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We Build Alaska

SB 115 is the wrong way to fix healthcare access in Alaska

Healthcare today is more complex and complicated than ever before. Rapidly evolving science and technology mean that we have more options than ever for diagnosing and treating many diseases. As the healthcare landscape continues to evolve and specialize, the demand for more qualified healthcare providers has outstripped the supply.

As a solution to this problem, physician assistant (PA) and nurse practitioner (NP) programs were started in the 1960s to augment the physician (medical doctors, M.D.s and doctors of osteopathy, D.O.) workforce. Collectively, PAs and NPs are referred to as Advanced Practice Providers (APPs). APPs are integral and essential components of much of American healthcare. They often work collaboratively on teams led by physicians in outpatient clinics and in hospitals.

While PAs play a critical role in the delivery of healthcare and are highly valued partners, Alaska Senate Bill 115, which would grant independent practice to PAs, raises several issues of concern. Independent PA practice without physician supervision has implications for patient safety, quality of care, and the cost of healthcare in Alaska.

Some of the arguments for independent PA practice include onerous financial and regulatory requirements in order to retain physician sponsors. This process is outdated and in need of reform and should be revisited. A multidisciplinary task force of physicians, PAs, and regulators would be an excellent first step. However, wholesale removal of the requirement for physician oversight is not the correct approach and is in many ways a separate issue from the scope of practice of a PA. Indeed, many physicians no longer own their own practices and work for large private equity conglomerates that dictate much of their practice and result in exploitative financial arrangements.

Additionally, it is not clear that passage of this bill would not create additional financial and regulatory problems for PA practice. There may be increased malpractice insurance costs and difficulty obtaining malpractice insurance. Many PAs do not want to practice without physician oversight, collaboration, and shared liability. It will likely be cheaper in the short run of large clinics, hospitals, and other organizations to drop physician sponsorship, in the process depriving many PAs of valuable collaboration and increasing their liability. Many PAs chose the profession counting on the shared collaboration and liability.

Other arguments revolve around access to medical care. As we know, Alaska is a unique place with unique problems and it is no secret that access to quality healthcare in many places in the state is a significant problem. However, Alaskans don’t want access to substandard healthcare, they want access to high quality care. PAs operating in collaboration with physicians, as was originally envisioned and intended, are critical to helping do this.

Unfortunately, many studies and examples demonstrate when APPs operate without physician collaboration there is increased testing, specialty consultation, emergency department visits, and hospitalizations. This translates to higher costs for patients. When there is a vast influx of referrals directly to specialists (such as cardiologists, endocrinologist, rheumatologists, etc.) for routine issues that could have been vetted through a primary care doctor, the wait list can grow to weeks, months, and even years.

In an experiment performed by the VA in which Emergency Departments were staffed by APPs without physician oversight, the VA found increased cost, increased wait times, and increased unnecessary hospitalizations. In another experiment by the Hattiesburg Clinic (a large clinic in Mississippi) they found that APP led patient panels had higher costs, lower quality of care scores, more emergency department referrals, more testing, more referral to specialists, and lower patient satisfaction scores. Other studies have demonstrated similar findings, including higher rates of unnecessary antibiotics and opioid prescribing by APPs.

The problems described by independent PA practice are not surprising given the vast difference in education and training compared to physicians.  PAs complete 2 years of school prior to clinical practice. Physicians complete 4 years of medical school followed by 3-10+ of residency / fellowship training. Much of this physician training occurs in accredited large academic medical centers. Typically, residents and fellows spend up to 80 hours a week for 3-10+ years in intensive direct patient care responsibilities. Most programs have designated numbers of supervised procedures required in order to graduate in a given specialty. There is no required residency or other additional clinical training for PAs and much of the clinical training can occur in non-research outpatient facilities with variable responsibilities and exposure.

The training and curriculum are fundamentally different for PAs. Just as a paralegal wishing to become a lawyer or a drafter wanting to become an engineer would need additional schooling and training, PAs have the option of pursuing additional training through medical school. Even within the nursing field a CNA does not become an RN regardless of hours worked unless they attend nursing school.

Currently, SB 115 would allow for PA independent practice with just 4000 hours of experience and no provisions that it should occur within a given specialty.  Given the concerns outlined, the Alaska State Medical Association, the Alaska Academy of Family Physicians, the Alaska Chapter of the American College of Physicians, and the Alaska Chapter of the American College of Emergency Physicians, among other groups, oppose SB115 as it is written.

Reform of the physician/PA collaborative relationship is overdue and needed to support our invaluable PA providers, but SB 115 is not the way to do this.

Dr. Thomas Quimby is a practicing doctor in Alaska. He is the president of the Alaska Chapter of the American College of Emergency Physicians. 

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1 month ago

I went to a PA with flu like symptoms a few years back and was sent home with some medication. My pain subsided with the medication but the PA called a couple of days later telling me to fly to my local hospital. (After consulting with his overseeing physician.) They found I had a burst appendix that required immediate surgery. The operation took 4 hours to clean up the paratenonitis and gangrene. The costs of my 10 days in the hospital was first considered ” more than reasonable and customary” by my insurance and they denied most of the bill.… Read more »

Tom Cho
1 month ago
Reply to  Psgbill

I’m sorry to hear that your experience didn’t go well. I bet some of us can think the same of physician encounters we’ve had too.

I did find more than 30 articles illustrating the quality of care PAs deliver and their safety.

1 month ago
Reply to  Tom Cho

Many of the studies cited at that link suggest that PAs can provide quality care as part of a team and within their current bounds. I’m not seeing anything in these studies that suggests that PAs can or should broadly take on new responsibilities in which they effectively replace doctors.

As evidence that PAs provide quality care within the current system, these studies are interesting. As support for SB115, this is concerning and not particularly persuasive.

Tom Cho
1 month ago
Reply to  Hmm

The study of particular is insurance malpractice, the state allowed PAs to practice to the level in which they were trained without collaboration plans and found no change in malpractice risk over several years. That is one example. One of the other examples as stated is that NPs have been proving out point for many years in Alaska in providing safe and effective care within a similar framework of training.

1 month ago

I don’t really have an informed opinion on this subject, other than me and my family’s personal experience having been treated by Dr. Quimby. His patient engagement, conservative treatment approach and obvious competence all are indicative of a physician with a certain amount of wisdom. On questions of medical practice I am quite inclined to defer to Quimby’s judgement. Anchorage is lucky to have him. It would really surprise me if this opinion piece is motivated by a desire for rent seeking, rather than by his honest assessment of things.

Bart daniel
1 month ago

The problem with DrQuimby’s theses is that nurse practitioners are already granted the freedom and independence to practice medicine in their own and the quality of medical care has not crumbled since. So what he is saying in effect is that papa’s are not as qualified as nurse practitioners and should not be allowed to operate on their own. I would like to see evidence rather than opinion which can be viewed as protectionist at best.would PA’s drive down the cost of medicine? I think so

concerned about the economics
1 month ago
Reply to  Bart daniel

Nurse practitioners became independent practitioners in 1984. Healthcare costs since that time have increased 101% when adjusted for 2018 inflation. That certainly does not show a decrease in healthcare costs.

Source: Bureau of Labor Statistics Consumer Expenditures Survey, Household healthcare-related expenses (1984-2018).

Robert Saget
1 month ago
Reply to  Bart daniel

That is correct, PAs are not as qualified to practice independently as nurse practitioners. A nurse practitioner has an additional 2-3 years of education after becoming a nurse, with didactics, training, and clinical exposure that give them the option of independent practice. Still, there is wide state-to-state variation in practice authority for nurse practitioners, and in about half the states they aren’t legally allowed to practice independently. PAs have less education than nurse practitioners. In terms of education, they are more similar to a nurse who completed a post-graduate bachelors in nursing to work as a floor nurse (18 months… Read more »

Tom Cho
1 month ago
Reply to  Robert Saget

Nurse practitioners have about half of clinical experience as a health provider in their training: 500-1000 vs >2000 hours.

Robert Saget
1 month ago
Reply to  Tom Cho

You’re not refuting any of my points. You’re also citing a document without references that was prepared specifically in support of this bill by its sponsor and includes misleading (at best) information. Let’s unpack this. The way that the document is presented implies that PA’s complete 27 months of school followed by 2,000 supervised clinical hours as a PA in order to practice. This isn’t actually the case, as PAs can go directly into practice after PA school. There is no postgraduate clinical experience required for PA licensure. The PA’s 2,000 “clinical hours” listed are lumped into their 27 months… Read more »

Jule Miller
1 month ago

How about medical people can’t lie? How about medical people can’t get kickbacks? How about pharmaceutical reps can’t talk to medical people? How about the medical people tell the truth about vaccine injuries and follow the minimum vaccine safety standards of one vaccine at a time, not when sick and not too early??? How about we give a people a hair test when we don’t know what is wrong with them? How about make diet a part of people’s healing journey? How about putting Naturopathic doctors in the hospitals for a second opinion? Ya, that’s too much to ask……………

Elizabeth Henry
22 days ago

I have been seeing a Dermatology PA for thirty years and he is excellent. MD’s refer to him and his knowledge of skin cancer is exceptional. He works with an MD dermatologist but has his own staff and office hours. Still, I would say it is a matter of experience and years of knowledge. Any practice of medicine improves with years of experience for all medical professionals.