How one licensing requirement limits patient access to PAs

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New Hampshire’s health care provider shortage has been a major news story for years. The demand for health care is growing as New Hampshire’s population ages. Yet the supply of providers is not keeping pace with demand, as physicians retire and too few young people enter the field, particularly in the three primary care occupations: physicians, physician assistants (PAs) and advanced practice registered nurses (APRNs). 

To illustrate the problem, a nationwide review of health care industry job listings on last fall found that New Hampshire had more than 1,000 listings per 100,000 residents, the highest number of listings per-capita in the United States.

Every New Hampshire county but Rockingham has at least some area experiencing a shortage of primary care providers.

The state’s 2023 annual report on the health care workforce availability found a very low rate of PAs offering outpatient primary care in New Hampshire per 100,000 residents. 

Counting providers offering outpatient primary care, the state found that New Hampshire has 54 physicians and 30.5 APRNs per 100,000 residents. But the rate for PAs is only 9.2 per 100,000. 

That falls even lower in rural areas. The number of physicians and APRNs per resident who offer outpatient primary care actually increases in rural parts of the state (to 56.9 for physicians and 36.3 for APRNs). But the number of PAs per resident offering that care falls from an already low 9.2 to just 6.3.

One likely reason for the shortage of PAs offering outpatient primary care, particularly in rural areas, is that the state essentially treats PAs as apprentices rather than the advanced practice health care professionals—with master’s-level education credentials and national industry certification—that they are.

State law (RSA 328-D:3) mandates that all PAs must have completed a nationally accredited PA education program (these are master’s degree programs) and have passed a national proficiency exam. 

RSA 328-D:3-b VII states that PAs “may provide any legal medical service for which they have been prepared by their education, training, and experience and are competent to perform.”

And yet the law prohibits them from offering the very same medical services they’re trained and qualified to perform unless they first obtain “a written collaboration agreement with a sole practice physician or a physician representing a group or health system….” 

The collaboration agreement is not supervision. The physician signing the agreement does not supervise the PA’s work and is not liable for the quality of the PA’s work product (outside of any direct involvement in a specific case). “Collaboration” is defined in law (RSA 328:D-1) as merely consultation or referral. 

APRNs, who have similar training to PAs, do not have a similar requirement. The law rightly treats them like advanced-degree professionals. PAs, despite having master’s-level medical training and being required by law to practice only within their area of training and expertise, are treated like untrained apprentices.

House Bill 1222 would remove the requirement that PAs enter into a collaboration agreement before being allowed to practice what they’re educated and trained to do.  

HB 1222 does not change the scope of practice for PAs in any way. Every other legal restriction on their work would remain. The bill would simply allow them to offer the services they’re fully qualified to offer without first finding a doctor to sign a contract agreeing to talk to them from time to time.

Despite their title, PAs are not really “assistants.” Under state law, they are authorized to offer services including, but not limited to:

“a) Obtaining and performing comprehensive health histories and physical examinations; 

“(b) Evaluating, diagnosing, managing, and providing medical treatment; 

“(c) Ordering, performing, and interpreting diagnostic studies and therapeutic procedures; 

“(d) Educating patients on health promotion and disease prevention;

“(e) Providing consultation upon request; 

“(f) Writing medical orders….”

PAs function as primary care providers, at a level below physicians but on par with APRNs. The requirement for a collaboration agreement is an unnecessary regulation that reduces the supply of PAs while likely hurting Granite Staters.

Some might consider this requirement a harmless rule that adds an extra layer of protection for patients. But if the requirement reduces the supply of trained, educated and licensed primary care providers in the state, as appears to be the case, then it hurts patients. By reducing the supply of providers and increasing wait times, it could reduce Granite Staters’ access to care, causing worse health outcomes. 

A proposed floor amendment would remove the collaboration agreement requirement after PAs have completed at least 8,000 hours of clinical practice. That’s a high hours requirement, and an unnecessary one. It would still create a needless barrier to entry into a profession that New Hampshire should by trying to expand, not limit. 

But if the choice is between the status quo and lifting the requirement after 8,000 hours, the pro-patient answer is easy. Patients would be better off if the state encouraged more people to become PAs by giving them a path by which to escape the collaboration agreement eventually.  

When licensing denies people services they need in the name of protecting them from fully educated, trained and credentialed professionals, it winds up hurting the very people it’s designed to protect by prohibiting them from accessing the care they need. The collaboration agreement is a perfect example of this unintended consequence.