Appendix D.  Professional Practice Index Calculations for PAs

This appendix contains a table that documents the detailed calculations used to compute the new professional practice index for PAs for each of the 50 States plus the District of Columbia. The criteria used in the new index include:

Legal Authority (Maximum = 35)

Title protection prevents those not qualified or certified by the State from practicing as a professional. Title protection provides safeguards to the public and to the professional.

Licensure implies approval of credentials and granting of professional status. Licensing of PAs occurs in many States, but certification and registration is used in other States. States vary on the qualifications for licensure which may include the passing of a national certification examination and in some States, an employment agreement with a physician.

Although having a supervising physician is fundamental to PA practice, the professional association for PAs suggests that employment agreements should be independent of licensure. PAs should not be required to have an employment contract to remain licensed [PAs 8th edition, p. v].

Professional Practice should be “dependent on what the supervising Physician wishes to delegate” [PAs 8th edition, p. xi] and not be finely detailed in law.

Supervision should be the least restrictive mode that permits appropriately supervised practice. “Continuous” [PAs, 8th edition, p. xvi] supervision which may be indirect, but which permits contact with the supervising physician as needed is most desirable.

Regulation by a PA Committee of the Board of Medicine is the optimal regulatory mechanism. Input by PAs is important to the profession.

Fees for supervisory agreements can create disincentives for association with a professional. High costs may limit the number of agreements between a physician and PAs.

The conditions and timing of review of records, although an implicit part of practice between a physician and a PA, is best determined by the agreement between the two professionals rather than by specific delineation in legislation.

Limiting the number of PAs with whom a physician may associate through legislated ratios may be unduly restrictive. Leaving that number to the discretion of the physician and PAs suggests confidence in the abilities of both professions to adequately provide care within the skill and competencies of each and “according to the tenets of good patient care, adequate supervision, and legal responsibility.” [PAs, 8th edition, p. vi]

Locum Tenens means “the temporary provision of services by a substitute provider.” [PAs, 8th edition, p xx]. Allowance for substitution in law provides legal means for a physician or a PA to continue to practice in the temporary absence or inaccessibility of the other.

Temporary License permits a PA to practice prior to taking the certification examination.

Supervising Physician Liability in law reinforces the legal relationship that exists between a physician and PA.

The ability to act independently in a declared emergency allows a PA to respond appropriately to emergency needs in a disaster. It provides legal protection for services provided by the PA in those circumstances.

Reimbursement (Maximum = 25)

Any mandated payment reflects the evolution of payment over the decade. Payment to PAs was changed after passage of the Balanced Budget Act in 1997 which extended payment for services rendered by PAs to all locations where they are employed.

Medicaid payment percentage varies by State and this category reflects that fluctuation.

Any language that permits reimbursement to “any qualified provider” is intended to describe the legal obligation to pay for services supplied by a PA. PAs are generally in employment situations in which the physician or the facility is billing for and receiving reimbursement for health services. Legislation that protects the right to payment is enabling to care.

Prescriptive Authority (Maximum = 40)

Prescriptive authority as delegated to PAs “can improve patient access to comprehensive care and provide for increased efficiency and cost effectiveness.” [PAs, 8th edition, p. vii]. It may be defined in law or by the supervisory agreement. The more extensive privilege allows the PA more latitude in patient care. DEA numbers are required when prescribing scheduled drugs. Points are allotted for a DEA number to emphasize the importance of the prescriptive privilege.

Accepting and distributing samples, having the PA name on the prescription pad and signing prescriptions are indicative of latitude in practice provided to the PA in law.

The actual point allocations for PAs for the 50 States are presented below.

FOOT NOTES

Alabama
h) Physician must review PA prescribing practices weekly by a review of 10% of patient charts
Alaska b) Lose authority to practice if lose collaborative agreement
c) Board approves "method for periodic assessment" and plan for delegation of prescriptive authority
p) Schedule ll allowed with approval of physician
Arizona
I) PA must meet with physician once a week but review of records is not defined
Arkansas
g) Board "may" appoint an Advisory Committee
j) No more than 2 PA's at onetime
p) Statute says pharmacists authorized to fill scripts from PA's but rules say physician must sign all scripts . 1999 statutory change not yet reflected in rules
California
I) Countersignature and dating of 10% of medical records within 30 days but review of records of patients receiving prescription within 7 days
p) Practice specific formulary and protocols that list specific criteria for prescribing. Controlled substance prescriptive authority is patient specific
Colorado
I) In statute, review of records every 2 days in HPSA. In regulations, chart notes of PA's reviewed and signed by physician within 7 days
j) No more than 2 "specific individual" PA's
f) PA practices "under personal and responsible direction and supervision of licensed physician"

REFERENCES

Main Resources
American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, Alexandria, Virginia 1992.
American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, Alexandria, Virginia 1998.
American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, Alexandria, Virginia 2000.
American Academy of Physician Assistants, http://www.aapa.org
Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service.
U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners
Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html
Washburn Law School, www.washlaw.edu Alabama State of Alabama Medicaid, http://www.medicaid.state.al.us
Alabama
Society of Physician Assistants, http://www.alabamapasociety.org
Alaska
Alaska Academy of Physician Assistants, http://www.akapa.org
Arizona
The Arizona State Association of Physician Assistants, http://www.asapa.org
Arkansas
Arkansas General Assembly, http://www.arkleg.state.ar.us
Arkansas Academy of Physician Assistants, http://www.aapa.org/states/arapa
California
Physician Assistant Committee, Medical Board of California, http://www.physicianassistant.ca.gov
Colorado
Colorado State Board of Medical Examiners, http://www.dora.state.co.us
Colorado Academy of Physician Assistants, http://www.corloradopas.org

FOOT NOTES

Connecticut
I) Regular review of records
p)Schedule II, III inpatients only, co-signature by physician within 24 hours
Delaware
f) Not more than 30 minutes distant
I) In regulation every 3 months (not merely up to physician and physician assistant team)
k) Maximum number of PA's is 2
DC
f) Present within a 15 mile radius of District
I) Countersign all medical orders and progress notes within 48 hours
k) No more than 2 PA's at one time
Florida
f) Reasonable physical proximity
I) Review and sign records within 7 days
j) No more than 4 at anyone time
o) Insurance must provide payment for PA first assist if coverage would have been provided to physician first assist
Georgia
d) But board must approve scope job description
f) Physician readily available for personal supervision
I) Physician to sign medical record entry for script within 7 days, review patient records daily in remote site
j) No more than 2 PA's at any onetime
p) Schedule II in emergency only
Hawaii
h) No agreement
I) Review of charts within 7 days
j) No more than 2 at one time
p) Administer, Prescribe, Dispense Schedule ll inpatient only
q,r) May request, receive or sign for professional samples, not controlled substances

REFERENCES

Main Resources

American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Sixth Edition, Alexandria, Virginia 1992.
American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Seventh Edition, Alexandria, Virginia 1998.
American Academy of Physician Assistants, Physician Assistants, State Laws and Regulations, Eighth Edition, Alexandria, Virginia 2000.
American Academy of Physician Assistants, http://www.aapa.org
Henderson T and Norris S, National Conference of State Legislatures, Health Policy Tracking Service.
U.S. Department of Justice, Drug Enforcement Administration, Diversion Control Program, Mid-Level Practitioners
Authorization by State, http://www.deadiversion.usdoj.gov/drugreg/practioners/index.html
Washburn Law School, www.washlaw.edu
Connecticut
Connecticut Academy of Physician Assistants, http://www.connapa.org
Delaware
Delaware Academy of Physician Assistants, http://www.delawarepas.org
DC
District of Columbia Code, dccode.westgroup.com
Office of Documents and Administrative Issuances, os.doc.gov/info
Florida
Nova Southeastern University, http://www.nova.edu/pa
Florida Academy of Physician Assistants, http://www.fapaonline.org
Georgia
Georgia Association of Physician Assistants, http://www.gapaonline.org
Hawaii
State of Hawaii, Office of the Auditor, http://www.state.hi.us/auditor
Hawaii Academy of Physician Assistants, http://www.aapa.org/states/hapa.htm.