HD29 - Prescriptive Authority of Physician Assistants

Executive Summary:

Authority for Study

House Bill 2318 (HB 2318) of the 2001 General Assembly Session expanded the prescriptive authority for physician assistants (PAs). Specifically, the prescriptive authority for PAs changed from the authority to prescribe only Schedule VI drugs to a time table (over a period of several years) for the authority to prescribe Schedules IV-VI drugs. An enactment clause in HB 2318 required the Joint Commission on Health Care to provide a report on the issue of prescriptive authority for PAs prior to the 2005 General Assembly Session. Specifically, the Commission is required by the enactment clause:

"…to study physician assistant prescriptive authority as provided in this act to determine the impact of the authority to prescribe Schedules IV through VI controlled substances and devices on patient care, provider relationships, third-party reimbursement, physician practices, and patient satisfaction with physician assistant treatment."

It should be noted that House Bill 2205 (HB 2205) of the 2003 General Assembly Session also expanded the prescriptive authority of PAs. HB 2205 provided PAs with the authority to prescribe Schedule III controlled substances on or after July 1, 2004.

Growth in the Number of Physician Assistants

The number of PAs in Virginia has increased more than 90 percent between 1999 and late-March 2004. As of late-March 2004, there were 957 licensed PAs in Virginia. The number of PAs with prescriptive authority was 697, appearing that almost 73 percent of PAs have prescriptive authority. Because only 771 of the 957 licensed PAs are engaged in active practice, the number of eligible PAs with prescriptive authority would actually be closer to 90 percent.

Virginia Data on Physician Assistants

The Board of Medicine (BOM) collects some information about its licensees including PAs and their practice locations. Having information regarding the practice location of PAs allows a comparison to the primary care health professional shortage areas (HPSAs). JCHC staff compared the PA addresses that were provided to the BOM with the primary care HPSAs. This comparison of data found that 94 records or 9.9 percent of records listed work addresses that were found to be in designated primary care HPSAs. (Analysis of 950 of 989 PA records listing a Virginia address were matched to a census tract). Seventy-two records or about 7.6 percent of records of PAs with prescriptive authority listing a Virginia address listed addresses that were found to be in primary care HPSAs.

Information concerning PA primary practice specialty is not collected. This information would be useful in comparing the locations in which PAs practice, the practice locations that are within a HPSA, and the practice specialties that are represented.

Information on Other States

Three states allow no prescriptive authority for PAs; Ohio, Louisiana, and Indiana. Twenty-eight states allow PAs to prescribe up to Schedule II controlled substances with physician involvement (although some states may have restrictions and/or formularies). Eleven states allow PAs to prescribe drugs through Schedule III controlled substances (although some states may have restrictions and/or formularies). A small number of states allow prescription of the lower schedules of controlled substances, a formulary of authorized drugs, or non-controlled substances.

At the time of this study, Virginia was in the mid-range of the level of prescriptive authority allowed to PAs in comparison to other states, but moved up by authorizing as of July 1, 2004, PAs to prescribe Schedule III through VI controlled substances. The level of supervision required for PAs varies widely between states. Although some states require direct, on-site supervision, most do not. Other states allow for supervisory contact via some type of telecommunication. There are also stipulations in some states for chart review or cosigning within a variety of time-periods. Virginia requires continuous supervision, but the physician does not have to be physically present at all times.

Mandated Areas of Study

With regard to areas mandated for study, JCHC staff found:

• A number of studies conducted in the United States have shown that quality care is being provided by PAs. Moreover, it is likely that the increase in PA prescriptive authority in Virginia has had a positive impact on patient care.

• The research on provider relationships is ambiguous; making further extrapolation to the impact increased PA prescriptive authority has had on provider relationships difficult.

• Reimbursement of PA services depends on the category of payer. Currently, under the Virginia Medicaid program, PAs do not receive direct reimbursement.

• The impact that the increase in PA prescriptive authority has had on physician practices is closely tied with other previous categories (for instance, physician practices are impacted by provider relationships). Physicians in practice were impacted in their day-to-day operations if they employed PAs when the PA prescriptive authority increased. Some individuals contacted as part of the study indicated that the prescriptive authority was beneficial to physicians and PAs in that it reduced some burdens. Some of these decreases in burdens likely increased the efficiency of some physician practices.

A number of studies indicated that patient satisfaction exists with PA services generally. In addition, anecdotal evidence suggested that patient satisfaction with regard to PA prescriptive authority was high.

Actions Taken by JCHC

Three policy options were offered for consideration by the Joint Commission on Health Care. On November 15, 2004, the Commission voted to take no action.