Background: A physician assistant (PA) is defined as a person who is licensed by the Washington Medical Commission (Commission) or the Board of Osteopathic Medicine and Surgery (Board) to practice medicine to a limited extent only under the supervision of a physician. To be licensed as a PA by the Commission, an applicant must satisfactorily complete a Commission-approved training program and pass a Commission-approved examination within one year of completion. A PA may only practice under the supervision of a physician and may not practice until a delegation agreement between the PA and supervising physician is approved by the Commission. A delegation agreement delineates the manner and extent to which the PA will practice and be supervised, and must jointly be submitted by the physician and the PA. A PA may provide services in which they are competent to perform based on their education, training, and experience, and only to the extent permitted by the Commission in a manner consistent with the approved delegation agreement, as long as the services are not beyond the scope of the supervising physician's own expertise and practice.

To be licensed as an osteopathic physician assistant (OPA) by the Board, an individual must satisfactorily complete a Board-approved training program and pass a Board-approved examination within one year of completing the training program. An OPA may only practice under the supervision of an osteopathic physician and may not practice until a delegation agreement between the PA and supervising osteopathic physician is approved by the Board. An OPA may provide services in which they are competent to perform based on their education, training, and experience, and only to the extent permitted by the Board in a manner consistent with the approved delegation agreement, as long as the services are not beyond the scope of the supervising osteopathic physician's own expertise and practice.

Physicians and osteopathic physicians may enter into delegation agreements with up to five PAs or OPAs, and the Commission or Board may consider requests to supervise more than five. The physician or osteopathic physician and the PA or OPA retain professional and personal responsibility for any act constituting the practice of medicine performed by the PA or OPA. The required supervision by a physician or osteopathic physician does not necessarily require the personal presence of the supervising physician at the place where the PA renders services. The agreement should allow for the physician to adequately supervise and review the PA's practice.

A PA may not practice at a remote site without approval of the Commission or Board. The Commission or Board 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 they demonstrate adequate supervision is being maintained through another method, such as telecommunication.

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

Summary of Bill: A PA is a person who is licensed by the Commission to practice medicine in accordance with a practice agreement with one or more physicians or osteopathic physicians and who is academically and clinically prepared to provide health care services. At least one physician on the agreement must work in a supervisory capacity. Entering into a practice agreement is voluntary, and 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 their designee must verify the PA's credentials.

Practice Agreements. The practice agreement must be maintained at the PA's place of work and must be made available to the Commission upon request. A PA must file their practice agreements with the Commission along with any amendments or termination notices regarding the agreements. A practice agreement must include:

the duties and responsibilities of the PA, the supervising physician, and alternative physicians—the agreement may only include acts, tasks, or functions that the PA and supervising or alternate physicians are qualified to perform by education, training, and experience and that are within the scope of expertise and clinical practice of both the PA and supervising or alternate physicians;
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 PA and the supervising physician.

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 physicians. 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.

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

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 PA. A PA or physician may participate in more than one practice agreement if they are reasonably able to fulfill the duties and responsibilities in each agreement.

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

Supervision. A physician may supervise no more than ten PAs. A physician may petition to the Commission for a waiver of this limit, although the physician may not supervise more PAs than they are able to adequately supervise. The Commission must automatically grant a waiver to any physician who possesses on July 1, 2021, a valid waiver to supervise more than ten PAs.

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

Remote Sites. The limitations on PAs working at remote sites are eliminated.

Osteopathic Physician Assistants. The OPA license is eliminated on July 1, 2022. Beginning July 1, 2021, no new OPA licenses may be issued, and existing licensees will be converted to PAs on their renewal dates. When disciplining a PA being supervised by an osteopathic physician, the Commission must consult with the Board.

The Commission must conduct an education and outreach campaign to make license holders, health carriers, and the public aware of the requirements relating to PAs and the elimination of the OPA credential. The Commission and the Board are authorized to adopt any rules necessary to implement the requirements.