Should physician assistants work without physician supervision? 2 bills under emotional debate

SALT LAKE CITY — Two Utah bills that would broaden the scope of physician assistants passed their first legislative hurdle on Friday after an emotional debate between members of the physician assistant and physician communities.

"During the pandemic we've seen a real challenge to health care accessibility because of limited traveling and distancing. ... And P.A.s have stepped up — and we learned that during the interim — and they've done so in a very real way," Sen. Curt Bramble, R-Provo, told members of the Senate Health and Human Services Committee on Tuesday.

Both sponsored by Bramble, SB27 would allow physician assistants to work without physician supervision, while SB28 would add them to the state's Mental Health Professional Practice Act and allow them to independently offer mental health care if they receive certain training and experience.

Members of the physician community, including the Utah Medical Association, spoke out against the bill last month largely due to the differences in education and training of physicians versus physician assistants.

A physician assistant's training lasts about three years and includes 2,000 hours of clinical rotations, according to the American Academy of Physician Assistants. A physician's training lasts between seven and 15 years — four years of medical school and three to seven years of residency.

Physician assistants can diagnose and treat illnesses, prescribe medication, conduct physical exams and perform many of the other tasks of general practice physicians. Most states, including Utah, require them to work under a physician and get paid through a physician rather than directly from the patient's private or public insurance — an aspect of the law physician assistants in the state say has impeded their ability to work.

Bramble said Tuesday he's worked with the Utah Medical Association and other stakeholders to reach compromises on the bills that would require physician assistants to get many more hours of experience before working independently.

Physicians' concern

But physicians voiced concern with both bills during the meeting and said they want to see more revisions before they reach a vote in the full Senate.

Michelle McOmber, CEO of the Utah Medical Association, said she "likes the direction" amendments to SB27 have taken.

"We are absolutely supportive of physician assistants and have a great deal of respect for them, and think they are an essential part of a health care team," McOmber said.

But she said the association fears SB27 would make a physician assistant a "super-provider outside of a health care system, outside of a physician's office, right out of school" and that the scope of physician assistants' practice isn't clearly defined.

McOmber said her group will continue to work with physician assistants and Bramble. The association supports physician assistants' desire to move forward but wants them to do so "in a way that makes sense," McOmber said.

P.A.s weigh in

Wade Anderson, who described himself as a practicing physician assistant in Gunnison, said his supervising physician recently died of COVID-19 "and our community lost so much when he passed away."

Despite having worked for many years, "I was no longer legally permitted to care for my patients following his death despite my scope of practice, my training, and the fact that I've taken care of many of these patients," Anderson said.

He said patients' care was delayed due to the need to find a new supervising physician and the clerical work that needed to take place.

Roger Machado, who also described himself as a physician assistant, said that at a clinic where he has worked "the work was carried by us as P.A.s," and he had little supervision from his physician supervisor. He called the bill a "formality" that would reflect how physician assistants are practicing now.

'Disenfranchising' medical school?

Gabby Saunders, with the American College of Obstetricians and Gynecologists, said the organization is "highly opposed" to the bill due to potential unintended consequences.

"This isn't fair to doctors. We don't know how this is not going to prevent someone from wanting to go to medical school in the future," Saunders said.

Sen. Mike Kennedy, R-Alpine, also expressed concern that the bill could lead to fewer people wanting to become doctors in the future.

"Essentially what we're authorizing with this, and it's a big deal ... we have to look to 30 years in the future," Kennedy said, questioning why those in the future will choose to go to medical school and go through a residency with low pay.

Kennedy questioned whether the bill would be "disenfranchising" the medical school system. But he ultimately called the bill "an opportunity for the best to rise to the top."

Kim McFarlane, with the Utah Academy of Physician Assistants, called SB27 a "modernization act," explaining that it would reflect how physician assistants "already practice."

During the pandemic, physician assistants got deployed to where they were needed. McFarlane said the bill would help them continue to fill gaps in the medical system.

Bill requirements

New changes to the SB27 bill include a requirement for new physician assistant graduates to work in collaboration with other health care providers for 5,000 hours, including 1,000 hours under direct tutelage of a physician, or 2,000 hours if they want to go into a certain specialty.

Under the bill, physician assistants would also need to identify themselves as such and not as doctors.

For physician assistants who want to open their own clinics or work in situations outside of current employment opportunities, the bill would require them to hold at least 10,000 hours of experience in addition to the 5,000 hours of collaboration. At least 1,000 of those hours would be with a physician mentor, McFarlane said.

Meanwhile, changes to SB28 would require a physician assistant who wants to specialize in psychiatric care to complete a doctoral-level certificate program, a doctoral degree or qualifying postgraduate residency. They would then be required to work under an experienced supervisor for 3,000 hours, 1,000 hours of which would be psychotherapy, said Tim McCreary, also with the Utah Academy of Physician Assistants.

Both bills will likely undergo further modifications as the Utah Academy of Physician Assistants and Utah Medical Association work on compromises before the bills make their way to the full House.

The bills received favorable recommendations from the committee. Bramble promised to work with the Utah Academy of Physician Assistants, the Utah Medical Association and other stakeholders to reach compromises on both bills before they make their way to votes in the full Senate.

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