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Supervisory and Collaborative Pacts Between Physicians and Physician Assistants Challenged

Analysis  |  By Christopher Cheney  
   April 29, 2020

Physician assistants need more leeway to practice medicine because of the coronavirus pandemic, a PA organization says. But a physician group is skeptical.

Particularly during the coronavirus pandemic, a national physician assistant organization is calling on states to drop laws that require collaborative or supervisory agreements between physicians and PAs.

At hospitals and other healthcare facilities, staffing shortages are one of the primary challenges of the coronavirus disease 2019 (COVID-19) pandemic. For example, to adequately staff new ICUs that have been created to address surges of seriously ill coronavirus patients, the Society for Critical Care Medicine is recommending tiered staffing that includes personnel redeployed from other hospital departments.

"These agreements are mainly relics of the past because most of the legislation establishing these arrangements was written 45 years ago, when PAs and nurse practitioners were much more of an experiment," says David Mittman, PA, president and chair of the Alexandria, Virginia–based American Academy of PAs (AAPA).

There are two primary reasons to drop the collaborative and supervisory agreement laws, he says.

"First, it is important to lift any agreement that is mandatory because they are barriers to care. They prevent PAs, physicians, and healthcare teams from practicing the way we need to practice. … Second, during the COVID-19 pandemic, it is even more important to eliminate these barriers because clinicians have to go to areas of need. It is important to allow PAs to practice at the highest level."

The collaborative and supervisory agreement laws are inappropriate during the COVID-19 pandemic, Mittman says. "The limitations on PAs don't make sense under normal conditions; and in a crisis where we need all-hands-on-deck, the limitations make much less sense. This is about saving lives, and legislation written decades ago to make sure that PAs and nurse practitioners were not dangerous in any way are barriers that need to be removed."

Last week, Virginia Gov. Ralph Northam issued an executive order allowing PAs with at least two years of clinical experience to practice medicine without a practice agreement during the commonwealth's COVID-19 state of emergency. 

According to the AAPA, seven other states have waived physician supervision or collaborative agreements for PAs in executive orders related to the COVID-19 pandemic: Maine, Michigan, New Jersey, New York, Louisiana, South Dakota, and Tennessee.

Up to the task

PAs provide the same services as physicians, and the differences between the clinicians are based mainly on specialty rather than training, Mittman says.

"For example, a PA who works in an emergency room and is comfortable doing procedures would be a lot more able to go to the ICU and function there than a PA or even a physician who is a psychiatrist. A PA in family practice could probably move to urgent care during the pandemic. A PA in urgent care could definitely move to the emergency room."

PAs are well-suited to work with COVID-19 patients, he says. "PAs are trained as generalists first. So, they all do rotations in emergency medicine and primary care. They are qualified to diagnose and treat patients in primary care, urgent care, emergency rooms, and hospital settings for patients who either have or could have COVID-19."

Many PAs are already on the frontlines of the pandemic in supervisory roles, Mittman says. "Drive-thru testing sites at large health systems are frequently staffed by and—in many cases—run by PAs. Drive-thru test sites operated by the military and public health departments have PAs in command positions."

PAs also are being called upon to utilize their primary care training to free up primary care physicians to work in urgent care and emergency rooms, he says.

"PAs are very flexible because of their training and clinical experience. They can function in almost any area. PAs are not only freeing up physicians to provide COVID-19 care. They are freeing up other PAs who have experience working in hospitals to treat pandemic patients."

Physician group skeptical

Physicians for Patient Protection—a grassroots organization of practicing and retired physicians, residents, medical students, and assistant physicians—is opposed to dropping the supervisory and collaborative agreement laws for PAs.

"Physicians for Patient Protection believes that physician-led care is the gold standard and is what patients expect and deserve. PAs right now, under current state laws, can absolutely assist in this COVID crisis to the full extent of their education and training. There is nothing stopping them from working right now and treating patients as part of a team," says Carmen Kavali, MD, a board member of the group and practicing plastic surgeon in Atlanta.

The COVID-19 pandemic should not be used as a justification for rescinding supervisory and collaborative agreement laws, she says. "During a pandemic is not the time to experiment with unsupervised practice by PAs, who have 27 months of medical education, compared with seven to 11 years of physician education. PAs are a valuable part of the team, but the profession was never intended to work independently of physicians."

Clinician liability is a concern, Kavali says. "We are unaware of any mandates that would ensure equitable malpractice limits for PAs, which should match those of physicians if a PA is practicing independently, so physicians would not have the 'deepest pockets' for attorneys to pursue."

Christopher Cheney is the senior clinical care​ editor at HealthLeaders.


Supervisory and collaborative agreements between physicians and PAs are barriers to care, according to the American Academy of PAs (AAPA).

PAs should be allowed to practice at the highest possible levels during the coronavirus pandemic, the AAPA president and chair says.

A national physician group is opposed to dropping the supervisory and collaborative agreements.

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