Our last episode focused on NP full practice authority. In this episode, we take a look at PA full practice authority. We share nationwide trends for a PA’s scope of practice and how a new law is impacting the supervision requirements for PAs. We discuss supervising physician vs collaborating physician relationships, the states moving towards independent PA practice and the limitations in other states. Additionally, we examine the intricacies of ownership regulations, addressing the question of whether PAs can own medical practices.
Listen to the full episode using the player below, or by visiting one of the links below. If you have any questions or would like to learn more, email us at info@byrdadatto.com.
Transcript
Intro: [00:00:00] Welcome to Legal 123s with ByrdAdatto, legal issues simplified through real client stories and real world experiences, creating simplicity in 3, 2, 1.
Brad: Welcome back to another episode of Legal one two threes with ByrdAdatto. I’m your host Brad Adatto, with my co-host Michael Byrd.
Michael: As a business and health care law firm, we meet a lot of interesting people and learn their amazing stories. Brad, our clients commonly come to us with the latest word on the streets that they heard from a friend. This season, we’ll talk about stories with a common legal urban legend and seek to either prove or disprove the legend. This season’s theme is Fake or Real.
Brad: Now, Michael, I was thinking we should do a TV show review first before we really get going. We can discuss like the Love Boat or maybe Fantasy Island, and then we could determine are they fake or real?
Michael: I had so much hope, Brad, for our YouTube audience, sees you all pretty with your suit and tie on today. Thank
Brad: Thank you, sir.
Michael: And I was like, okay, [00:01:00] today is going to be a different day, but no, it’s not. we are talking about old TV shows again. I wish I could receive instant feedback from our audience as to how many have even heard of the shows you just referenced. And for context audience, these are both shows, Love Boat and Fantasy Island that originally aired in the seventies and may have trickled into the eighties.
Brad: Okay. This is not on me, Michael. You opened Pandora’s Pox earlier this season when you want to talk about Partridge Family.
Michael: Okay, well just give me a second. I need to add on my decisions. I regret list talking about the Partridge Family. So when you mentioned the love boat, it did remind me of an article I read recently. I think we discussed this on a prior show, but are you a cruise person?
Brad: I’m not an anti-cruise person. I’ve only done really one cruise in Alaska, but I would do it again.
Michael: Okay. Yeah, I kind of remember that.
Brad: [00:02:00] Well, what about you?
Michael: I’ve never been on a cruise and I don’t have a big desire to do so. I would try it if my wife wanted to go on one, but she’s kind of apathetic as well. So, you know, when we’re planning our trips, cruise is not kind of one of the ideas that comes to mind.
Brad: Okay. What article did you read, Michael?
Michael: Okay, Brad, there’s an article that discussed a two year cruise that goes around the world starting in Florida.
Brad: Are you sure this is not from the TV show that they get on a two hour cruise not two years with a skipper, and maybe a deckhand named Gilligan?
Michael: Okay. So you doubled down from Love Boat and Fantasy Island and now going to Gilligan’s Island. I see. Audience, that also is an old show that originally aired in the seventies.
Brad: Riley, do you have any idea what we’re talking about? She’s shaking her head audience members.
Michael: Yes. Unfortunately. I know all the theme songs in my brain as you mentioned them. And I won’t sing.
Brad: Oh, good.
Michael: And please don’t. [00:03:00] So here’s some data points about the two year cruise, not the two hour cruise. So it’s a Victoria cruise line. It hits 214 point ports in 115 different countries and seven continents.
Brad: Well, how big is this ship?
Michael: The ship will hold 1000 passengers. It is 750 feet long and a hundred feet wide.
Brad: Okay. So, audience members who aren’t really putting math together, that’s like the size of those cargo ships, so it’s fairly large. Well, how much will this cost the average person jumping on this boat?
Michael: So you go on this two year cruise, it’s going to be $5,119 per month. And it includes the cabin, meals, TV, Wi-Fi, gym, pool, spa, and access to doctors, nurses, and dentists on board.
Brad: [00:04:00] So it’s an all you can eat buffet or gourmet meals? Are there any tasty drinks maybe included with that?
Michael: Well, as someone who’s never been on a cruise, what I picture on all cruises is the all you can eat style for all the meals and all you can read – the all-inclusive vibe. And that’s kind of what I got from this article. I’m not a hundred percent. I did not read the fine print, Brad, if you order the premium Tito’s, if that’s an extra charge or not. But I did note that you can actually sign up for a 37 month version, so over three years. And that knocks your cost down to $2,400 per month. Yes, Brad, you heard that, right? You can live your dream and make it a three year cruise.
Brad: Okay. I’m not sure if that’s my dream, but that’s a big commitment considering life kind of happens outside of your cruising vacation. I mean, you could lose some serious money [00:05:00] or if you leave too early or there’s death in the family, your kids or grandkids or getting married or graduating, of course, most importantly, if the Saints in the Super Bowl, you got to go. I mean, there’s a lot that could happen.
Michael: Well, that’s not very likely. But never fear Brad. According to the article, they have a plan for everything. Oh. Passengers are allowed to take a break and they can pay 30% of their rent while they’re gone if they have to go to a family member wedding, a grandchild being born, et cetera, et cetera.
Brad: Well, I guess that sounds reasonable, but how does that, I mean, does someone else get in my room? I mean, I’d hate to have to unpack and repack.
Michael: Well, first I think they’d be afraid to give you a room away, so you would just have it locked down. But I feel like they couldn’t give you room away because it’s a two year minimum commitment. And so, [00:06:00] I feel like that 30%, you know, locks your room down. According to the article, about 70% of the passengers are actually choosing the three year version. And there was a quote from one person that said, I’m going to stay on this ship until the day I die.
Brad: Well, audience members are probably having the same questions. It’s pretty obvious to me what to do with the person that does die since they’re going to stay on the ship till they do die?-
Michael: Yeah. I’m picturing, you know, kind of the retiree crowd, older crowd.
Brad: Like your age.
Michael: Yes. And so there’s probably going to be – there will be deaths. And what’s their plan for that? The article doesn’t address it. My lawyer brain’s going off. And I’m thinking, well, they probably have some sort of strong consent that everyone has to sign that maybe it allows them to dump the bodies overboard. Now my marketing brain is thinking, well, you could brand that as a burial at sea or something like that. [00:07:00] That would make it seem a little less gruesome than just flipping the body overboard.
Brad: Sure. And do you think the spouse gets like a 30% discount on the day someone dies in that boat? Or do they wait until they dump the body overboard?
Michael: I feel like that for some married couples, that might be too much of a financial incentive.
Brad: Oh, no.
Michael: So I don’t know, Brad. I don’t know. I have so many questions. Tell me, do you have any other questions that jump to your mind?
Brad: Yeah. Like how long did they stay in each port or what excursions are available at each port? And can a guest meet you on the ship when you are at Port? Or, you know, asking her for a friend here? Do they have a podcast room? Just curious. How about you?
Michael: The Legal 123s from international waters, I’m sure.
Brad: Riley, in for that? Riley’s nodding your head, audience members.
Michael: All right. Well, I’m curious about the mention of the health care. They talk about that you have access to doctors, nurses, [00:08:00] and dentists. And you know, I’m probably revealing too much about my lawyer brain, but I’m thinking where are they licensed? What scope of practice do they have? Like, you get your medical license in the State of Texas, and then all of a sudden you’re around the world. What does that allow you to do and what risks do you have?
Brad: You know, you and I both have buddies who are maritime lawyers and we have buddies pf ours that are international lawyers. I’m hoping maybe one of them maybe could answer that question. However, I feel like this is truly only a question a health care lawyer would actually ask even if it might be a good question.
Michael: From one health care lawyer to another, we can resonate. But Brad, it is a super smooth segue into our topic today. The question that we’re going to solve today, Brad, fake or real, a PA has full practice authority.
Brad: Okay. I’m not so sure what you consider smooth, but okay, let’s get started. [00:09:00] And before we start the story, audience members, this is not a mistake. You may think, I thought I heard this podcast last week. No, last week we addressed some on NPs, so this week we’re addressing the PA, so this is not a rerun.
Michael: The main character in today’s story, Brad is a physician assistant in the state of Wisconsin named Vicki Stubing. The cast includes her father, Dr. Meryl Stubing. Brad, do you know what I’ve done here? This is a special gift for you.
Brad: Yes, of course. Michael set the course for adventure because the love boat promises something for everyone. You want me to keep going?
Michael: No.
Brad: No, I think I know most of the lines.
Michael: Please, my eyes are bleeding right now.
Brad: Do you even know what we’re talking about Riley? She’s still shaking her head now.
Michael: For the few people out there old enough to know what the Love Boat is, yes, that is the theme song. [00:10:00] It’s going to be a brain worm for the rest of the day for me now that Brad sang. I’m so happy. Before we get started, Brad, let’s talk about our first vocabulary word for the day, physician assistant.
Brad: Yes. A PA or physician assistant is a term with often used in our profession, but it’s important to know that each state has a slightly different definition. As usual, we reached out to our trustee research assistant Siri, who gave us a technical definition, which is as follows, “A physician assistant is a licensed medical professional who holds an advanced degree and is able to provide direct patient care. They work with patients of all ages and virtually all specialties and primary care heirs, diagnosing and treating common illnesses and working with minor procedures.”
Michael: Okay. That was pretty heavy. Do we have a Brad definition?
Brad: Yeah. So that was the formal definition. But really at the end of the day, these are our advanced providers. Sometimes they’ll call them mid-levels, which I know that’s not what they go by, but you’ll hear them talk about that. [00:11:00] Or you also might hear them talk them about a physician extender. Again, that’s another verb that you used to use. But historically speaking, their scope of practices really is that they are assisting that physician and they’re under the supervision of a typical physician day-to-day.
Michael: Yeah. And you mentioned earlier, Brad, last week we talked about nurse practitioners and one early important context difference is that they’re regulated by different boards. So, nurses, nurse practitioners, regulated by the nursing board; physician assistants are actually regulated by the medical board of their particular state. So Vicki called me because she was aware of a new law in Wisconsin that made PAs independent and she wanted to know if she still needed to involve her father, Dr. Stubing in the Love Boat Medical Spa.
Brad: Is the Love Boat Medical Spa a spinoff of the Love Boat show? Don’t answer that. No, okay. So, what law was he referencing? [00:12:00]
Michael: The new law shifts the nature of the relationship from a supervising physician to a collaborative relationship.
Brad: What does that even mean, Michael?
Michael: I know exactly. I don’t know, Brad. Oh, wait, I’m supposed to know. You asked me.
Brad: I did ask you.
Michael: Sorry. I fell asleep when I heard that. Heard myself say that. Let’s break it down so we can talk about these different vocabulary words so that we can help make sense of the story. Brad, you can use your own words. First, what is a supervising physician type relationship mean to you?
Brad: Yeah, and I’ll take an even bigger step back real quick is, and we talked about this a little bit last week, you know, there’s a difference between when you hear the word supervision and collaboration and we went in more detail last week, but it’s really about their relationship. So let’s jump into the supervision. So supervision is the type of relationship that was the most common that was out there. And that’s really where there’s a more direct role where the physician is overseeing the PA throughout [00:13:00] the processes. It’s much more of a high level oversight is required for that relationship to continue. Of course, it varies from state to state as to what that means from a supervision, but they are more intimately involved when they’re supervising.
Michael: Yeah. Nice job, Brad. So when a PA has a supervising physician relationship, they often have a written agreement and they’re ground rules for scope of practice chart review and other quality control type measures. So talk a little bit about a collaborative relationship.
Brad: Collaborative relationship is basically watering down what we just said. It’s less formal, I guess is the first thing to say on the oversight rules. And it’s a more mentoring relationship between the physician assistant and the physician themselves. And so, again audience members, it can be very different from state to state depending on the type of provider, depending the procedure. I mean, [00:14:00] there’s a lot of different elements to that.
Michael: Another gold star for you, Brad. Congratulations.
Brad: Put that on my chart.
Michael: Yes. So the collaborative relationship is really common with nurse practitioners with the different states around the country. Again, we went deep on that last week. This new law is noteworthy because it’s less common as we’ve kind of alluded to with physician assistants. And I think it’s kind of intuitive. A physician assistant being regulated by the medical board is by its nature, the board regulating the practice of medicine. And there are physicians that are kind of the most senior level license there. And so, the law has kind of followed that where if you have a licensee with less scope of practice, they would be delegated by the physician in a supervision type role. Nurse practitioners on the other hand are kind of the highest level [00:15:00] licensee according to the nursing board. And so that there’ve been more traditional variance between what their relationship with the doctor needs to look like.
Brad: So what does the collaborative relationship look like in Wisconsin?
Michael: So there are limited circumstances where a pa when employed by a physician practice may not even need a written collaborative agreement. But, you know, that’s kind of a limited, so they would only need to kind of designate the supervising physician in most cases, including the one for Vicki, she would need a written collaborative agreement.
Brad: All right. Well, what does this collaborative relationship require between the doctor and PA?
Michael: Again, this is super state specific, and we talked more about this last week what collaboration looks like can vary so much, but in this new law in Wisconsin, it really came down to two things. And it was that the collaborating physician had to be reasonably available to the [00:16:00] physician assistant, and it could be by telecommunications or electronic means, and it had to be within a medically appropriate timeframe. Whatever that means. So that’s one thing is that the physician, the collaborative physician had to be reasonably available to the PA. And then secondly, there had to be a process for arrangement for a physician consultation with the patient within, again, this medically appropriate timeframe if requested by the patient or the physician assistant.
Brad: My audience members, I don’t know if you caught all that, but there’s a lot of reasonableness. A lot of appropriateness, and there’s some lot of timeframes. Sounds as clear as mud. All right. I should have asked this earlier, but do does Dr. Stubing and Vicki both own the love boat? Med Spa?
Michael: That’s a great question, Brad. Thank you. And yes, you should have asked that earlier. Oh, sorry. They do both own the medical spa, [00:17:00] but only for compliance reasons. Yeah. So Vicki was actually calling to see if she could drop her father now that this new law was put in place and they can have this collaborative relationship. Her, you know, this is, you know, her business and dad became an owner because the law required it. And so she’s like, you know, freedom and Dad would be cool with dropping ownership if, if it were allowed.
Brad: Right. Well, Michael, this obviously is a source for confusion across states; collab relationships gives a ton of autonomy, but it doesn’t necessarily mean that, that they can own some and own a medical practice by themselves.
Michael: The law now states that deal with ownership. To your point, Brad, are usually different than the laws that deal with scope of practice. So in this story, Wisconsin has not clearly articulated yet that a PA can own the professional service corporation without the doctor. And so, [00:18:00]when we dug deep, there are reasons to believe that that’s how it will unfold, that ultimately the PA might be able to own now that they have this collaborative relationship without doctor ownership, the law’s not clear on that yet, and so there’s risk. And we talk all the time about what’s the risk tolerance of someone. Well, if you are a PA in this example of our story today in Wisconsin, and you own without the doctor, you’re living in the gray zone until the law further unfolds.
Brad: It’s a great example of what happens day to day in the grind with health care when statutes are modified and one change, it’s almost like a domino effect, does it actually fall into another area? And you’re right, it’s a gray area at some point, and eventually they will have to make a call based on their risk tolerance.
Michael: Exactly. And this, Brad, sets up our broader myth. Across all the states today. Fake or real, [00:19:00] a PA has full practice authority?
Brad: Are you going to tell me – this is the last episode of the scene or do we have to wait till the break?
Michael: It’s fake, Brad. Now there are nuances, particularly in states like Wisconsin.
Brad: All right, well, let’s go to commercial. And on other side we’ll talk about PA Full Practice Authority.
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Brad: Welcome back to Legal 123s with ByrdAdatto. I’m your host Brad Adatto with my co-host Michael Byrd. [00:20:00] Michael, this season theme is Fake or Real. And today we talked about Dr. Myrtle Stubing. Vicki Stubing and the Love Boat Medical Spa.
Michael: Yes. And audience, after we all recovered from hearing Brad sing, we got to hear the story that started with Vicki Stubing, a physician assistant in the state of Wisconsin, reaching out to us excited because a new law had passed in Wisconsin. And in this new law, they were creating or changing the nature of the required level of supervision from a supervision type relationship to a collaboration type relationship. And it just so happens that her father, Dr. Meryl Stubing was her supervising physician and the co-owner of the Love Boat Medical Spa. And so, as we kind of unpacked this new law to use this example as an illustration [00:21:00] of kind of how PAs are supervised and how the laws can change, we talked about the evolution of what a collaborative relationship looks like and what in this state, Wisconsin, exactly what that means. And then we talked about ownership and how these scope of practice changes may or may not ultimately impact ownership. And we concluded, and we gave the answer away to the question, you know, fake or real a PA has full practice authority, and we said it’s fake. And we want to kind of unpack that a little bit more, especially since we talked about a story today where arguably a PA is getting super close, but not quite having full practice authority. So let’s talk about, Brad, the trends with a PA scope of practice around the country.
Brad: Yeah. And audience members, you may have heard us talk a little about this last week. You know, [00:22:00] there are a lot of different states that are reevaluating the nurse practitioners and PA’s abilities to be more autonomous. And what does that mean with their relationship with those physicians? So I’ll give you a couple of other states for as examples. For example, in Montana, they’re considering a bill that would allow physician assistants to practice without any supervision agreement. Now, again, without a supervision agreement doesn’t mean they’re fully autonomous. Now Montana is actually following suit with its two day bring states, North Dakota and Wyoming, who have already basically sign off basically saying they’re “independent”. But again, understand that doesn’t mean full autonomy. Other states are moving from supervising relationship to the collaborative relationships that we talked about. That means they’re loosening up the rules. And for some states, the physician assistants actually have started their own regulatory boards. So states like Arizona or Iowa or California. Now, audience members, [00:23:00] that does not mean the board still doesn’t answer to the medical board. So I know it gets confusing when they have these sub boards that are out there. But what some of these physician assistants have talked to us about is that they’re hoping that eventually these physician assistant boards will have complete autonomy from the medical boards. Now, Michael, can you provide our audience a few examples where it seems to be that either the PAs are locked down or have even a, a more limited scope?
Michael: Yeah. And so even before this movement that you just spoke about in a lot of states, and we talked about in today’s story, we’ve pretty safely recognized, or the state safely recognized across the board that a PA generally has the ability to diagnose and to treat. And they have a lot of scope of practice within, you know, a lot of practices including medical spas, which is what we’re talking about in today’s story. And so there’s these [00:24:00] outliers, and one is Maryland where Maryland, a PA cannot do the good faith exam, the initial diagnosis and treatment plan. And so, this is a pretty big step back even from before the movement. It’s kind of a pretty limited limiting scope for what you’ll see across the country. And if you thought that was bad or not up to par with what you typically see, Alabama has even more restrictions for physician assistant and they restrict their ability to inject
Brad: Botox and fillers.
Michael: Exactly. And so that’s again, an outlier that you won’t see in other states. So I guess the greater point is it’s super important to understand the nuances on a state by state basis.
Brad: And let’s talk a little bit more about ownership and how it affected the scope of practice. [00:25:00]And I guess also maybe you can give a summary of what happened in the story too.
Michael: Yeah. So the laws are set up oftentimes based on a couple of different ways, and so the laws on ownership. And so, some states will say, okay, they’re looking at the underlying things that are happening inside the business. And some laws will say, if the nature of these services are medical services, then you have to follow those rules for ownership because this is the practice of medicine. And if that’s the case, because in those states where this is kind of the viewpoint, because PAs are supervised by the medical board, they’re almost always not going to be able to have ownership or full ownership. They may be able to partly own. There are other states that are a [00:26:00] little looser in the sense that you could say, or they will say, you can own a business as long as the professional services are within your scope of practice. And so we talked a little bit about that last week. And if you’re an independent nurse practitioner, you might be able to own a business that provides independent nursing services that’s different than medical services. Again, the nature. What gets tricky here with a PA is because, again, they’re regulated by the medical board, and so what are independent PA services? And so, we’ll watch that. I do think using today’s story as an example, that the way the laws are built, that it will unfold eventually, that they’ll say, you know what PA, as long as you are in your scope of practice, you can own. And so we’ll want to watch what happens there to see if this progression to full practice authority really happens. [00:27:00] And that would be ability to own and really know to very little oversight by a physician and maybe collaborative relationship where they’re available as a mentor would get you to that full practice authority level, but we’re not there yet.
Brad: Well, what happened with Vicki or Dr. Stubing?
Michael: So Vicki’s a risk taker. You know, she’s part of the love boat, you know, Brad, so she is going to go forward with owning her own business. Dr. Stubing is bailing out, and he will of course go forward with a collaborative relationship. She’s willing to take that risk that the law will be on her side as to how that’s interpreted.
Brad: Yeah. And I think you raise a really – it’s a great point is like, again, audience members, as you can imagine, certain [00:28:00] statutes change and other statutes remain the same. And now you have to figure out, well, how would the board enforce this? And then where are the board normally side with, and that’s the tricky part for physician assistances. Most of these medical boards are still run by physicians. And if the physicians feel like the physician assistant should not be a competitor and own their own separate practice, of course the board’s going to enforce that statutory rules. Or if they’re like, no, we’re fine with it, then they may be safe. But again, that’s a risk. So, Michael, final thoughts?
Michael: It probably makes sense to all of us if we think that you’re on a cruise across seven different continents, that you know, what the scope of practice may be for a PA that happens to be on board will be murky at best. What is probably less intuitive is that you can just come to the United States and go across all 50 states, and it’s going to be murky. There’s going to be differences as [00:29:00] to what would happen if you were a PA in one state versus the state next door.
Brad: All right. Well, audience members, that’s all the time we have today, and that’s all the time we have for season 13. Goodbye to the age of our humor season. Michael, do we have to be more mature next season since we’ll be our 14th season?
Michael: Well, Brad I’ve heard that the human male brain doesn’t fully develop till they’re 25. It somehow missed us, but I think we get to keep being us in season 14.
Brad: Awesome. Well, friends, we’ll see you next Wednesday. We’ll reveal what will be in store for season 14. Michael, I can’t wait to find out.
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