PracticalDermatology

The SDPA recently released a position statement in response to the American Academy of Physician Assistants (AAPA) task force’s proposal to pursue full practice authority and responsibility (FPAR) for the PA profession. In light of discussions that have followed the release of the proposal and our position statement, the SDPA has made a recommendation to AAPA to consider changing the name of the proposal to “PA Practice Reform” to more accurately reflect the intention of the proposal to simplify the PA licensure and regulatory process while maintaining PA commitment to team-based practice with physicians. We encourage every SDPA member, dermatologist, and others with vested interest in PA practice to take the time to fully understand the significance of the proposal as it relates to licensure, viability of PA job opportunities, and inclusion in the ever increasing numbers of corporate owned and managed medical practices.

The PA profession was built on a team-based approach to medical practice, which the SDPA and the task force proposal continue to recognize as foundational to our goal of providing patients better access to care as a part of a healthcare team. The SDPA has always been, and will continue to be, an advocate for team-based practice and collaboration between PAs and dermatologists. The knowledge and skills we gain from working alongside our collaborating physicians is essential to our continued growth and ability to provide the best care for our patients. Contrary to what a few have misinterpreted, the SDPA does not support independent or autonomous practice for PAs, but rather a mutually agreeable team approach to providing dermatologic care that recognizes both the capabilities and limitations of each individual PA’s education and experience. Our commitment to maintaining the integrity of the physician-PA team is best demonstrated by our membership requirements and bylaws, which require fellow members of the SDPA to be working with a board-certified or board-eligible dermatologist.

The SDPA’s response to AAPA’s proposal stems from a trending development in medicine that reaches far beyond our small world of dermatology. Model legislation for nurse practitioners, which has already been adopted in 21 states and the District of Columbia (www.aanp.org/legislation-regulation/state-legislation/state-practice-environment), provides full practice authority to NPs and has seemingly been less controversial in the dermatology community. Though it is important to note that the goal is not to achieve independent practice as some states allow for NPs, we do need reform in the licensure and regulatory processes that currently serve as a barrier to timely transition to PA practice.

The unfortunate consequence of current PA practice regulations versus that of NPs is in the job market we share. The rise of corporate medicine and recent VA regulations have made it increasingly more difficult for PAs to compete for positions they are well qualified to fill, simply because our licensure requires a physician to agree to a varied degree of supervisory terms and liability for the care we provide. Hiring a PA, in these situations, has become more cumbersome than hiring an NP for some physicians. Additionally, the rapid rise of corporate owned medical practices has affected the willingness by physicians, who are now employees of the practice, to accept PA collaboration/supervision agreements and the liability they imply. Physicians who are employees, rather than owners or stakeholders in a practice, are less likely to accept the liability of PA supervision because the corporation reaps the majority of the benefits from adding a PA to the clinic staff. As a result, the viability of the PA profession in the job marketplace is being threatened in a time when we should be thriving.

Collectively, these issues pose a serious threat to PA opportunities in the workforce when compared to our NP colleagues, in all disciplines of medicine including dermatology. A prime example of this issue revolves around the Department of Veterans Affairs’ December 2016 rule to allow for NPs to exercise full practice authority in order to allow veterans to have direct access to care provided by NPs within the VA system (www.va.gov/opa/pressrelease.cfm?id=2793). Though the ruling uses the terms “full practice authority,” NPs in the VA setting will still be practicing alongside physicians to maintain collaborative relationships with them. The ruling will undoubtedly provide a larger set of healthcare providers to offer more timely care for our nation’s veterans, which is long overdue. Unfortunately, the regulation was not inclusive of PAs (whose practice is governed under a different title in the law), and has great potential to negatively affect the ability for PAs to secure employment in the VA system until a new ruling is passed. The difference in practice guideline semantics for PAs, in this instance, has created a clear gap in the ability of PAs to contribute equally to increased access to care for veterans. This same scenario can be applied to any healthcare system or corporate practice to demonstrate how regulations play a vital role in our ability to join forces with our physician and NP colleagues to meet the rapidly changing needs of our patients.

It is important to note that the SDPA has also suggested an edit to the proposed FPAR language from AAPA to make clear that we remain committed to “team-based practice, rather than autonomous care.” Another goal of the FPAR proposal is to establish state PA licensing boards with a voting membership that includes PAs to allow for involvement in licensure, regulations, and disciplinary action for our own profession. This model mirrors that of NPs, which are governed by state nursing boards with the best understanding of NP education, training, and legislation. Physicians are similarly governed by medical boards comprised of physicians. Several states do include a percentage of PAs on their medical board, and the goal is to ensure that PAs are represented on medical boards nationwide.

We recognize the issues within state PA licensure protocol, which require a varying degree of time-consuming and unnecessary steps for PAs to obtain a license, practice, or prescribe medication. Simply put, we believe the PA licensure and regulatory process should be simplified, while maintaining the collaborative relationship with physicians in clinical practice. The FPAR proposal, as defined for individual PAs, asserts that PAs should continue to practice as part of a team with physicians and other providers, practice to the highest level of their education and training, and most importantly, recognize the limits of their knowledge and abilities. It also seeks to place liability and responsibility on each PA for the care they provide, rather than requiring a physician to accept that undue burden under the current “supervising physician” rules (www.news-center.aapa.org/fpar/), while still maintaining collaboration with physicians in day to day practice. Some states require an in-person meeting between the medical board, physician, and PA before the PA may begin seeing patients, which obviously causes unintended delays in patient access to care. Others require approval from the state medical board for PAs to perform a procedure they are trained on in the clinic beyond that which is listed in the initial supervisory terms. Ideally, PA scope of practice should be defined at the practice level between the PA and collaborating physicians, rather than by an overarching state or federal regulation that has no regard for individual training and skills.

A recent example of legislative action similar to the FPAR proposal occurred with Michigan House Bill 5533, which was enacted in December 2016. The updated legislation removed the requirement for physicians to sign on as a supervisor for PA licensure. However, it does require that PAs maintain a practice agreement with a physician, which is much different than independent practice. This agreement defines the communication and decision making process by which the PA and the participating physician provide medical care to their patients and may place conditions on specific duties, procedures or prescriptions based on individual knowledge and training. It also removed the limitation on the number of PAs that may practice with a physician, which allows for physicians to build their healthcare team to meet the needs of the patient population they serve within the capabilities of their specific healthcare team. These changes are essentially technical and involve a shift in the mechanism by which PA practice is defined.

The SDPA, as a whole, has the responsibility to advocate for the practice of PAs in dermatology, both today and in the future. Our support of FPAR reflects the need to support the evolution of PA practice as it relates to the healthcare team and protect the viability of our profession, not a desire to practice apart from the dermatologists whom we learn from at all stages of our careers and with whom we share our passion for excellence in dermatologic patient care. We fully recognize the value of the dermatologist-PA team in providing more timely access to care, ongoing collaboration, and lifelong learning as all members of the healthcare team seek to better the lives of the patients we serve.

—Signed, The SDPA Board of Directors