Commentary

Putting the “PA” in “FPA”


 

References

The term full practice authority (FPA) means different things to different clinicians. Some think it is a code phrase for “independent practice,” while others regard it as the ability to practice to the fullest extent of their education and licensure. The American Association of Nurse Practitioners (AANP) defines FPA as the “collection of state practice and licensure laws that allow for NPs to evaluate patients, diagnose, order and interpret tests, initiate and manage treatments—including prescribe medications—under the exclusive licensure authority of the state board of nursing.1 Whatever the definition, it is an emotionally packed phrase for NPs, PAs, and our physician colleagues.

While NP and PA scope of practice is largely dictated by state laws and regulations, it is also impacted by other factors, including employment agreements, practice setting, and billing requirements of Medicare and other third-party payers.2 In the past decade, there has been increasing support for eliminating barriers to practice. Advocates say the current supply of health care services is unnecessarily limited—a problem that will increase as our population ages and people live longer with chronic conditions. With the health care system under constant pressure, many believe that all clinicians should be able to provide care to the full scope of their education and expertise.

Proponents of FPA, including the Institute of Medicine and the National Governors Association, cite improved access to and efficiency of care and reduced costs as the main motivations for lifting practice restrictions.3,4 In an extensive document, the RAND Corporation called for states to relax scope-of-practice restrictions for NPs.5 Findings from the Federal Trade Commission assert that NPs are safe and effective as independent providers of health care services within the scope of their training and licensure.6

Meanwhile, opponents—such as the American Academy of Family Physicians (AAFP) and the American Medical Association—express concerns about the lack of clinical education compared to physicians, as well as patient choice and fragmentation of care.7 Back in 2010, the AAFP objected to statements from the National Board of Medical Examiners (NBME), which alleged that physicians and nurse clinicians have comparable scopes of practice; NBME further suggested that licensing authorities for both professions “should be required to create common means of assessing proficiency for entry to and continuation in practice.”8 Osteopathic physicians pushed back on FPA, worried that NPs would be confused with physicians.9 But as NPs have clarified, their license is an extension of their RN license; they do not need physician endorsement for the advanced component.

What goes without saying is that NPs and PAs play a large and expanding role in the American health care delivery system. NPs constitute the fastest-growing segment of the primary care workforce in the United States. And because they are proven to be highly educated clinicians who take responsibility for their clinical decisions, many states are relaxing scope-of-practice restrictions to allow them to provide more extensive services to their patients. Currently, 21 states and the District of Columbia allow FPA for NPs.10 Furthermore, in a recent landmark decision, the US Department of Veterans Affairs (VA) announced new rules granting Advanced Practice Registered Nurses (APRNs) FPA within the VA system.11

In contrast to the varying degrees of autonomy with which NPs practice, PAs provide medical services exclusively under the delegation of physicians. Although many function in autonomous practices, PAs have no authority to function independently or to provide services unless assigned by and under the auspices of a supervising physician.12 This should not come as a surprise, since PAs have always touted that the profession was created for physicians, by ­physicians.

But as NPs have advanced their FPA agenda, many PAs have asked, “What about us?” Brian Sady, a PA from Nevada, has been advocating FPA for many years to enhance the accessibility and quality of care in his rural state.13

In fact, the American Academy of Physician Assistants has been lobbying the VA to grant FPA to PAs in parity with their recent action regarding NPs.14 And now, the Academy has gone a step further with the creation of the Joint Task Force on PA Practice Authority. Their raison d’etre is to develop a proposal that supports the elimination of regulations that require PAs to have and/or report supervisory, collaborating, or other specific relationships with a physician in order to practice.15 This is a significant change of direction for the PA profession and is stimulating a great deal of discussion.

In order to accomplish their goal, the task force must emphasize the PA profession’s continued commitment to team-based practice. Interestingly, Michigan recently enacted a law that distinguishes participating physicians from supervising physicians in order to better reflect the PA and physician roles within the team. The law removes physician responsibility for PA practice, making each member of the health care team responsible for his or her own decisions. It also removes the ratio restriction that limited the number of PAs with whom a physician may practice. By recognizing PAs as full prescribers, rather than limiting their care to “delegated prescriptive authority,” the law grants PAs more autonomy to serve patients.16

PAs are regulated by the state medical board or a subset of it—only five states have a PA-specific board—whereas NPs have always practiced under the auspices of their state nursing board. If the task force proposals are adopted by the AAPA House of Delegates, they will support the creation of autonomous state boards with a majority of PA members to regulate practice. (Iowa is currently the only state PA board that has a majority of PA members.)

Some argue that FPA for PAs would disrupt the current PA-physician relationship. Others contend that FPA for PAs will strengthen that relationship and balance the respect, support, and professionalism that enable PAs to consistently provide high-quality care.

Both NPs and PAs assert that they have, throughout 50 years, demonstrated a commitment to competent, quality care for patients. By defining the future of our professions, we make our professions more accountable, preserve our positive relationships with physicians and other members of the health care team, decrease unnecessary administrative burdens on physicians and employers, and most importantly, increase access to quality care for our patients. Share your expectations and opinions regarding professional autonomy with me at ­PAEditor@frontlinemedcom.com.

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