Pennsylvania Proposed Regulations Regarding PAs

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December 7, 2005

Karen Dalton, Esq.

GOP Executive Director

House Professional Licensure Committee

Capitol Building

Harrisburg, PA  17120

Dear Ms. Dalton:

The American Academy of Physician Assistants (AAPA) is the national professional society for physician assistants (PAs). In this capacity the Academy represents nearly 60,000 PAs in clinical practice in the United States. In addition to its other duties, the Academy serves as an information resource on state regulation of physician assistant practice.

The physician assistant profession is now nearly forty years old. PAs have been regulated in Pennsylvania for nearly 30 years; the initial PA statute was enacted in Pennsylvania in 1978. This history means that there is substantial experience with PA regulation by the states. There are observed and recorded trends, “best practices” and common themes that have developed as states strive to attain the twin goals of public protection and maximizing the access to health care provided by physician-PA teams.

We have been asked to comment on three specific topics regarding the proposed changes to Pennsylvania regulations governing physician assistants (Chapter 18 State Board of Medicine Subchapter D. Physician Assistants.)   

How do the proposed regulations compare with those of other states?

 The revisions proposed reflect the current standard for PA regulation. The requirements for licensure, definition and requirements for supervision, determination of PA delegated scope of practice including physician-delegated prescriptive authority and other technical provisions are in line with language used in the vast majority of states.

The provisions in the proposed regulations are also consistent with those in states in your region. The lone exception is Ohio which does not yet authorize supervising physicians to delegate prescriptive authority to physician assistants. This is very likely to change in the near future. Senate Bill 154 which authorizes PA prescribing and removes archaic supervision requirements has been passed by the Ohio Senate. House action is anticipated just after the first of the year.

The proposed regulations remove some very archaic provisions. It is noteworthy that the current regulations have not been revised since 1993. This is unique in your region. Pennsylvania’s surrounding states have been more timely in making changes to regulations to accommodate updated concepts in physician-PA team practice. The dates of most recent regulatory revision for the states surrounding Pennsylvania include:

Delaware            April, 2000

Maryland            May, 2004

New Jersey        April, 2005

New York          March, 1998

Ohio                   September, 2000

West Virginia      August, 2003

What is the role of chart review in assuring quality of care provided by the PA?

The earliest state laws for PAs commonly required physician co-signature of charts or orders. More modern revisions have adapted these provisions, and in many cases removed co-signature requirements. Mississippi, the last state to authorize PA practice, adopted regulations for PAs in 2000. This inaugural set of regulations requires a supervising physician to sign only 10 percent of PA charts on a monthly basis. Thirteen states have no requirement for physician chart co-signature in law or rule.

As regulatory agencies, physicians and institutions seek to increase efficacy and efficiency in medical practice, and as technology changes the way in which care is delivered, many aspects of medical systems are being critically evaluated. Among these is the role of physician co-signature of chart entries and orders written by physician assistants.

There are times when chart co-signature by physicians is appropriate. PAs have a responsibility to ensure that a supervising physician reviews complex problems and that the review is documented. Supervising physicians should review PA-written chart entries, either every one or selected records, if that is the physician's preference. Licensed health care facilities, institutions, and group practices are obligated to put in place those requirements that best suit the needs of the patients served by their organization. Facilities and groups may decide that a targeted co-signature requirement is consistent with their mission.

The American Medical Association has recognized the individual physician's role in determining specific aspects of PA practice and oversight. In 1995, the AMA House of Delegates adopted Guidelines for Physician/Physician Assistant Practice. As noted in the Guidelines, review of PA practice is the responsibility of the physician and PA.

The Joint Commission on Accreditation of Healthcare Organizations recommends that each accredited organization determine the necessity for co-signature. The relevant standard says:

"The medical staff rules and regulations or policies define what entries, if any, by house staff or nonphysicians must be countersigned by supervising physicians."

Early state laws were written without the benefit of experience with PA practice. As previously noted, American healthcare now has nearly forty years of history with physician-PA teams. The early state laws requiring all PA written chart entries to be signed by physicians were drafted to assure ongoing physician oversight. But like many aspects of clinical medicine, the best patient care decisions are made not as blanket requirements in law, but rather as a customized response to individual practice situations.

Rigid co-signature requirements with short time frames in state law can actually serve to diminish the opportunity for quality physician oversight. If, for example, a physician is required to counter-sign all routine orders within a specified number of hours, the doctor's time is less available for in-depth discussion of specific cases, or for review of practice guidelines or systems for care.

The ideal system for physician oversight is designed at the practice or the facility in a way that maximizes excellent care for patients. The proposed Pennsylvania regulations call for an increase in the time of physician chart review from three days to ten days. This is consistent with requirements in other states.

What Schedules of medications should PAs be authorized to prescribe?

Initial state laws for PAs authorized minimal physician-delegated prescriptive authority. As experience with physician-PA practice has grown, states have increased the authority of physicians to delegate prescriptive authority for controlled drugs to PAs.

The first state law to authorize controlled medication prescribing for PAs was passed in 1977.  No state that has passed legislation authorizing controlled medication prescriptive authority for PAs has ever repealed the provision. At present 34 states authorize supervising physicians to delegate Schedule II prescriptive authority to PAs.

The reason for this change has been two-fold. First and foremost delegated Schedule II prescribing by PAs has been shown to be extraordinarily safe. No increase in malpractice claims or disciplinary action has occurred when states have authorized Schedule II prescriptive authority for PAs. Some states have put time limits on the Schedule II prescriptions that PAs may issue (as is the case in the proposed Pennsylvania rules.)  These limits are increasingly being repealed.

The second reason for change has been the increasing concern for appropriate treatment of pain. State legislatures and regulatory agencies have recently enacted measures to remove unnecessary barriers to pain treatment. Allowing physicians to delegate prescriptive authority for Schedule II medications is consistent with this goal. PAs have commonly been utilized to extend are to rural and underserved populations. This can only be effective when the physician assistant is able to adequately provide primary care services, including routine analgesia and the stabilization and preparation for transport of patients with injuries. Allowing PAs to prescribe Schedule II medications can also decrease unnecessary visits to the emergency department or return visits to the office.

We hope this information is useful in your review of the proposed regulations. Please feel free to call on the Academy if there is more information we might provide.

Sincerely,

Ann Davis, PA-C

Director of State Government Affairs