Background:

I. Physician Assistants.

A physician assistant is an individual licensed to practice medicine pursuant to a delegation agreement with a physician. A physician assistant may only practice with the approval of the Washington Medical Commission (WMC) and only to the extent allowed by the WMC. A physician assistant may provide a service that he or she is competent to perform based on his or her education, training, and experience.

A. Delegation Agreement.

The delegation agreement must be submitted jointly by the supervising physician and the physician assistant. The agreement must delineate the manner and extent to which the physician assistant will practice and be supervised.

A physician may enter into a delegation agreement with a maximum of five physician assistants, unless the WMC grants a waiver. Regardless, a physician may not supervise more than three physician assistants at a remote site or more physician assistants than the physician can adequately supervise.

B. Supervision.

Physician assistants may practice only under the supervision and control of a physician, but the supervision does not require the physical presence of the physician. The physician and physician assistant determine which procedures may be performed and the degree of supervision for the procedures. The physician assistant's practice may not be beyond the expertise and practice of the physician. The physician and physician assistant retain professional responsibility for any act performed by the physician assistant that constitutes the practice of medicine.

C. Signing Documents.

A physician assistant may sign and attest to any certificates, cards, forms, or other documentation that his or her supervising physician may sign as long as it is within the physician assistant's scope of practice and consistent with the practice arrangement plan.

D. Remote Sites.

A physician assistant may not practice at a remote site without approval of the WMC. The WMC may approve such practice if:

there is a demonstrated need;
there is adequate provision for timely communication between the physician and the physician assistant; and
the supervising physician spends at least 10 percent of the practice time in the remote site, unless he or she demonstrates that adequate supervision is being maintained through another method, such as telecommunication.

A physician assistant holding an interim permit may not practice in a remote site.

II. Osteopathic Physician Assistants.

An osteopathic physician assistant is an individual licensed to practice osteopathic medicine under the supervision of an osteopathic physician and pursuant to a delegation agreement. Osteopathic physician assistants are licensed and regulated by the Board of Osteopathic Medicine and Surgery.

Summary of Substitute Bill:

I. Physician Assistants.

A. Practice Agreements.

Instead of a delegation agreement, a physician assistant must practice pursuant to a practice agreement with one or more physicians. At least one physician on the agreement must work in a supervisory capacity. Entering into a practice agreement is voluntary—a physician may not be compelled to participate in the agreement as a condition of employment. Prior to entering into the agreement, the physician or his or her designee must verify the physician assistant's credentials.

The practice agreement must be maintained at the physician assistant's place of work and must be made available to the WMC upon request. A physician assistant must file his or her practice agreements with the WMC along with any amendments or termination notices regarding the agreements.

A practice agreement must include:

the duties and responsibilities of the physician assistant, the supervising assistant, and alternative physicians—the agreement may only include acts, tasks, or functions that the physician assistant and supervising or alternate physician are qualified to perform by education, training, and experience and that are within the scope of expertise and clinical practice of both the physician assistant and supervising or alternate physician;
a description of supervision requirements for specified procedures or areas of practice;
a communication, availability, and decision making process when providing medical treatment in the event of an acute health care crisis not covered by the practice agreement (communications may occur in person, electronically, by telephone, or by an alternate method);
if there is only one physician on the agreement, a protocol for designating an alternate physician when the physician is not available; and
the written or electronic signature of the physician assistant and the supervising physician.

The practice agreement for a physician assistant delivering general anesthesia or intrathecal anesthesia must show evidence of adequate education and training in the delivery of the type of anesthesia being delivered.

The practice agreement must also include a termination agreement, which may be used for a single supervising physician without terminating the agreement with the remaining physician. If a termination results in no physicians being party to the agreement, the agreement is not valid unless a new physician is designated. A party to the agreement must provide at least 30 days' notice prior to termination, unless there are good faith concerns regarding unprofessional conduct or failure to practice medicine with reasonable skill and safety, in which case the agreement may be terminated immediately.

A practice agreement may be amended for any reason, including to add or remove supervising or alternate physicians or to amend the duties and responsibilities of the physician assistant. A physician assistant or physician may participate in more than one practice agreement if he or she is reasonably able to fulfill the duties and responsibilities in each agreement.

The WMC may take disciplinary action against a physician assistant for practicing inconsistent with the practice agreement. Physicians subject to discipline related to the practice of a physician assistant must be referred to the appropriate disciplining authority.

B. Supervision.

The prohibition against a physician assistant's practice being beyond the expertise and practice of the physician is limited to expertise and clinical practice of the physician. It is clarified that the physician and physician assistant each retain professional responsibility for any act performed by the physician assistant that constitutes the practice of medicine.

A physician may supervise no more than 10 physician assistants. A physician may petition to the WMC for a waiver of this limit, although the physician may not supervise more physician assistants than he or she is able to adequately supervise. The WMC must automatically grant a waiver to any physician who possesses on July 1, 2021, a valid waiver to supervise more than 10 physician assistants.

C. Signing Documents.

A physician is not required to countersign orders written in a patient's clinical record or an official form by a physician assistant with whom the physician has a practice agreement.

D. Remote Sites.

The limitations on physician assistants working at remote sites are eliminated.

II. Osteopathic Physician Assistants.

The osteopathic physician assistant license is eliminated on July 1, 2022. Beginning July 1, 2021, no new osteopathic physician assistant licenses may be issued, and existing licensees will be converted to physician assistants on their renewal dates.

When disciplining a physician assistant being supervised by an osteopathic physician, the WMC must consult with the Board of Osteopathic Medicine and Surgery (BOMS).

III. Miscellaneous.

The WMC must conduct an education and outreach campaign to make license holders, health carriers, and the public aware of the requirements relating to physician assistants and the elimination of the osteopathic physician assistant credential. The WMC and the BOMS are authorized to adopt any rules necessary to implement the requirements.

Staff Summary of Public Testimony:

(In support) This bill will address gaps in rural access and telehealth opportunities, reduce administrative burdens, and improve access. Increasing numbers of patients with more complex conditions are a stressor to the health care system. Physician assistants generate many patient encounters per year in rural and urban settings. This has led to excellent outcomes. Modern health care is team-based. This bill does not change the physician assistant scope of practice or the collaborative relationship with the physician—the supervising physician and the physician assistant will agree on the supervision required. This bill will remove roadblocks to employment, which will increase access. For example, requiring WMC approval of the agreements is time consuming and does not add value. Removing the WMC approval requirement will streamline the process and allow physician assistants to start working once the agreement is signed. Supervising physicians often feel like they are solely responsible for supervising the physician assistant. This bill will remove the requirement of multiple delegation agreements, which are an unnecessary barrier. The bill will also remove the five physician assistant cap, which will allow flexibility to work with many physician assistants, including part-time physician assistants. This bill will also help reduce licensing fees and will protect physicians who do not want to participate. This bill will make Washington a friendly place to work for physician assistants, who have lots of choices of where to work.

(Opposed) Spinal manipulation is the same as chiropractic care, regardless of who performs the service. Chiropractors are trained to do this, while physician assistants are not. Health professions should not be allowed to self-assign spinal manipulation. Chiropractors do not use drugs to treat patients, but are the only profession that is subject to visit limits, excluded from Medicaid, and subject to copays that exceed allowed amounts.

(Other) The practice agreements established in this bill will allow practice in any area that is not beyond the expertise of the physician. The agreements can be amended to allow additional duties. This bill would allow a physician assistant to perform anesthesia, which is not a core competency.