By Dennis Hursh, Esq.
Many physician practices have found that use of “physician extenders” such as physician assistants can dramatically increase both practice income and patient satisfaction. Physician assistants can provide excellent care in routine matters, freeing up the practice’s physicians for more complex (and generally more lucrative) activities.
However, physician assistants are not independent practitioners; they work under the supervision of a supervising physician. Regulations promulgated by the Pennsylvania Board of Medicine address permissible activities of physician assistants, impose strict requirements for a written agreement between the physician assistant and the supervising physician, and require the supervising physician to assume several obligations in supervising and overseeing the physician assistant. A physician may serve as a supervising physician for no more than two physician assistants.
Permissible Duties of Physician Assistants
The regulations list 14 functions which physician assistants may perform, and provide that this list is not intended to be all-inclusive. The functions listed in regulations are the following:
· Screen patients to determine need for medical attention.
· Review patient records to determine health status.
· Take a patient history.
· Perform a physical examination.
· Perform developmental screening examination on children.
· Record pertinent patient data.
· Make decisions regarding data gathering and appropriate management and treatment of patients being seen for the initial evaluation of a problem or the follow-up evaluation of a previously diagnosed and stabilized condition.
· Prepare patient summaries.
· Initiate requests for commonly performed initial laboratory studies.
· Collect specimens for and carry out commonly performed blood, urine and stool analyses and cultures.
· Identify normal and abnormal findings on history, physical examination and commonly performed laboratory studies.
· Initiate appropriate evaluation and emergency management for emergency situations, for example, cardiac arrest, respiratory distress, injuries, burns and hemorrhage.
· Perform clinical procedures such as: venipuncture; intradermal tests; electrocardiogram; care and suturing of minor lacerations; casting and splinting; control of external hemorrhage; application of dressings and bandages; administration of medications, intravenous fluids, whole blood and blood components (as permitted by law); removal of superficial foreign bodies; cardio-pulmonary resuscitation; audiometry screening; visual screening; carrying out aseptic and isolation techniques; provide counseling and instruction regarding common patient problems.
A physician assistant may also execute and relay medical regimens. If the supervising physician was not physically present when the medical regimen was executed or relayed, the physician assistant must report to the supervising physician within 12 hours, and state the basis for each decision to execute or relay a medical regimen. Regulations also provide detailed requirements and limitations with respect to prescribing and dispensing drugs by a physician assistant.
Duties of the Supervising Physician
The supervising physician must accept full professional and legal responsibility for the performance of the physician assistant in the care of the physician’s patients. If the primary supervising physician is unavailable to supervise the physician assistant, the primary supervising physician may not delegate care to the physician assistant unless the supervising physician has made appropriate arrangements for substitute supervision. The substitute supervising physician is required to ensure that supervision is maintained in the absence of the primary supervising physician.
The supervising physician is required to see each patient in the physician’s office every third visit, but at least once a year, and at least once during each hospitalization. In addition, the supervising physician must review all medical records prepared by the physician assistant to assure compliance with all legal requirements.
Finally, the supervising physician is responsible to be alert to patient complaints concerning the type or quality of services provided by the physician assistant.
Pennsylvania law requires that a written agreement identify and be signed by the physician assistant and each supervising physician. This written agreement is in essence a detailed job description for the physician assistant, describing the manner in which the physician assistant will be assisting the physician and listing the functions delegated to the physician assistant. Regulations are quite clear that only functions specifically listed in the supervisory agreement may be performed by the physician assistant.
The supervisory agreement must describe the time, place and manner of supervision and direction each named physician will provide the physician assistant, including the frequency of personal contact with the physician assistant. One named physician (a medical doctor) must be designated as the primary physician assistant supervisor. All locations and practice settings where the physician assistant will serve must also be set forth in the agreement. The supervisory agreement must be submitted to and approved by the Board of Medicine.
The supervisory agreement must be provided to anyone who seeks to confirm the scope of the physician assistant’s authority. Accordingly, the author always advises clients to create a separate supervisory agreement outside of any employment agreement. Nevertheless I have seen employment agreements utilized for this purpose, which presumably passed muster with the Board of Medicine.
The supervising physician must register with the Board of Medicine as a “physician assistant supervisor.” Monitoring compliance with the written agreement is the responsibility of the supervising physician, and the supervising physician is also required to inform all parties of any failure to comply with the agreement or the law and regulations governing physician assistants.
Identification and Notice Requirements
A physician assistant may not render medical services to a patient until the patient (or the patient’s legal guardian) has been informed that: the physician assistant is not a physician; the physician assistant may perform the service required as the agent of the physician and only as directed by the supervising physician; and the patient has the right to be treated by the physician if desired.
A notice plainly visible to patients must be posted in a prominent place explaining that a “physician assistant” is authorized to assist a physician in the provision of medical care and services. The registration of the supervising physician and the physician assistant’s certificate must also be displayed. The physician assistant is required to conspicuously wear an identification tag which uses the term “Physician Assistant” in large type.
If a physician assistant provide services at a location other than the primary place where the supervising physician provides services (a satellite location), additional requirements apply.
Specific approval must be obtained from the Board of Medicine for each satellite location, with a separate application for each location. To obtain approval for use of a physician assistant at a satellite location, the supervising physician must demonstrate that:
· The physician assistant will be utilized in an area of medical need.
· There is adequate provision for direct communication between the physician assistant and the supervising physician and that the distance between the location where the physician provides services and the satellite location is not so great as to prohibit or impede appropriate support services.
· The supervising physician will see each patient every third visit, but at least once a year.
· The supervising physician will visit the satellite location at least weekly and devote enough time on-site to provide supervision and personally review the records of each patient seen by the physician assistant in this setting.
The use of a physician assistant can do wonders for a physician practice. However, competent legal counsel should be involved to insure that all legal requirements have been appropriately addressed.
Dennis Hursh, Esq., is a principal in Hursh & Hursh, P.C., a Middletown, Pennsylvania law firm concentrating on representation of physicians and physician group practices.