Physician Assistant Employment Arrangements

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Testimony presented by Ramon Gardenhire, Assistant Director, State Government Affairs

on behalf of

The American Academy of Physician Assistants

to

Georgia Composite Board of Medical Examiners

 

December 8, 2006

Good morning, Mr. President and members of the board. My name is Ramon Gardenhire. I am the assistant director for state government affairs at the American Academy of Physician Assistants. The American Academy of Physician Assistants is the national professional society for physician assistants (PAs). In this capacity, the Academy represents over 60,000 physician assistants in the United States.

We appreciate the opportunity to speak to you briefly about the proposed addition of a paragraph (21) to Rule 360-3.02 of the Rules of Composite State Board of Medical Examiners which would add “To be employed by an individual whom the physician supervises in the performance of medical tasks or providing patients’ services and/or to whom the physician delegates authority” to the definition of unprofessional conduct for physicians. In addition to today’s testimony, the Academy sent written comments during the public comment period for this proposed regulation.

The physician assistant profession was created by physicians to allow doctors to extend their ability to care for patients by working with professionals trained in the medical model who would practice with physician delegation and supervision. During the nearly forty year history of the profession this basic principle has held true. PAs embrace and seek practice with physician supervision. Physician assistants readily recognize physicians as the most comprehensively educated members of the health care team, and believe that the PA’s ability to provide patient care is enhanced by this sustained relationship with supervising physicians.  The physician assistant profession is enduringly committed to the tenet that PAs practice with physician supervision. To quote from Academy Policy:

The AAPA believes that the physician-PA team relationship is fundamental to the PA profession and enhances the delivery of high quality health care. As the structure of the health care system changes, it is critical that this essential relationship be preserved and strengthened.

 

Physician and Physician Assistant Interests are Aligned

Every physician and every physician assistant have medical, ethical and legal obligations in patient care. With the exception of the obligation to supervise, these obligations are the same for physicians and PAs. Education of physicians and physician assistants focuses on the means and methods to assess patients, promote wellness and treat injury and illness. The ethical codes of both professions hold physicians and PAs to similar obligations to patients. Under Georgia Code the board may discipline a physician for “any departure from, or failure to conform to, the minimal standards of acceptable and prevailing medical practice.”1 The board is also expressly authorized to discipline PAs for “unethical conduct.”2  Both physicians and PAs are at risk for malpractice litigation if an unacceptable outcome of medical care occurs.

With due respect for the board’s concern for employment arrangements, the Academy believes that physicians and PAs share legal and ethical obligations to patients that are in force independent of the business arrangements involved. A physician who is an employee of a hospital is held to the same medical, ethical and legal standards as a physician who is in private practice and is directly compensated by the patients seen in the practice. The same would be true for a physician who is an employee of a practice partly or totally owned by a physician assistant.

Physician Assistants as Shareholders in Professional Corporations

An increasing number of states are recognizing that employment and supervision are separate and unrelated aspects of medical practice. As practice changes from solo physician based to group and partnership based practice models, a growing number of states allow PAs to become shareholders in professional corporations. In fact in the 2005 legislative session the Tennessee State Legislature amended its code to allow physician assistants to form professional corporations and professional limited liability companies with physicians.3 Indeed, only three states (Maine, Oklahoma, and Utah) restrict a physician from supervising a PA who is the employer of the physician.

It is not the goal of most PAs to participate in the ownership of clinics. However, the ability of PAs to have flexibility in clinic ownership and administration can have dramatic impact on access to care. For example, in rural practice a single physician and PA may work together. If the physician leaves the practice the clinic is forced to close unless another physician can be located to act as a supervising physician. A physician in a neighboring community may be perfectly willing to supervise the physician assistant, but may not want to assume the burden of owning another medical practice. The physician should be compensated for the time it takes to supervise the physician assistant. In this scenario restricting the physician from supervising the PA who provides compensation to the doctor has the potential to cause the clinic to close. This restricts access to medical care for the patients in the community.

The Board’s Authority to Regulate Supervision

While the Academy does not believe that the rule as proposed should be adopted, we do agree that the board should have authority to regulate supervision. Currently the board’s rules for physician assistants define unprofessional conduct for physicians to include lack of appropriate supervision of PAs.4 The board should take disciplinary action against physicians who fail to appropriately supervise PAs. This should be the case irrespective of the physician’s employment arrangements. The board should also take disciplinary action against PAs who practice without physician supervision.    

Conclusion

With due respect for the board’s concern for appropriate supervision, the Academy opposes adoption of the regulation as published. We believe that the interests of patients can be appropriately served irrespective of employment arrangements, and that adoption of the rule as drafted has the potential to restrict access to care for some of Georgia’s most vulnerable populations.

We would encourage the board to withdraw the proposed regulation, and instead consider promulgation of a regulation to add “inappropriate supervision of physician assistants and other supervised health care providers” to the definition of unprofessional conduct for physicians. We believe that this option would accomplish the board’s goals without placing unnecessary restrictions on providers or potentially decreasing access to care for patients.

I sincerely thank you for the opportunity to present these comments.

1. Georgia Annotated Code 43-34-37

2. Georgia Annotated Code 43-34-107

3. 2005 Tenn. Pub. Acts ch. 59

4. Rules of the Composite State Board of Medical Examiners Chapter § 360-5.09