Montana Considers Allowing Physician Assistants to Practice Independently

Megan Zawacki started working at St. Peter's Health in Helena, Montana, in 2020 as a physician assistant trained in treating addiction. She had gone through specialized training that allowed her to prescribe Suboxone, a medication to fight opioid addiction, but she couldn't do so for six months.

That's because Zawacki was hired to work with a doctor who specialized in addiction medicine, but that doctor did not join St. Peter's until three months after Zawacki was hired, and it was another three months before he became her supervisor. Under Montana law, physician assistants must be supervised by a licensed physician, with a supervision agreement filed with the state Board of Medical Examiners.

Zawacki had an interim agreement that allowed her to begin work, but she needed that supervision agreement to prescribe Suboxone. While Zawacki was waiting, the only way her patients could get Suboxone was in the emergency room, where it costs more and comes in only a three-day supply. Zawacki said a three-day supply is meant to get a patient through withdrawal, but months of treatment are needed to end substance use.

"Any time that you're limiting access to care, you're putting patients at risk," Zawacki said.

As Montana grapples with a health care provider shortage, state lawmakers are trying to find ways to increase access to care. One proposal up for debate is to give physician assistants like Zawacki more independence to practice unsupervised. Republican Rep. Jodee Etchart is sponsoring House Bill 313, which would let physician assistants practice without a supervision agreement. The bill is similar to laws in neighboring North Dakota and Wyoming.

Many physicians oppose the measure. Jean Branscum, CEO of the Montana Medical Association, said the bill expands a physician assistant's scope of practice with no added training requirements.

"They can be in any area with no supervision," Branscum said.

Yiqun Chen, an assistant professor of economics at the University of Illinois in Chicago, said physician assistants can play a valuable role in augmenting the supply of health care providers, but not as substitutes for physicians.

Chen co-authored a 2022 study that found patient outcomes were worse when care was given by a nurse practitioner instead of a physician, and she said she believes those findings could relate to physician assistants, too.

Instead of thinking of nurse practitioners or physician assistants as substitutes for doctors, Chen said, they should be integrated as part of a patient's collaborative care team.

According to the American Academy of PAs, more than 750 physician assistants practice in Montana, 95.5% of them in rural areas.

Etchart has been a physician assistant herself for 20 years. At the first hearing for her bill in the House Business and Labor Committee on Feb. 3, she said it would allow physician assistants to perform the work they are trained to do without the limitations of direct supervision.

"This is not practicing out of our scope," Etchart said. "Our scope of practice is already set at the practice level."

Travis Booke, president of the North Dakota Academy of Physician Assistants, said his state passed a similar law in 2019 with little opposition. Booke said the law removed an administrative burden but didn't let physician assistants expand their practice without extra training or licensure requirements.

It doesn't give physician assistants more authority to practice, Booke said, "it's just taking away some of the red tape to do it."

There has been no increase in formal disciplinary actions against physician assistants in North Dakota under the new law, according to Sandra DePountis, executive director of the North Dakota Board of Medicine.

Wyoming's law passed in 2021. Eric Boley, president of the Wyoming Hospital Association, said it helped fill the void left by many retiring physicians, particularly in family practice and primary care.

"This is a good option for us to be able to provide that primary care in rural communities," Boley said.

The Wyoming bill drew some of the same opposition HB 313 has seen in Montana - primarily physicians worried about training and education. But Boley said he wasn't aware of any bad results with physician assistants having more independence.

Branscum said her group would be amenable to letting physician assistants practice independently, with proper training and education. She said she worries that without a supervisor there to show physician assistants the ropes, patients might get inferior care.

Etchart said she would consider amending the bill to require physician assistants to work under supervision for two years before practicing independently, if they didn't already have two years of experience after completing school.

Keely Larson is the KHN fellow for the UM Legislative News Service, a partnership of the University of Montana School of Journalism, the Montana Newspaper Association, and Kaiser Health News. Larson is a graduate student in environmental and natural resources journalism at the University of Montana.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.