Full practice authority (FPA) for physician associates (PAs) significantly increases patient access to healthcare and offers advanced practice providers a smoother path to private practice. Each state’s variation of FPA laws leaves providers responsible for navigating the ambiguity.
Full practice authority for advanced practice providers (APPs) is an obvious solution to the ongoing physician shortage in the United States. One story of a PA working in Gunnison, Utah without full practice authority is a cautionary tale for why FPA is necessary.
Gunnison is a rural area that can’t sustain a physician’s salary. For over a decade, a physician associate was the primary care provider for many residents. –– until the PA’s collaborating physician died suddenly during the pandemic.
With no one supervising the PA, the provider was legally prohibited from seeing his patients from the day the physician died until he eventually found a new collaborating doctor.
“He was serving that community for years and then suddenly lost his supervising physician and could no longer practice,” says Viet Le, PA-C, DMSc, an associate professor of research and a preventive cardiology PA at Intermountain Health in Utah.
Utah is one of only a handful of states leading the charge toward more PA practice authority.
What is full practice authority?
Full practice authority allows PAs to evaluate patients, diagnose conditions, order and interpret diagnostic tests and initiate treatment plans without requiring physician oversight.
While NPs have seen broader adoption of FPA across the United States, PAs have only recently gained ground toward more independence in states, including:
- Utah
- North Dakota
- Wyoming
- Iowa
- New Hampshire
- Montana
In 2021, Utah became the first state to adopt a PA Interstate Licensure Compact, recognizing the credentials of PAs licensed in other compact member states.
The American Academy of PAs has outlined specific criteria for PAs to achieve optimal practice authority. Click here to read more about Optimal Team Practice where PAs, physicians, and other healthcare professionals work together to provide quality care without burdensome administrative constraints.
PAs must meet specific criteria in those states with optimal practice authority, such as accruing thousands of hours of clinical experience. In Utah, PAs must demonstrate at least 10,000 hours of practice within their specialty to qualify, says Le. “It’s about the amount of time doctors spend in residency and a fellowship,” says Le.
Le sees full practice authority for APPs as a natural shift rooted in other past primary care shortages. For example, Eugene Stead Jr., MD, created the PA profession in the mid-1960s to address a critical shortage. His experience with medics during World War II and the Vietnam War inspired the idea. “Essentially, he recreated the same three-year program for medical school, but as a separate profession,” says Le.
Benefits of full practice authority for patients and providers
Full practice authority laws directly address the healthcare provider shortage by significantly increasing the provider pool. This is especially true in rural areas where communities can’t afford to support a physician’s salary. APPs typically work at a lower rate, saving communities and health systems money.
Research shows patients view APP care favorably, and improving patient access to care is better for everyone’s health.
In states with FPA laws, PAs are already filling care gaps in person and on telehealth, especially in underserved areas where physician shortages are most acute. This ability benefits patients and helps alleviate pressure on overstretched healthcare systems.
Adopting FPA broadly needs a formalized roadmap
The shift to FPA raises questions about how PAs and other stakeholders can navigate the transition responsibly.
“Full practice authority does not mean we practice like our physician partners. I think the least complicated area to initially implement FPA is through internal medicine and family practice, in relation to foundational PA training in general medicine,” says Le.
While there’s an obvious need for full practice authority to fill healthcare gaps, there still needs to be a standardized training plan and certification. Presently, states and health systems are left to determine when an APP is considered FPA.
Ambiguity in oversight and structure
The current lack of uniform guidelines raises questions but also provide opportunities to understand how to develop appropriate training, assess and validate competency and create appropriate pathways for having FPA.
There needs to be standardized processes to ensure PAs transitioning to FPA are fully prepared and have a clear process to prove it. “PAs are left to navigate what demonstrates proficiency and competency and in the absence of formalized metrics, ask supervising physicians to sign off that the PA has demonstrated minimum proficiency in specific areas,” says Le.
Training gaps and procedural competency
FPA doesn’t mean PAs can practice in any area of medicine. Transitioning from one specialty to another requires specific procedural expertise. For instance, a PA with decades of family medicine experience isn’t equipped to perform procedures in dermatology or cardiology without additional training.
Clinical risks to consider for full practice authority
For clinicians considering FPA, consider the following risks:
- Transition to new specialties with caution
Jumping into a new procedure without adequate preparation poses significant risks. Even experienced PAs must evaluate whether their skills align with the demands of their desired practice area. Procedures such as suturing, curettage and injections require documented proficiency. Inadequate preparation can lead to adverse patient outcomes and legal risks.
- Know your scope of work laws in any state where you practice
FPA, scope of practice and interstate compact laws vary across the country and can change yearly. Be sure to stay knowledgeable about the requirements in your state by checking with your professional association, attorney or insurance advisor.
In the meantime, stay current with your state’s laws, especially as these change.
- Document your procedural care
Without a formalized process for full practice authority, the onus to keep a record of experience and competencies falls on you as the clinician. Le recommends asking your supervisor to help attest to your experience by signing letters outlining specific skill areas with hourly amounts.
- Get specialty-specific liability coverage
FPA brings increased autonomy but also increased risk. Clinicians practicing independently must carry robust malpractice insurance tailored to their specialty and scope of practice. A one-size-fits-all approach to liability coverage is inadequate for the complexities of FPA, particularly for those performing advanced procedures or transitioning into new specialties.
As more states adopt FPA for PAs, the need for clear training pathways, procedural documentation and specialized coverage will only grow, says Le. “I expect full practice authority to increase because it has to happen. States like my own will lead the charge.”
