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 This process is outdated and in need of reform and should be revisited.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.