New law loosens oversight of physician assistants

A new Missouri law is paving the way for physician assistants to treat patients in high traffic and rural areas. On Aug. 28, Missouri Senate Bill 219 went into effect, relaxing the supervisory restrictions for physician assistants who practice in Missouri.

Previous law dictated a dedicated supervisory physician must be located within 30 miles of the PA, and be present two-thirds of the time the assistant is providing care to patients. SB 219, sponsored by Sen. David Sater, R-Cassville, will make it easier for PAs to practice medicine, expanding the supervising physicians’ proximity to a 50-mile radius, and requiring the supervising doctor be present for only four hours out of every 14 days that the PA practices.

Sometimes called mid-level providers or physician extenders, PAs are part of a class of advanced health care providers that include nurse practitioners and nurse midwives. Through a combination of post-graduate education and about 2,000 hours of clinical experience, PAs are trained in a variety of primary and specialty care settings. They have the ability to interpret tests, diagnose illnesses, prescribe non-narcotic medicines and perform basic procedures. Off-limits care areas for PAs in Missouri include general anesthesia, vision-related care and abortions.

If the new measure sounds like a drastic reduction in oversight, that’s because it is. According to Paul Winter, president of the Missouri Academy of Physician Assistants, the Show-Me State’s previous law was outdated, with Missouri trailing only Mississippi on the list of most-restrictive states. Still, the U.S. Bureau of Labor Statistics listed 980 practicing PAs in Missouri last year – a number closely in line with the state’s Midwestern neighbors. The median PA salary in Missouri was more than $83,000 annually, more than double the $41,000 statewide median income across all professions.

Country problems
One area that stands to benefit most from the change is rural medicine.

Dr. David Barbe – the Springfield-area president of Mercy Clinic and newly elected chairman of the American Medical Association Board of Trustees – is a longtime family medicine provider in his hometown of Mountain Grove and knows first-hand the difficulty in recruiting and retaining qualified providers in rural areas.

Mercy has struggled for years to maintain provider coverage at its small clinics in Summersville and Eminence, he said. Through a special exception granted by the state, a Mercy PA has practiced in those locations for two years under a lesser supervisory level Barbe said is comparable to the new law.

“Quite honestly, we could not have kept those clinics open under the old law,” he said. “Now, with only the four-hour requirement every 14 days, that is something that we can do. This new environment will give us much greater flexibility in the type of practitioners that we consider hiring for those positions.”  

Beyond the rural health care setting, Barbe expects the greatest changes to come in retail, charity and employer-based clinic settings – places where it is usually not practical to have a full-time physician on-site.

“PAs are a very valuable part of the health care team right now,” he said, “and they will continue to be even more so in the future.”  

Retaining talent
Missouri’s ranks of uninsured and medically underserved have grown in both rural and urban locations. Winter speculates the previously more-restrictive environment was responsible for up to 50 percent total out-migration of new graduates from Missouri’s two PA programs. Currently located at St. Louis University and Missouri State University, the two schools will be joined by University of Missouri-Kansas City as it launches its own PA program in January 2014.

MSU PA program department head Steven Dodge said his graduates leave the state at about the same rate as they come from out-of-state to study here – between 25 and 35 percent. Dodge doesn’t expect any marked changes as the new law goes into effect, though in response to growing demand, his program will increase from 25 students to 30 students this coming semester. He hopes increased opportunities will entice some of his non-native graduates to practice in the Ozarks.

“Both Cox and Mercy seem to understand that mid-levels will carry a larger and larger burden of primary care in the coming years,” Dodge said. “They’ve been very supportive of efforts to increase the number of PAs that get trained and are recruited to stay in the area.”

Acceptance issues
With roots in the armed forces, PAs have been a slow-growing part of the medical field since the first graduate-level training programs were launched in the 1970s, leveraging the field experience of combat medics and corpsmen with formalized medical education.

Air Force veteran Ron McCall is a certified physician assistant at Springfield’s Ferrell-Duncan Clinic. Following 23 years of primary care practice in the military setting, he has worked since 1995 in private practice as a PA in neurosurgery, occupational medicine and orthopedic surgery.

As past president of the Missouri Academy of Physician Assistants, McCall said he has seen a lot of progress in the field since leaving the military. In those days, PAs were required to have 100 percent physician supervision and couldn’t write basic prescriptions without an MD sign-off. Remedying the lack of acceptance, he said, has been a political exercise.

“In the past we’ve had to fight pushback from some physicians’ organizations,” McCall said. “It’s taken a lot of tact, diplomacy and education to show that we really are qualified to do the job.”

However, with each state determining its own restrictions, criteria has varied widely, said Winter. He expects the new Missouri measure to improve access for many patients in underserved areas by increasing the overall number of practicing PAs, who can expand the reach of physicians by staffing satellite clinics, performing house calls and nursing home visits, or making hospital rounds.  

“Today, we have an increased level of cooperation among physician groups,” he said.

“They recognize that the concept of mid-level providers is not going away, and are very focused on maintaining a team-based approach to medicine.”

Winter said thanks to an aging population and the adoption of the Affordable Care Act, a team approach is needed. The health care industry is facing a prolonged increase in demand and is recognizing PAs represent a big part of the solution to a projected national shortfall of more than 33,000 primary care providers by 2015, as estimated by the Association of American Medical Colleges.

Beyond easing Missouri’s state restrictions, the PA profession has experienced recent workplace gains. According to a study released last year by the American Medical Group Association, the 82 large-group primary care practices surveyed had increased PA staffing by 21 percent during 2011 –  growth that is not expected to abate any time soon. According to the BLS, PAs are expected to be the second-fastest-growing profession this decade, with national practitioner totals increasing to 103,900 in 2018 – growth of nearly 40 percent compared to 2008 totals.

Back in Mountain Grove, Dr. Barbe doesn’t expect to see a hiring boom for PAs within Mercy or elsewhere, but believes the effects in the southwest Missouri region will be felt over time.

“Just as in the physician workforce right now, demand exceeds the supply,” he said. “In both rural and hospital settings, this easing of the PA practice restrictions will open the market and help create a supply of more mid-level providers to do this kind of work across southwest Missouri.”