This story was originally produced by the New Hampshire Bulletin, an independent local newsroom that allows NHPR and other outlets to republish its reporting.
The state’s nearly 1,340 physician assistants, the provider many patients see during a medical appointment, would no longer have to have a signed “collaborative agreement” with a physician for their entire career under a bill that is headed to the Senate over the objections of the New Hampshire Medical Society.
The bill’s sponsors said House Bill 1222, which has passed the House, is a health care workforce bill brought in response to two primary complaints from physician assistants: Some said they are being charged $1,000 a month for a document they argue does not change how they practice. Others testified they’ve lost jobs when new physicians arrive at their practice and refuse to sign agreements.
“It will make it possible for there to be more physician assistants in New Hampshire because they won’t be driven away due to a bureaucratic requirement which provides no clinical value,” said Rep. Jess Edwards, an Auburn Republican, who co-sponsored the bill.
Some physicians and the New Hampshire Medical Society have said dropping the collaborative agreement would endanger patients. Dr. Maria Boylan, president of the society, said its physicians respect the role physician assistants play but are also mindful that their training prepares them to practice collaboratively with a physician, not independently.
“We do not allow medical students to practice medicine right out of medical school, instead they have to train in a residency program for three to five years under strict supervision of attending physicians and then have to take a board exam in their respected specialty,” said Boylan in an email. “This proposed legislation sets a much lower, unsafe bar for the independent practice of PAs than is set for physicians.”
Edwards had hoped to eliminate the collaborative agreement. In a compromise with the bill’s opponents, he and co-sponsor Rep. David Rochefort, a Littleton Republican, agreed to require collaborative agreements in limited circumstances. It would apply only to physician assistants with fewer than 8,000 hours of clinical practice whose office or health care system does not include at least one physician doing similar work.
Edwards said physician assistants would still be required to consult with their practices’ health care teams whether or not there is a collaborative agreement. They would also remain under the authority of the state Board of Medicine, which investigates complaints, he said.
The compromise doesn’t resolve the New Hampshire Medical Society’s concerns, Boylan said.
“The collaborative agreement language in statute today delineates clear guardrails and responsibilities of both physicians and PAs when collaborating and determining the scope of practice of a PA,” Boylan said. “The … amended version strips away those vital guardrails, creating unnecessary and dangerous holes in our state law.”
Boylan said physician assistants’ scope of practice is defined by their relationships to their collaborating physicians, and their expertise and training grows while working and gaining experience under the guidance of a physician. She said nothing in HB 1222 would set limits on a physician assistant’s scope of practice in place of the collaborative agreement.
In persuading the House to pass the bill, Edwards and Rochefort argued that nurse practitioners, who similarly provide care to patients, can practice without a written agreement, yet both must have a master’s degree and complete clinical hours under supervision.
“We have an opportunity to fix and rectify this incongruence (between nurse practitioners and physician assistants) and accord our mid-level providers the respect they deserve as the professionals that they are,” Rochefort told House members before they passed the bill last month on a voice vote.
Some of have disputed the similarity in training programs for physician assistants and nurse practitioners, saying while both must have advanced degrees, both are not trained to practice independently.
Nearly 50 people submitted testimony to House members ahead of the vote, all but 16 of them in support of the bill.
Sarah Leslie, of Deerfield, a physician assistant for 14 years, said she has never met or worked with the physician who signed her collaborative agreement.
“It’s a farce to say that removing the legal tether (of a collaborative agreement) is unsafe for patients,” Leslie wrote. “No one in medicine practices independently. We all rely on other providers, other specialties, other health care members to provide the care that we do. … To say that removing the legal tether somehow means that PAs would behave differently and wouldn’t reach out with their questions or concerns is outrageous.”
Dr. Gregory Kaupp disagreed in his written testimony.
“Physician assistants have very limited medical training compared to the rigorous years of training physicians complete,” Kaupp wrote. “Expanding the scope of practice for PA’s is not in the best interest of the people of NH. At a minimum it will dilute the level of care received in NH and at worst it is unsafe and will put patients into potentially dangerous medical situations with under-qualified providers. Patients in NH still deserve and should expect to receive care from a board certified doctor, with physician assistants continuing to play an important supporting role.”
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