Montana Considers Expanding Scope of Practice for Physician Assistants

A few days ago I wrote about that Montana is considering expanding pharmacists’ dispensing authority without a physician’s prescription. The following is what I wrote:

A bill before the Montana Senate (SB 112) would expand the prescribing authority of Montana pharmacists. Montana has only one primary care physician for every 1,210 residents. There are counties in Montana with no primary care physician, but most at least have a pharmacy.

Montana is now considering giving physician assistants the authority to practice independently of a physician. That is not how it currently works though.

Under Montana law, physician assistants must be supervised by a licensed physician, with a supervision agreement filed with the state Board of Medical Examiners.

Why would Montana consider allowing physician assistants (and pharmacists) more autonomy? This is what I wrote about Montana pharmacists, but it also pertains to physician assistants.

[A]ccording to a report by George Mason University’s Mercatus Center, there are approximately 228,000 primary care physicians spread across the United States. They aren’t evenly distributed. Some states have more than others. Cities have more than rural areas. Yet, even rural areas generally have pharmacies. According to the report, there are roughly 315,000 pharmacists spread across the U.S. Seniors especially visit pharmacies a lot; a lot more than they visit primary care physicians.

In some areas of Montana patients must drive three hours to see a physician

There you have it. Because many Montana counties have no physicians and residents of some areas have to drive three hours to see a physician. How far is a three hours drive in Montana? I suspect it’s between 200 and 225 miles. Can you imagine having to drive 200+ miles for a physician visit? What if your test was inconclusive and your doctor asks you to come back by? It would be nice to have some alternatives to a three-hour, 200 mile drive.

As Montana grapples with a health care provider shortage, state lawmakers are trying to find ways to increase access to care. One proposal up for debate is to give physician assistants like Zawacki more independence to practice unsupervised. Republican Rep. Jodee Etchart is sponsoring House Bill 313, which would let physician assistants practice without a supervision agreement. The bill is similar to laws in neighboring North Dakota and Wyoming.

Physicians tend to guard their turf fiercely, however. Under the current law physician assistants must be supervised by a licensed physician, which in many cases, means working for them. Many Montana physicians don’t want to change the status quo.

Many physicians oppose the measure. Jean Branscum, CEO of the Montana Medical Association, said the bill expands a physician assistant’s scope of practice with no added training requirements.

There are generally three types of practice for nurse practitioners and physician assistants. These are supervision, collaboration and independent practice. Supervision is the most restrictive practice type. Depending on the state supervision requires a physician review case files for a percentage of patients, while restricting how many PAs/NPs one physician can supervise. In Montana supervision agreements must be filed with the state Board of Medical Examiners. Collaboration is less restrictive generally just requiring a collaboration agreement on file at a physician’s office. Independent practice is the least restrictive, requiring no supervision or collaboration agreement, but not precluding physicians and NPs/PAs from collaborating in some way.

Chen co-authored a 2022 study that found patient outcomes were worse when care was given by a nurse practitioner instead of a physician, and she said she believes those findings could relate to physician assistants, too.

Instead of thinking of nurse practitioners or physician assistants as substitutes for doctors, Chen said, they should be integrated as part of a patient’s collaborative care team.

It is true there is no substitute for a trained physician, and a specialist for serious health conditions. However, having a lesser trained health professional nearby, who can refer patients to physicians and specialists in larger cities, would benefit many patients who lack easy access to a physician. Just as primary care physicians are quick to refer patients to specialists trained in a particular area, so would NPs/Pas.

Wyoming and North Dakota passed similar laws recently and have not experienced any adverse effects. The problem is there is a shortage of primary care physicians and many physicians are retiring. Sparsely populated rural areas have a hard time attracting physicians who may prefer the amenities of city life.