Enhancing healthcare access and quality

In the dynamic landscape of US healthcare, physician associates/assistants (PAs) have emerged as crucial players in expanding access to quality healthcare. One aspect of their role that is growing significantly is their authority to prescribe medications. This commentary delves into the beneficial evidence surrounding PA prescribing in the United States, comparing it with physician prescribing and highlighting its potential to address healthcare access disparities and optimize healthcare delivery. However, more research is needed on how PA prescribing affects specific patient populations and healthcare settings so that the profession can optimize practice models and address potential challenges. A GROWING LANDSCAPE Since the inception of the PA profession in the 1960s, its scope of practice has steadily evolved, and a uniform national standard has emerged. All PAs in the United States graduate with a master's degree, undergo a national certification examination, obtain a state-based medical license, and continue their medical education.1 By accepting their comprehensive education and clinical experience, all 50 states, the District of Columbia, and most US territories grant PAs prescriptive authority to some degree.2 As of 2024, full prescribing authority exists in 45 states, the District of Columbia, the US Virgin Islands, Guam, and American Samoa. Less than full prescribing authority exists in Oklahoma, Arkansas, West Virginia, Georgia, Kentucky, Missouri, and Puerto Rico. This widespread recognition of PA prescribing reflects a growing appreciation for their ability to contribute effectively to medication management. Ninety-five percent of the 178,000 certified PAs who responded to the 2023 National Commission on Certification of Physician Assistants annual survey reported providing at least 30 prescriptions weekly.3 Confirmation is by identifying all three major prescriber types (MD/DO, PA, NP) in the Medicare Part D population.4 To support this observation, a 10-year prescribing trend analysis was undertaken. In this analysis, the number of broad categories of prescriptions filed by PAs and NPs trended upward; that of family medicine physicians generally was static (Figure 1).FIGURE 1.: Drug categories by type of prescriberReproduced with permission from Hooker RS, Zobitz JM. Prescribing by physician associates and nurse practitioners in older adults is outpacing traditional prescribers: implications for practice in American medicine. Med Care Res Rev. 2024;81(2):156-163.EVIDENCE FOR BENEFIT Evidence supports the positive effect of PA prescribing on several healthcare domains: Increased access to care. PA prescribing addresses physician shortages, particularly in rural and underserved areas.5 Studies have shown that clinics employing PAs with prescribing authority exhibit significantly higher visit volumes and prescription rates than those without.6 This enhanced capacity to manage medication directly translates to improved access to essential primary care, particularly for patients in communities facing physician scarcity.7 Efficient healthcare delivery. PAs collaborate with physicians, functioning as key clinicians on healthcare teams. This collective approach, facilitated by physician oversight and PA prescribing autonomy, promotes efficient workflow and patient navigation through the healthcare system.8 For patients requiring routine medication management, visits with PAs can alleviate pressure on clinic schedules and improve access to care. Quality of care and patient outcomes. One study revealed no significant differences in quality of care or patient outcomes, whether PAs or physicians prescribed medications.6 These findings suggest that PAs, armed with their extensive training, experience, and collaborative partnerships with physicians, deliver medication management at a level comparable to their physician counterparts.9 Some studies have indicated that PA-managed medication regimens may be associated with higher adherence rates, potentially because of enhanced patient interaction and communication.10 Cost-effectiveness of healthcare. PAs significantly improve cost-effective healthcare delivery.8 Compared with physicians, PAs typically are compensated at a lower rate, reducing overall healthcare expenditures.11 PAs' ability to prescribe medications further increases their cost effectiveness by enabling them to manage a broader range of patient needs, optimizing resource allocation. COMPARING PRESCRIBERS Although significant similarities exist between PA and physician prescribing, key differences warrant consideration: Scope of practice. PAs and physicians possess broad medical knowledge, but their areas of expertise may differ. Physicians specialize in 120 or more specific medical domains; PAs practice in 70 specialty areas, often teamed with physicians and NPs. This difference suggests variations in their prescribing patterns, with physicians potentially focusing on complex diagnoses and medications and PAs managing more routine medication needs. Collaborative models. PA prescribing inherently operates within a shared framework involving physician oversight and communication.12 This collaborative approach ensures patient safety and medication management consistent with physician guidelines. In contrast, physician prescribing may not always involve direct collaboration with other healthcare providers, potentially leading to independent decision-making. THE ROAD AHEAD The growing evidence demonstrates the positive effect of PA prescribing on healthcare access, delivery, and cost-effectiveness. Looking ahead, several factors will optimize the potential of PA prescribing: Continued regulatory support. Maintaining state-level recognition of PA prescribing authority is essential for expanding healthcare access and efficient healthcare delivery. Streamlining regulations for PA prescribing of controlled substances can further enhance PA practice capabilities. Fostering collaborative practice. Cultivating strong collaborative models between PAs and physicians is key to ensuring patient safety and maximizing the benefits of PAs' skills. Clear communication channels are a requirement for continuity of care, and defined roles in the healthcare team are essential for optimal collaboration. Investing in research and education. Ongoing research exploring the effect of PA prescribing on specific patient populations and healthcare settings is needed. Outcomes of care analyses should include prescribing effects. CONCLUSION The evidence supports that PAs are well-partnered with physicians across medical and surgical settings and disciplines. They are growing as medication managers for various diseases in this collaborative role. Comparing each prescriber's effect on population-based care outcomes is a topic of healthcare system science waiting for further examination.