Liza Bryant, a physician assistant (PA) for the past 20 years, is currently working with Afghan refugees in a government contract job. Through the height of the pandemic, she worked in a primary care office. When asked about the PA expansion of duties through the Coronavirus Aid, Relief, and Economic Security (CARES) Act, she says the main thing it helped her with was being able to write home-health orders without having to have a physician sign off. “It did save time,” says Bryant.
“I could just sign the orders sent to me electronically in our DHR [device history record] system,” says Bryant. “However, we did get pushback with several home-health companies still demanding signatures from supervising physicians.” Bryant repeatedly wrote back, “See the CARES Act.”
Many states relaxed or waived the scope of practice (SOP) for PA duties so as to expand access to healthcare during the COVID-19 pandemic. The move to expand duties was temporary — it was designed to expedite patient care at a time when resources were slim and all medical professionals were pushed to their limits.
Many states waived or suspended supervisory or collaborative agreements for PAs. Some allowed PAs to practice remotely without a physician present. Others increased the number of PAs one physician could supervise. Others decreased the need for telehealth supervision, relaxed billing requirements, and changed PA prescriptive and dispensing regulations. Certainly, PAs played a crucial role in diagnosing and treating patients with COVID-19 during the pandemic. There’s little debate about that.
The problem, however, is that no time line was established as to when the healthcare system would go back to “normal.” Now many PAs who’ve enjoyed additional autonomy and the job satisfaction of increased responsibility don’t want to return to their prepandemic duties and the limits that defined their SOP.
Some think that a reversal of SOP expansions could adversely affect PAs’ job satisfaction and well-being and could damage relationships with their healthcare providers and the institutions where they risked their lives. The Medscape Physician Assistant Career Satisfaction Report 2022 found that 21% of the PAs surveyed contracted COVID-19 while working on the front lines.
Ultimately, the fundamental question is whether PAs can safely and effectively provide expanded care, given their professional education and training.
The Case for Making Practice Expansions Permanent
In the Medscape Physician Assistant Career Satisfaction Report 2022, PAs were asked whether the expansion of their practice should be permanent; 91% said yes. A majority (67%) of PAs also thought they should practice independently. “I still hope the American Academy of PAs pushes for more autonomy,” says Bryant. “But it’s been a struggle since I’ve been a PA.”
Bryant has rarely come across physicians who are reluctant to make the expansions permanent or think that she, as a practicing PA who has more than 20 years of experience, lacks the judgment to perform her duties with little supervision. Aside from having her supervising physician sign off on about 10% of her charts, Bryant said she gets little oversight.
“I think of all the doctors I’ve worked with; some find it a burden to be a supervising physician because they are legally responsible for us,” she says. One problem, she adds, is that many states tether a PA license to a physician or require a minimum physical distance between PA and physician. This can restrict PA mobility and limit telehealth options for PAs.
SOP regulations often set maximum PA-to-physician ratios, which limits innovative care in inpatient settings and rural practices. Practice agreements also can specify which drugs PAs can prescribe.
Most PAs think returning to pre-CoVID-19 SOP would be detrimental to professionals, patients, and the healthcare workforce.
“Of course, there’s probably a handful of physicians who don’t want us to be autonomous and independent because we don’t have the medical training,” says Bryant.
The Case Against Making Practice Expansions Permanent
Many physicians disapprove of making the expansions permanent.
The American Medical Association (AMA) believes that patients deserve physician-led care and are opposed to permanent SOP expansion, saying it is detrimental to patient safety. Michaela Sternstein, JD, vice president of the AMA’s Advocacy’s Resource Center in Chicago, Illinois, says that physicians recognized and favored the all-hands approach during the pandemic. Having nonphysician providers working independently on the front lines was an unprecedented emergency practice to increase successful health outcomes.
“But we also knew that by allowing for unprecedented activity and scope of practice during an emergency, that it would be likely that many of these nonphysician provider groups would then take that and try to extrapolate it outside of the pandemic,” said Sternstein.
The Future of SOP
For now, PAs are hoping that regulators at the state level will consider making SOP expansions permanent. In addition, the timing for a full pandemic recovery is uncertain and will vary by state. Transitioning to a postpandemic, normal status will likely be gradual, as will decisions about returning to prepandemic SOP. Regardless of where one stands, the matter calls for the careful evaluation of healthcare outcomes and patient safety.
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