspects of ideal PA legislation into an easy to understand and describe version in its Six Key Elements of a Modern PA Practice Act ( Box 9.1 .)

Individuals: Part of the Whole

This section provides information on the structure and mission of your professional organizations: the AAPA and the state PA academies. Many PAs also find great value in belonging to an AAPA specialty organization, caucus, or special interest group.

The AAPA, established in 1968, is the national professional society for PAs. At the headquarters in Alexandria, Virginia, a full-time staff carries out the organization’s major activities: advocacy and government relations, research and data collection, public education, publications, continuing medical education and professional development, employment, and other member services. One of the Academy’s most important functions is to speak for the profession before the U.S. Congress and federal agencies. Even in a representative democracy such as the United States, it is difficult for one person to singlehandedly affect the shape of laws and regulations. It is generally true that legislators and bureaucrats are more responsive to organizations that convey the interests of a large group than they are to individuals. Efficiency, accountability, and credibility come into play here. Therefore, the Academy performs an important role when it voices the PA profession’s views on federal legislation and regulations.

Lobbying is done daily by the professional staff of the AAPA. At congressional hearings, during individual meetings with lawmakers and their aides, and at meetings with leaders in federal agencies, AAPA staff may be accompanied by PAs who are elected officers of the Academy or who have special expertise or established relationships with legislators or regulators. Coordinating grassroots advocacy is an important part of AAPA’s legislative strategy and success on Capitol Hill. Legislative alerts, AAPA social media channels, and Academy publications are used to inform AAPA members about important issues or to request that they contact their congressional representatives or a federal agency about a particular subject. Annually, the AAPA invites members to attend a government affairs and leadership conference in Washington, DC, that includes a day on Capitol Hill. The AAPA welcomes and relies on PAs from across the country to speak for the profession and the patients PAs serve and helps to make this effective by coordinating the profession’s federal advocacy and providing training, support, and direction for its members as advocates.

On the state level, PAs’ interests are represented by state PA associations. These associations are chartered constituent chapters of AAPA. Among its other projects, each state academy must advance the interests of the profession before the legislature, the licensing board, and other state agencies. A majority of PA state societies employ professional association management staff, lobbyists, and legal counsel. However, even in the chapters with a significant number of paid employees, much of the substantive work is done by the members themselves. The AAPA’s advocacy and government affairs staff helps chapter leaders with these projects by providing information, technical resources, and consultation services. For example, the AAPA supplies summaries of state laws, model language, fact sheets, and demographic data, as well as analyses of proposed rules and legislation. The Academy can also assist state chapters by sending statewide email “legislative action alerts” on behalf of the chapter. The Academy’s goal is to maximize the ability of PAs to provide care through appropriate state laws and regulations.