Optimal team practice: enhancing flexibility and reducing barriers for physician assistants in a changing health care landscape—a review of current state legislation

Introduction The landscape of health care is ever evolving, and the roles of health care providers are adapting to meet the demands of a changing world. Caring for patients in the COVID-19 era taught us that flexibility to move within health care delivery teams is paramount. In many states, physician assistant (PA) licenses uniquely disadvantage the profession and limit this flexibility to deliver care. Historically, a PA’s license is linked to a specific physician’s license. This license link is unique to PAs; nurses, nurse practitioners, occupational therapists, hairdressers, acupuncturists, and physical therapists all have licenses that are uncoupled with another individual’s license. Removing the license link between PAs and specific physicians would decrease physician liability,1 allow practices to determine how to deploy PAs, and decrease administrative burden associated with onboarding PAs and physicians moving through the workforce. Defining optimal team practice The American Academy of Physician Associates (AAPA) introduced the concept of optimal team practice (OTP), defined as PAs and physicians working collaboratively without legal requirements linking their licenses. Under OTP, each provider is independently accountable for the care he or she delivers. The goal of OTP is to remove the mandatory license connection between PAs and specific physicians, not to alter the collaborative relationship. Physician collaboration remains integral to the PA practice model, with the scope of practice determined at the practice level. OTP adopted at the state level does not affect practice-level policies regarding scope of practice. Advantages of optimal team practice for dermatologists Removing the license link between specific providers would decrease physicians’ liability.1 Physicians and PAs would be legally responsible for the care that each provides. Several studies show that the employment of PAs may actually reduce malpractice liability compared with physicians. For example, a study by Hooker and colleagues published in 2009 found that over a 17-year period, there was one payment report for every 2.7 active physicians, but only one for every 32.5 active PAs. During this period, 37% of physicians, 3.1% of PAs, and at least 1.5% of advanced practice nurses (APNs) made a malpractice payment, and physicians’ payments were twice that of PAs. Also, the probability of making a malpractice payment in this study was 12 times less for PAs than physicians.1,2 Additionally, data from the National Practitioner Data Bank (NPDB) reveal that, nationally, there were 1.4 to 2.4 malpractice payment reports per 1,000 PAs between 2005 and 2014. By comparison, physicians during this period had 11.2 to 19.0 malpractice payment reports per 1,000 physicians and these physician payments were about 2 times higher than those paid on behalf of PAs.3 This analysis of decades of national data suggests that PAs do not increase liability and may decrease liability, potentially resulting in cost savings for the health care industry along with improved patient safety.1,2 Dermatology specifically stands to benefit significantly from the dissolving of the licensing link between specific PAs and dermatologists due to the large amount of autonomy in the specialty. Removing the license link between specific providers would decrease physicians’ liability.1 Physicians and PAs would be legally responsible for the care that each provides. Benefits to the health care system OTP benefits health care employers seeking more versatile staffing solutions and underserved areas grappling with limited access to care; in this model, providers can be deployed based on need. PAs are often limited by states in the distance they can practice from their supervising or collaborating physicians; this limits access to care for patients in rural settings.4 Currently, the license link between PAs and physicians limits flexibility within health care teams and creates administrative burdens for physicians working with different PAs. The implementation of OTP not only offers health care employers a more versatile staffing solution but also addresses the challenges faced by underserved areas with limited access to care, providing the opportunity to deploy health care providers based on the specific needs of the community. Removing the restrictive license link between PAs and physicians enhances flexibility, particularly in rural settings, while alleviating administrative burdens for health care teams. Benefits of optimal team practice for patients OTP holds numerous benefits for patients, especially as access to care becomes increasingly strained. The average wait time for a physician appointment in the 15 large metro markets surveyed in 2022 was 26.0 days, up from 24.1 days in 2017.5 As the country faces a growing shortage of physicians, the problem is compounded by the fact that nearly half (46%) of US physicians are 55 or older as of 2021.6 Physician retirements, deaths, or relocations can severely limit patient access to care. Currently, one physician leaving a region can disrupt the ability of multiple PAs to continue seeing their patients, creating a gap in care. Granting PAs untethered licenses would allow for greater flexibility in building health care teams and deploying providers where they are most needed. In 2019, the Indian Health Service enacted such changes for PA licenses to reduce regulatory barriers in medically underserved areas, helping to ensure that patients maintain access to essential care.7 Direct payments Economic implications also surface in the form of direct payment disparities. PAs’ workforce contributions are likely undervalued due to current insurance billing practices. As of 2022, Medicare and most commercial policies have the ability to make direct payments to a PA’s national provider identifier (NPI) as opposed to making payments using a physician’s practice identification number or the physician’s NPI (then disseminated to the PA by the practice).8 However, not all commercial payers pay PAs in a direct billing model. Direct payments to PAs ensure that the work they perform is credited directly to them, enhancing transparency. This improved transparency provides health care researchers and workforce analysts with more accurate data on who is delivering care and the types of care being provided across the United States, leading to better-informed conclusions. Direct billing could expand opportunities for PAs at health care staffing companies and other business arrangements that currently require PAs to reassign insurance payments. Transitioning toward optimal team practice: The process The journey toward OTP is underway, albeit unevenly across the nation (Fig. 1 and Table 1). Achieving this “license uncoupling” requires action by individual state legislatures. Six states—New Hampshire, Iowa, Montana, North Dakota, Utah, and Wyoming—have successfully enacted OTP by eliminating the requirement for PAs to be tethered to a specific physician.9 In Montana, for instance, PAs with more than 8000 hours of clinical experience can now practice with licenses independent of another provider. Similarly, Wyoming passed Senate Bill 0033 in 2021 to address health care shortages caused by retiring primary care physicians. Importantly, these bills streamline processes without expanding PAs’ scope of practice, which continues to be determined at the practice level. Notably, there has been no increase in disciplinary actions since these laws took effect.1Figure 1: Current as of July 2025 Practice Categories: Optimal—PAs can practice to the full extent of their medical education, training, and experience. PAs continue to collaborate, consult, and/or refer to the appropriate member(s) of the health care team as indicated by the patient’s condition, the PA’s competencies, and the standard of care. The health care team, and/or their employer, may establish guidelines for collaboration, consultation, and/or referral beyond state laws and regulations. Advanced—PAs practice to the full extent of their medical education, training, and experience, but must comply with additional administrative requirements as mandated in state law and/or regulation. Moderate—State law and/or regulation requires additional administrative burdens that impact the practice environment. The PA and the health care team are limited in flexibility due to these administrative burdens. Reduced—State law and/or regulation restrict the healthcare team and PAs’ ability to practice in at least one element of PA practice. Requires outdated practice models of limited delegated authority and/or restrictive supervision requirements. The map depicts all the state laws currently active as of May 2024 (Accessed September 2, 2025: https://www.aapa.org/advocacy-central/state-advocacy/state-maps/pa-state-practice-environment/). Table 1 - Collaborative practice laws States with partial removal of relationship with physician North Dakota • A physician assistant with <4000 hours of practice shall execute a written collaborative agreement—available to the board upon request• A physician assistant with more than 4000 hours of practice shall collaborate with the appropriate member of the health care team as necessary—degree of collaboration determined at the practice site and no written agreement is required• N.D. Cent. Code § 43-17-02.1(2),(4)-(6) Utah • A physician assistant with less than 10,000 hours of postgraduate clinical experience shall: - Practice under written policies and procedures established at the practice level - Except for a physician assistant specializing in mental health care, engage in collaboration with a physician for the first 4000 hours of the physician assistant’s postgraduate clinical practice experience.• Except for a physician assistant specializing in mental health care, a physician assistant who has more than 4000 hours and <10,000 hours of practice experience shall enter into a written collaborative agreement with: - A physician, or - A licensed physician assistant with more than 10,000 hours of practice experience in the same specialty as the physician assistant• A physician assistant who wishes to change specialties to another specialty in which the PA has <4000 hours of experience shall engage in collaboration for a minimum of 4000 hours with a physician who is trained and experienced in the specialty to which the physician assistant is changing• Utah Code Ann. § 58-70a-307• A physician assistant specializing in mental health care shall complete 10,000 hours of clinical practice in mental health - At least the first 4000 hours shall be completed under the supervision of a psychiatrist - At least 2000 hours of the clinical practice shall be completed in psychotherapy under the supervision of a mental health therapist or a psychiatrist who has been trained in and has at least 2 years of practice experience in psychotherapy - The remaining clinical practice hours shall be completed in collaboration with a psychiatrist• Utah Code Ann. § 58-70a-501.1(4)(a),(d) Wyoming • A physician assistant may collaborate with or refer to the appropriate member of a health care team as necessary. The degree of collaboration shall be determined at the practice level• Wyo. Stat. Ann. § 33-26-502(b) Iowa • Passed HF 424 in 2023 legislative session—effective July 1, 2023 - Requires supervision only for physician assistants with less than 2 years of practice who are opening their own clinic - Following the 2 y of supervision, the board’s rules shall determine the terms of collaboration for a physician assistant engaged in independent practice• Iowa Code § 148C.3 Montana • Passed and enacted HB 313 in 2023 legislative session - Allows physician assistants with fewer than 8000 practice hours to practice in collaboration with a physician or with a physician assistant with 8000 or more practice hours - PAs with 8000 practice hours are exempt from the collaboration agreement• 37-20-203, Montana Code Annotated New Hampshire • Passed and enacted HB 1222 in 2024 - Allows physician assistants with fewer than 8000 practice hours to practice in collaboration with a physician or with a physician assistant with 8000 or more practice hours - PAs with 8000 pracitce hours are exempt from the collaboration agreement States with partial removal of the relationship with a physician Arizona • Passed HB 2043 in 2023 legislative session— will be enacted December 31, 2023 - Physician assistants with 8000 hours practice in collaboration with physicians—no written agreement required - Supervision is required for physician assistants with <8000 hours with a written supervision agreement required Maine • Collaborative agreement required for a physician assistant with <4000 hours of clinical practice - Upon submission to the board of documentation of 4000 hours of clinical practice, a physician assistant is no longer required to have a collaborative agreement - A physician assistant working in a physician group practice setting or a health care facility setting under a system of credentialing and granting of privileges and scope of practice agreement may use that system of credentialing and granting of privileges and scope of practice agreement in lieu of a collaborative agreement• Submit to the board for approval and the agreement must be kept on file at the main location of practice and made available to the board upon request• Me. Rev. tit. 32, § 3270-G(5) Minnesota • Written collaborative agreement required for physician assistants with <2080 hours of clinical experience• Collaborative agreement must be submitted to the board with the application or upon completion of the required collaborative practice experience• Minn. Stat. § 147A.02(c) New Mexico • A physician assistant whose practice in a specialty care shall be supervised by a licensed physician• A physician assistant whose practice is primary care, as defined by the board, may collaborate with a licensed physician• N.M. Stat. Ann. § 61-6C-8• A physician assistant may perform the acts and duties that are within the physician assistant’s scope of practice in collaboration with a licensed physician if the physician assistant has: 1. Completed 3 y of clinical practice as a physician assistant with the supervision of a licensed physician, and 2. Complied with rules adopted by the board establishing qualifications for when a physician assistant may engage in the practice of medicine in collaboration with a licensed physician• N.M. Stat. Ann. § 61-6C-6 Oregon • Written collaboration agreement required - If the physician assistant has fewer than 2000 hours of postgraduate clinical experience, a plan for the minimum number of hours per month during which the physician assistant will collaborate, both in person and through technology, with a specified physician or podiatric physician must be included in the collaboration agreement• Must be kept on file at the physician assistant’s primary location of practice and made available to the Oregon Medical Board upon request• OR. Rev. Stat. § 677.510(2)-(5) States with collaboration agreements only (still have relationship/tether to physician) • Delaware – Del. Code Ann. Tit. 24 § 1771• Idaho – Idaho Code § 54-1807A(2)• Illinois – 225 Ill. Comp. Stat. 97/7.5(a)• Indiana – Ind. Code § 25-27.5-5-2(e)• Michigan – Mich. Comp. Laws § 333.17047• New Hampshire – N.H. Rev. Stat. Ann. § 328-D:3• Tennessee – TENN. CODE ANN. § 63-19-107• Vermont – 13-141-001 VT. Code R. § 25.1 and 13-141-001 VT. Code R. § 28.1-28.2• Virginia – VA. Code Ann. § 54.1-2952 Source: personal correspondence with Shannon Morey, JD, Senior Director, State Advocacy and Outreach at AAPA and American Academy of PAs. PA State Practice Environment. Accessed November 11, 2024: https://www.aapa.org/advocacy-central/state-advocacy/state-maps/pa-state-practice-environment/ Conclusion The concept of OTP presents an opportunity to maintain PAs as active health care providers in the United States. Currently, increased administrative burden and regulations around insurance payors disadvantage PAs in the marketplace and decreases the number of competent providers that could be caring for patients. The potential ripple effects extend beyond the PA-physician dynamic, ultimately limiting the way care is delivered and experienced. As we envision a care delivery model that is optimized, advocating for OTP emerges as a necessity, aligning with the ethos of collaborative health care provision with providing competent care to all. Conflicts of interest The author declares that there is no financial conflict of interest with regard to the content of this report. Data availability The data underlying this article is publicly available.