Alabama health committee hears how physician assistants could expand access amid regulatory hurdles

On Jan. 14, 2006, the Alabama House Health Committee heard from Heather Neighbors, legislative committee chair of the Alabama Society of Physician Assistants, about PA education, certification and regulatory obstacles that she said constrain PAs from helping to address primary care shortages in the state.

Neighbors told the committee that PAs receive graduate-level, medical-model training and that the profession was founded in 1965 by Dr. Eugene Stead at Duke. "PA education is medical model based. It is nationally standardized and designed to prepare graduates to deliver safe, high quality, cost effective care across all specialties and settings," she said. She noted the University of Alabama at Birmingham's PA program, founded in 1967, is one of the earliest programs and that Alabama now has four PA programs.

Neighbors described certification and maintenance requirements: graduates take the national certification exam to become PA-C, report continuing medical education through the NCCPA and face periodic recertification. "We have to get 100 category or a 100 CME credits every 2 years to maintain national certification," she said, adding that roughly 50 of those must be Category 1 credits.

Summarizing PA clinical duties, Neighbors said PAs "take medical histories, perform physical exams, diagnose illness and injury, order and interpret diagnostic tests, develop and implement treatment plans, prescribe medications including controlled substances, assist in surgery, [and] provide patient education." She told members PAs complete extensive supervised clinical rotations (she cited more than 2,000 hours) and that about 1,300 licensed PAs practice in Alabama, with roughly 200 graduates entering the workforce each year; she said only about 16% currently practice in primary care.

Committee members pressed Neighbors on barriers that prevent PAs from practicing to their full training. She identified two central problems: a lack of understanding among some physicians and an outdated, burdensome regulatory framework. "Our administrative code was written over 20 something years ago, and it has not been reviewed as a whole in a very long time," she said, describing application and approval processes that require repeated documentation, protocol approvals and ongoing reporting that she called "cumbersome."

As a policy option, Neighbors proposed practice-level agreements in which hiring physicians and PAs jointly define the PA's scope, submit the agreement to the board for rapid review, and update it as the PA gains experience. "If you make those decisions between the two of you and then you submit it to the board, let the board do a cursory review and approval," she said, adding that a Tennessee-style approach could speed approvals while preserving physician oversight.

Neighbors also noted incremental regulatory changes made recently in Alabama, citing a tunneled catheter protocol approval and the state's approval to allow PAs and nurse practitioners to provide cosmetic Botox injections. She offered to provide the committee with a current list of ophthalmology privileges and other procedure-specific protocols.

Chairman Lee and committee members discussed next steps; Lee said he plans to carry a bill to create an interstate licensure compact that would allow PAs to transfer credentials across state lines, citing recent action in other states. The committee did not take formal votes during the presentation.

The committee is expected to consider policy proposals and possible regulatory updates at future meetings, including the compact Lee described.