In 2020, Megan Zawacki joined St. Peter’s Health in Helena as a physician assistant specializing in addiction treatment. Despite completing specialized training to prescribe Suboxone, a medication used to combat opioid addiction, she had to wait for six months before being granted this authority.
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 possessed a temporary agreement that permitted her to commence her work, but she required the supervision agreement to have the authority to prescribe Suboxone. While awaiting the supervision agreement, Zawacki’s patients could solely obtain Suboxone in the emergency room, which not only incurred higher costs but also provided only a three-day supply. Zawacki clarified that a three-day supply is intended to assist patients in overcoming withdrawal symptoms, but several months of treatment are necessary to effectively address substance use.
Zawacki stated that whenever access to care is restricted, patients are being endangered.
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. Rep. Jodee Etchart, R-Billings, 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.
The measure is opposed by numerous physicians. According to Jean Branscum, CEO of the Montana Medical Association, the bill allows physician assistants to broaden their scope of practice without any additional training prerequisites.
Branscum stated that they have the freedom to be in any area without supervision.
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.
Chen suggests that instead of viewing nurse practitioners or physician assistants as replacements for doctors, they should be seen as essential members of a patient’s collaborative care team.
The American Academy of PAs reports that over 750 physician assistants are currently practicing in Montana, with 95.5% of them serving in rural areas.
Having worked as a physician assistant for two decades, Etchart emphasized during the initial hearing on Feb. 3 in the House Business and Labor Committee that her bill aims to grant physician assistants the freedom to carry out their trained duties without the constraints of direct oversight.
Etchart clarified, “Practicing beyond our scope is not what we should be doing. Our practice level already defines our scope of practice.”
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.
According to Booke, the changes do not grant physician assistants additional practice authority; instead, they simply remove certain bureaucratic obstacles.
According to Sandra DePountis, executive director of the North Dakota Board of Medicine, the new law has not led to any rise in formal disciplinary actions against physician assistants in North Dakota.
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.
Boley stated that this option is beneficial for us to offer primary care in rural communities.
Physicians in Wyoming expressed similar concerns as those in Montana regarding the opposition to the Wyoming bill, HB 313, mainly related to training and education. However, Boley mentioned that he had not come across any negative outcomes resulting from granting more independence to physician assistants.
Branscum expressed her group’s willingness to allow physician assistants to practice autonomously, given they receive adequate training and education. She voiced concerns about the potential consequences of patients not receiving optimal care in the absence of a supervisor to guide physician assistants.
Etchart expressed her willingness to potentially modify the bill, suggesting that physician assistants without a minimum of two years of post-graduate experience should be required to work under supervision for an additional two years before being allowed to practice independently.
