COMMENTARY

PAs Can Do More Under New Laws, Coast to Coast

Ilaria Gadalla, DMSc, PA-C

Disclosures

August 13, 2021

Another frustrated patient awaits transfer from the hospital to a nursing home. The do-not-resuscitate form must be signed by a physician. I (a physician assistant [PA]) am available, but the physician is with a medically unstable patient. Another patient in the emergency room waits for this hospital bed, lying uncomfortably on a stretcher in the hallway.

As a Florida PA who has practiced in other states with far fewer barriers to medical care, I applaud the advancement of House Bill (HB) 431. PAs can now sign certain documents, ensuring accelerated access to therapeutic interventions and honoring end-of-life wishes with timely do-not-resuscitate orders. Children now have improved access to psychiatric medications without a lengthy wait for an appointment with a psychiatrist, given the demand for mental health services and limited physician availability.

HB 431 expands medical care to patients in a state experiencing exponential growth in patient healthcare demands. HB 431 removes the following barriers to patient care as summarized by the Florida Academy of Physician Assistants. HB 431:

  • Changes the physician: PA ratio from 1:4 to 1:10

  • Allows PAs to authenticate documents such as death certificates and involuntary examinations; to order durable medical equipment, home health services, physical therapy, occupational therapy, and speech-language therapy

  • Allows do-not-resuscitate orders; workers' compensation claims; and school physical examinations with the exception of medical marijuana documents and maximum medical improvement/impairment rating documents for workman's compensation

  • Allows a fully licensed PA to procure medical devices and drugs

  • Codifies that a PA can supervise a medical assistant

  • Allows PAs to receive direct payment for services rendered

  • Removes the long-standing restriction of PAs to prescribe any controlled psychiatric medication to patients under age 18 years, and now allows PAs working with a pediatrician, family practice physician, internal medicine physician, or psychiatrist to prescribe a 14-day supply of schedule II psychiatric medications for those under the age of 18 years

  • Removes the requirement that a PA must inform a patient that they have the right to see the physician before a prescription is prescribed or dispensed

  • Removes outdated language regarding prescriber number

  • Improves the supervision data form submission process

Oregon HB 3036, also passed this year, significantly expands medical care provided by PAs. The Oregon legislation allows collaborative agreements with physicians at the practice level and removes the submission requirement for board approval. In contrast to Florida, Oregon completely eliminated PA ratios, improved PA prescriptive and dispensing regulations, and developed an environment that fosters team-based collaboration with accelerated patient access to quality care.

Many other states reduced these supervisory barriers during the pandemic. Even before the pandemic, federal systems such as the Veterans Affairs Medical Centers and the military had removed supervisory restrictions, which subsequently reduced the overall cost of care.

PAs are trained to be flexible and meet the needs of the patient through a medical rather than nursing model. By allowing PAs to determine how best to collaborate with their clinical teams, patients are provided more efficient, patient-centered healthcare. Team members rely on each other for operational and clinical support through a degree of autonomy that contributes to effective patient management. These skills are expanded with the modernization of PA clinical practice and the removal of legislative barriers. A benefit to physicians through collaborative practice agreements is the reduction of their own liability for the care that PAs provide. Unlike Oregon, the state of Florida has not approved collaborative practice agreements and has retained physician supervisory barriers.

There are misconceptions in the medical community regarding the PA profession's legislative goals. These efforts are not aimed at replacing physicians and competing for employment. The goal is to expand access and reduce barriers to patient care. There are not enough providers available to support comprehensive patient care. This is a fact.

Gaps in medical care exist and have existed since the PA profession was developed in the 1970s. Our vision has been to expand medical care through collaboration with physicians and assist with recruitment and retention challenges in various medical disciplines, particularly primary care. This is why all PA programs are based on a primary care medical model to care for patients across the lifespan, from infant care to geriatrics.

The spirit of collaboration in a team-based environment is challenged by these misconceptions and compounded by supervisory legislative and outdated practice requirements. PAs not only collaborate but also consult with and refer patients to other healthcare providers whenever the patient's condition falls outside the PA's education, training, and experience.

The changes in Florida's HB 431 do not remove the requirement to clearly identify our roles. PAs still continue to identify themselves as physician assistants, and should a patient refuse to see a PA, they have the right to see any other provider they choose. Finally, patients are safe in the hands of a PA, as supported by numerous patient studies comparing PA clinical skills to other providers', including nurse practitioners, medical students, residents, fellows, and physicians.

Nonetheless, Florida is still behind other states in providing patients access to collaborative, team-based medical care with skilled PAs practicing as trained. Removing the remaining legislative barriers, hospital credentialing barriers, and healthcare perspectives will successfully provide patients superior medical care and improve the health outcomes of Florida residents.

Ilaria Gadalla, DMSc, PA-C, is a hospitalist at Treasure Coast Hospitalists in Port St. Lucie, Florida. She is a member of The Hospitalist's editorial advisory board and also serves as a physician assistant program director at South University in West Palm Beach, Florida.

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