Health Care, Human Resources, and Law

New law gives physician assistants greater autonomy

Guidance requires written practice agreements between doctors and physician assistants, gives PAs option to prescribe controlled substances.

March 17, 2017
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A new law will expand the scope of possibility for care providers, such as Libby Anderson, a physician assistant at Spectrum Health.

Anderson, who works in pediatrics at Spectrum Health Medical Group, 1545 68th St. SE, sees children for routine care, as well as treating ailments ranging from colds to the flu to ADHD.

A new Michigan law called Public Act 379, which takes effect March 22, refines the relationship between PAs like Anderson and the physicians in their practice.

Whereas before, the law required all PAs to work under the “supervision” or “delegation” of a physician, the amended law requires PAs to work with a “participating physician” under terms spelled out in a written practice agreement.

The law also deems PAs to be independent prescribers and grants them authority to obtain a state of Michigan Controlled Substance License to prescribe schedule 2-5 drugs, including opioids.

John Lichtenberg, a health care attorney at Rhoades McKee, said while the law may not substantially change the duties of a PA, the refined terminology does have other implications.

“What this statute does conceptually, in my view, is it (says) that the physician assistant is the deliverer of the medical treatment and care,” he said. “They still need to work in conjunction with a physician who is available to be contacted for advice, counsel and direction, but it is not a relationship where the physician is deemed the provider of the medical care. The physician is there as a resource for the PA.”

All physicians and PAs must clearly define the authority the PA holds in a practice agreement containing the following elements:

  • An agreed process between the PA and physician for communication, availability and decision making when providing medical treatment to a patient.
  • A protocol for designating an alternative physician for consultation in situations in which the participating physician is not available for consultation.
  • The signature of the PA and the participating physician on the agreement.
  • A termination provision that allows the PA or participating physician to terminate the practice agreement by providing written notice at least 30 days before the date of termination.
  • A requirement the participating physician verify the PA’s credentials.
  • The duties and responsibilities of the PA and participating physician.

Lichtenberg said while those basic elements of a practice agreement are set in stone, the details will vary depending on the type of practice in question.

“The practice agreement should be crafted to apply to each practice a PA is engaged in,” he said. “What a PA in a family practice setting will be asked to do is examining patients, limited prescribing, assisting in physicals or acute care evaluations for patients who show up, but they’re not going to be assisting and preparing an operating venue for orthopedic surgery or assisting in doing things an emergency room PA might do.

“If you think about the range of practice specialties in the medical world, there’s probably about the same range in the world of PAs. It might not be quite as deep, but it’s probably about as broad.”

Anderson said that although the new law won’t affect the “good working relationship” she has with the physicians in her practice, it will give her new opportunity and a little more risk.

“I will now carry more liability, since I will have my own Controlled Substance License instead of being under a physician,” she said. “I prescribe stimulants for ADHD treatment, and those meds are controlled substances.”

Another facet of the law, Anderson noted, is it shifts the balance of liability to take some of it off the physicians’ shoulders.

“My interpretation of supervising physician versus participating (physician) is that there is less liability for the physician,” she said. “This law also allows physicians to have as many PAs in his/her office as needed. The previous law limited the number under one physician’s supervision.”

The so-called “practice ratios” that limited the number of PAs a physician could supervise were part of the “tethered practice” model that required physicians to sign and license every prescription alongside the PA, as well as to supervise their practice.

Lichtenberg said the new law largely untethers a PA’s daily practice from the physician but includes a “cryptic provision” that says physicians still must delegate tasks to and work with PAs according to the general statute governing physician licensure and discipline.

“It makes things more uncertain for the doctors, as well as more liberating,” he said. “I have not talked to any doctors who say this is going to alter how they use PAs, but I suspect that will be evaluated in the months ahead.

“If people want to explore beyond the barrier, they can do that, but I don’t think there’s going to be a sudden rush where you’ll go to the doctor and there’s 40 PAs there working under one doctor.”

For health care attorneys like Lichtenberg, there may be some complications ahead.

“Some of the lawyers in our office who do professional liability defense work have the question that if the PA goofs up something, is there still physician liability other than they weren’t available to be called upon?” he said.

“The act is trying to say the physician assistant is the one responsible for the care you receive at their hands. But at least in the current environment, where you have a doctor and I have a doctor, and when I go in and see physician assistant Henry and something bad happens, do I think that was PA Henry’s problem or Dr. Smith’s problem?

“It poses an interesting question.”

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