California’s Physician Assistants: How Scope of Practice Laws Impact Care SEPTEMBER 2018 Contents Authors 3Overview of the Profession Timothy Bates, MPP, is an analyst at the Philip Physician Assistant Education R. Lee Institute for Health Policy Studies at Practice Oversight of Physician Assistants in California UCSF. Joanne Spetz, PhD, is associate director of research at Healthforce Center at UCSF. She Collaboration Limits is also a professor at the Philip R. Lee Institute Cosignatory Requirements for Health Policy Studies, Department of Family Comparison to Other States and Community Medicine, and the School of Nursing at UCSF. Miranda Werts is a research 5Examining the Evidence for Practice Expansion: intern at the Philip R. Lee Institute for Health A Summary of Research Policy Studies at UCSF. Access to Care Quality of Care Acknowledgment The authors thank Kristine Himmerick, PhD, PA, Cost of Care for providing information included in this brief. 7Appendices About Healthforce Center at UCSF A. The Landscape of Physician Assistants Healthforce Center at UCSF prepares health B. Physician Assistant Scope of Practice Elements, care organizations for success by combining a by State, 2018 deep understanding of the issues facing their workforce with the leadership skills to drive 11Endnotes progress. They work with foundations, hospitals, delivery systems, organizations, and individuals to ensure more effective health care delivery and to inform health care policy. Their efforts are focused in the core areas of leadership pro- grams and workforce research. ABOUT THIS SERIES Learn more at healthforce.ucsf.edu. This paper is one of a series that examines the scope of practice of selected California health professions. The About the Foundation series looks at professions discussed by the California The California Health Care Foundation is Future Health Workforce Commission and its subcom- dedicated to advancing meaningful, measur- mittees and workgroups during spring and summer of able improvements in the way the health care 2018. Each brief begins by describing the profession, delivery system provides care to the people of including its legally permissible scope of work, and California, particularly those with low incomes educational requirements. The brief then outlines how and those whose needs are not well served by California’s permissible scope of practice compares the status quo. We work to ensure that people with that of other states and provides a summary of have access to the care they need, when they research studies on the impact of the profession’s need it, at a price they can afford. scope of practice on access to care, care quality, and costs. Finally, it summarizes demographic characteris- CHCF informs policymakers and industry lead- tics, practice settings, and geographic distribution. ers, invests in ideas and innovations, and connects with changemakers to create a more Visit www.futurehealthworkforce.org to learn more. responsive, patient-centered health care system. For more information, visit www.chcf.org. California Health Care Foundation 2 N umerous studies find that physician assistants PA education programs are offered at the master’s (PAs) provide high-quality care and are more likely degree level, and the vast majority now require prior to practice in rural regions and with underserved health care experience and possession of a bachelor’s populations. California’s restrictions on physician assis- degree for admission, although some programs offer a tant practice create a barrier to growth of team-based combined, accelerated bachelor’s and master’s degree. care and to improvements in the efficiency of health care The curriculum includes instruction in basic medical sci- services. ences along with clinical rotations in medical and surgical disciplines, and students must complete at least 2,000 This paper describes the regulations that govern the hours of supervised clinical practice.5 PAs in California are scope of practice for PAs in California and in other states, licensed by the California Physician Assistant Board and and summarizes recent research on how these laws must obtain a qualifying score on the Physician Assistant impact care. National Certifying Exam, administered by the National Commission on Certification of Physician Assistants Overview of the Profession How Scope of Practice Is Modified in California Physician assistants are state-licensed health profes- sionals who practice medicine in collaboration with Scope of practice laws establish the legal framework physicians and other providers, including diagnosing that controls the delivery of medical services. The reach of these laws encompasses the full range illness, creating treatment plans, and prescribing medica- of licensed health professionals — ranging from tions.1 The education and training that PAs receive allows physicians and physical therapists to podiatrists and them to occupy a wide range of clinical practice areas, dental hygienists. Scope of practice laws govern including family medicine / general practice, emergency which services each category of licensed health medicine, surgical subspecialties, and internal medicine professional is allowed to provide and the settings subspecialties,2 and it significantly overlaps with medical in which they may do so. education.3 With few exceptions, scope of practice statutes are set by state governments. State legislatures consider and pass the statutes that govern health Physician Assistant Education care practices. Regulatory agencies, such as medical Duke University founded the nation’s first PA program and other health professions boards, implement in 1965. It was a two-year program that was based on the statutes through the writing and enforcement of traditional medical education, and it provided training rules and regulations. for individuals without prior health care experience. This Such laws and regulations vary widely from state approach was expanded upon by the MEDEX program to state. Some states allow individual professions at the University of Washington in 1968, which focused broad latitude in the services they may provide, on training those who already had considerable health while others employ strict limits. The nature of the experience — in particular, returning veterans who had limitations can either facilitate or hinder patients’ been trained as medics. By 1974 there were MEDEX pro- ability to see a particular type of provider, which in grams across the nation, and today all states have at least turn influences health care costs, access, and quality. one physician assistant education program.4 California’s Physician Assistants: How Scope of Practice Laws Impact Care 3 (NCCPA). Although PAs must take the certifying exam as Cosignatory Requirements part of the initial licensure process, California does not The second area for potential statutory reform concerns require PAs to maintain NCCPA certification to practice cosignatory requirements, which function as the process in the state, but most choose to renew their certifica- by which physicians review PA medical decisionmaking. tions; the share of licensed PAs in California who are not California defines cosignatory requirements for PAs and NCCPA-certified is estimated to be less than 10%.6 physicians by statute, rather than allowing such require- ments to be determined at the organization or practice Practice Oversight of Physician level. However, the state enacted legislation recently (SB 337, ch. 536 of 2015) that provides an alternative Assistants in California mechanism for demonstrating physician oversight. The In California, PA practice is regulated by the Physician legislation was intended to reduce the administrative Assistant Practice Act (Bus. & Prof. Code §§ 3500 et burden of the review process and was supported by the seq.), which establishes the Physician Assistant Board California Physician Assistant Committee (CPAC). within the jurisdiction of the California Medical Board, and sections 1399.500 et seq. of the California Code of Prior to the passage of SB 337, physicians were required Regulations.7 These statutes define the requirements of to review, countersign, and date a sample of at least 5% PA education and training, stipulate the authority of PAs of a PA’s caseload within 30 days of treatment; this is to provide medical services (including the prescribing of still an accepted mechanism for physician oversight of medications), and define the structure of the collabora- PAs. As an alternative, SB 337 allows a PA and collabo- tive relationship between physicians and PAs regarding rating physician to conduct a monthly review (either in supervision and oversight. person or electronically) of at least 10 medical records of patients who were treated by the PA, for at least 10 The American Academy of Physician Assistants (AAPA) months of each year. It is also allowable for a PA and outlined six key elements of a modern physician assis- collaborating physician to use some combination of the tant practice act.8 These elements, which are meant to new monthly review process and the preexisting “sample encourage practitioner accountability, allow PAs to prac- caseload” review mechanism. The new law also reduced tice to the fullest extent of their education and training, the review requirement for cases where a PA has pre- promote flexibility and efficiency at the practice level, scribed a Schedule II drug from 100% to a sample of improve health care access and quality, and reduce costs. 20%, provided the PA is prescribing per protocol and has States meet these six criteria to varying degrees; eight successfully completed an approved education course states have a practice act that includes all of the ele- on controlled substances.12 ments. California’s PA practice act reflects four of the six elements; the following two gaps represent opportuni- ties for statutory reform. Comparison to Other States A taxonomy of restrictiveness developed at George Washington University categorizes California among the Collaboration Limits middle group of states: In terms of scope of practice The first concerns limits on the number of PAs with whom restrictiveness, there are 22 states less restrictive and 15 a single physician may collaborate. The current ratio is states more restrictive.13 (See Appendix B for a schematic a maximum of four PAs per physician and was defined illustrating state-level differences in the adoption of each in the California Physician Team Practice Improvement practice element.) Act of 2007 (AB 3, ch. 376); the previous ratio had been two PAs per physician. The American Academy of Physician Assistants9 and both the American College of Physicians10 and the American Osteopathic Association11 have adopted a formal policy position stating that physi- cian-to-PA ratios should not be standardized, but rather determined at the practice level and be reflective of practice and community needs. California Health Care Foundation 4 Key Elements of a Modern Physician Examining the Evidence Assistant Practice Act for Practice Expansion: $$ Licensure as the regulatory term. Licensure, in contrast to “certified” or “registered,” denotes A Summary of Research a higher level of scrutiny regarding professional Physician assistants are trained to provide medical qualifications, in addition to vesting regulatory services across a range of settings. Allowing them to authority with the state. practice to the fullest extent of their education and train- $$ Fullprescriptive authority. The ability of PAs ing is widely seen as an effective way to address issues to prescribe all legal medications including of health care access, quality, and cost. This section sum- Schedule II–V controlled substances. marizes recent research on this interrelated set of issues. $$ Scope of practice determined at the practice level. The ability of PAs and the care teams of which they are part to determine what medical Access to Care services the PA provides within the legal scope The statutory limit on the number of PAs a single physi- of practice, rather than having to use a defined cian may collaborate with can negatively affect access to list of services determined by statutory lan- care. Such a cap limits the ability of health care organiza- guage or a state agency. tions to expand to meet demand for services, particularly $$ Adaptable collaboration requirements. The as community health centers are increasingly reliant on ability of PAs and physicians to determine how PAs to provide care within tight budget constraints.14 In they work together to provide medical care, addition, PAs are more likely than physicians to provide without regulations such as requirements that a care in rural areas and to low-income and underserved physician be on-site. populations; supervision regulations can impede PA $$ Cosignatory requirements determined at the workforce growth in these settings.15 Similarly, the chief practice level. The ability of PAs and the care nurse practitioner officer for MinuteClinic has cited PA-to- teams they collaborate with to determine when, physician ratios as one of the biggest issues limiting the and the extent to which, a physician signs off use of PAs to provide care in the retail clinic setting.16 on a PA’s medical orders or otherwise reviews a PA’s medical decisionmaking. $$ Number of PAs a single physician may collab- Quality of Care orate with determined at the practice level. A body of research dating from the early 2000s indicates The ability of PAs and their health care teams to that PAs are providing care that achieves similar clinical determine how many PAs can collaborate with a single physician, as opposed to having a limit outcomes to those produced by physicians. In addition, imposed by statutory language. there is evidence that patients are increasingly comfort- able and satisfied with the care provided by PAs.17 PAs Source: American Academy of Physician Assistants. play important roles alongside nurse practitioners (NPs) in many outpatient and primary care settings, and thus researchers often consider both in studies of quality of care. These studies have reported similar quality of care, service utilization, and referral patterns for physicians, PAs, and NPs in community health centers, and PAs and NPs were more likely to provide health education.18 Research in the VA health care system has reported similar quality of care in the treatment of diabetes and cardiovascular disease.19 House calls conducted by PAs for cardiac surgery patients have been shown to reduce 30-day readmission rates by 25%.20 California’s Physician Assistants: How Scope of Practice Laws Impact Care 5 A number of studies have examined the quality of care provided by PAs in hospital settings. One reported that increasing the number of PAs on hospitalist care teams had no effect on clinical outcomes and resulted in a lower cost of care;21 similarly, pediatric patients treated by PAs in emergency departments had similar rates of return- ing to the emergency department and readmissions as physicians did.22 A study of a PA consultation service for patients with acute myelogenous leukemia reported shorter lengths of stay, lower readmission rates, and fewer additional consultations, with equivalent mortality rates.23 PA leadership of a preoperative venous thromboembo- lism risk-assessment process resulted in improvements in patient safety.24 One study of patients in an intensive care unit staffed with both PAs and NPs reported similar outcomes as other intensive care units.25 Cost of Care The cost-effectiveness of PA-provided care is largely the result of two interrelated factors. The first is that PAs are paid less than physicians. The second factor is productiv- ity; as part of a team-based practice, PAs can significantly increase team productivity by assuming responsibility for portions of the care that might otherwise be provided by physicians.26 Researchers have found that health care organizations that employ more PAs and NPs and/or allow them to provide a full range of primary care services have lower costs, lower use of services and advanced diagnos- tic imaging, fewer ED visits, and fewer inpatient hospital stays.27 PAs and NPs are no more likely than physicians to provide care that deviates from well-established guide- lines or to offer low-value health care services.28 A key challenge associated with measuring the cost- effectiveness of care provided by PAs is the phenomenon of “incident to billing,” whereby care provided by a PA is billed under a collaborating physician’s National Provider Identifier number. There are specific guidelines that gov- ern how collaborating PAs and physicians bill for the services they provide,29 but there remain concerns that a lack of transparency in the process continues to obscure the direct care provided by PAs, which in turn contributes to the challenge of measuring the full impact of PAs on both cost and quality of care. California Health Care Foundation 6 Appendix A. The Landscape of Physician Assistants Current Number of PAs and Their highest 2016 per capita ratio (34 per 100,000 population) Geographic Distribution (see page 8). The Los Angeles, Greater Bay Area, and As of December 31, 2017, California had a total of 9,499 San Joaquin regions had considerably lower per capita certified PAs (only New York has more). However, Figure ratios. Prior research has found higher concentrations of A1 shows that California had one of the lowest rates of PAs (along with NPs) in geographic areas with low ratios PAs per capita, at 24 per 100,000 residents.30 of physicians per capita,31 such as the Northern and Sierra region of California, and these data underscore The per capita distribution of PAs across California varies that finding. PAs are an effective means of addressing widely by region. Figure A2 shows that California’s most access-to-care issues for underserved areas. rural region (the Northern and Sierra region) had the Figure A1. Certified Physician Assistants per 100,000 Population, by State, 2017 1.0 – 29.9 30.0 – 38.0 38.1 – 54.9 55.0+ Source: 2016 Statistical Profile of Certified Physician Assistants by State, National Commission on Certification of Physician Assistants, www.nccpa.net. California’s Physician Assistants: How Scope of Practice Laws Impact Care 7 Figure A2. Actively Licensed PAs per 100,000 Population, by California Region, 2016 Central Coast Monterey, San Benito, San Luis Obispo, Northern and Sierra 34 Santa Barbara, Santa Cruz, Ventura Orange 30 Greater Bay Alameda, Contra Costa, Marin, Napa, Area San Francisco, San Mateo, Santa Clara, Solano, Sonoma Sacramento Area 28 Inland Empire Riverside, San Bernardino San Diego Area 28 Los Angeles Los Angeles County Central Coast 27 Northern and Alpine, Amador, Butte, Calaveras, Sierra Colusa, Del Norte, Glenn, Humboldt, California 25 Inyo, Lake, Lassen, Mariposa, Mendocino, Modoc, Mono, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Inland Empire 25 Tehama, Trinity, Tuolumne, Yuba Orange County Orange Greater Bay Area 23 Sacramento Area El Dorado, Placer, Sacramento, Yolo San Joaquin Valley 23 San Diego Area Imperial, San Diego San Joaquin Fresno, Kern, Kings, Madera, Merced, Los Angeles 22 Valley San Joaquin, Stanislaus, Tulare Sources: Custom tabulation, California Department of Consumer Affairs, 2016; and Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2015, US Census Bureau. Demographic Characteristics Table A1. Demographic Characteristics of Certified PAs, Table A1 compares the 2016 demographic profile of cer- California vs. United States, 2016 tified PAs in California with the United States. There is CA US only a small difference in the gender composition of PAs Gender in California compared to the US overall. The age distri- $$ Male 34.9% 32.3% bution of certified PAs in California skews toward older $$ Female 65.1% 67.7% providers compared with the US, as the share of PAs in California under the age of 30 is approximately half what Age Group it is nationally. The racial composition of certified PAs $$ Under 30 9.2% 17.2% in California is considerably more diverse compared to $$ 30–39 37.5% 37.6% the US. Although Table A1 does not distinguish Latino $$ 40–49 27.7% 23.2% or Hispanic ethnicity from race, data reported separately $$ 50–59 15.7% 13.7% (from the same source) indicate that in 2016 approxi- $$ 60 and over 10.0% 8.3% mately 17% of certified PAs in California identified as Latino or Hispanic, compared to just 6% nationally. In Racial Group* addition, over 50% of certified PAs in California reported $$ White 67.0% 86.7% the ability to communicate with a patient in a language $$ Asian 16.3% 5.4% other than English, compared to just 23% of the US PA $$ Black / African American 4.6% 3.9% workforce overall.32 $$ Native Hawaiian / Pacific Islander 1.7% 0.4% $$ American Indian / Native Alaskan 0.4% 0.4% $$ Other 10.0% 3.2% *Does not distinguish Latino or Hispanic ethnicity from race. Source: 2016 Statistical Profile of Certified Physician Assistants by State, National Commission on Certification of Physician Assistants, www.nccpa.net. California Health Care Foundation 8 Practice Settings Physician assistants in California predominantly work in an office-based private practice (46%) or in a general acute care hospital (30%). Other common employment settings include community health centers (9%) and rural health clinics (3%).33 Table A2 shows the clinical prac- tice areas most frequently reported by certified PAs and demonstrates that PAs in California are more likely to be working in the area of family medicine / general practice compared to the US overall. In addition, in 2016, 34% of PAs in California were practicing in a primary care setting compared to 28% of PAs nationally. Table A2. Common Clinical Practice Areas for Certified PAs, California vs. United States, 2016 CA US Primary Care* 34.1% 27.8% Family Medicine / General Practice 27.4% 20.6% Surgical Subspecialties 17.5% 18.5% Emergency Medicine 14.6% 13.2% Internal Medicine Subspecialties 6.6% 9.2% *Includes family medicine / general practice, general internal medicine, and general pediatrics. Source: 2016 Statistical Profile of Certified Physician Assistants by State, National Commission on Certification of Physician Assistants, www.nccpa.net. Educational Pipeline in California There are currently 15 PA education programs in California. All but three are located in the Greater Bay Area or the Los Angeles area (LA/Orange/Riverside Counties). In combination, these 15 programs produce approximately 350 to 400 new graduates per year, which is less than half the annual number of new PA licenses issued by the state in recent years34 and indicates that California has more PAs moving to California from other states than moving from California to other states. In 2015, graduates of PA training programs in California were 70% female and pre- dominantly white (44%) or Asian (30%).35 California’s Physician Assistants: How Scope of Practice Laws Impact Care 9 Appendix B. Physician Assistant Scope of Practice Elements, by State, 2018 Licensure as regulatory term Full prescriptive authority SOP practice determined at practice level Adaptable collaboration requirements Cosignatory requirements determined at practice level MD to PA ratio determined at practice level Source: American Academy of Physician Assistants. California Health Care Foundation 10 Endnotes 1.“Become a PA,” American Association of Physician Assistants 15.K. Grumbach et al., “Who Is Caring for the Underserved? (AAPA), www.aapa.org; “What Is a PA,” AAPA, www.aapa.org. A Comparison of Primary Care Physicians and Nonphysician Clinicians in California and Washington,” Annals of Family 2.2017 Statistical Profile of Certified Physician Assistants, Medicine 1, no. 2 (July 2003): 97–104, doi:10.1370/afm.49; National Commission on Certification of Physician Assistants, C. M. Everett et al., “Physician Assistants and Nurse www.nccpa.net. Practitioners as a Usual Source of Care,” Journal of Rural 3.A. J. van Vught et al., “Analysis of the Level of General Clinical Health 25, no. 4 (Fall 2009): 407–14, doi:10.1111/j.1748- Skills of Physician Assistant Students Using an Objective 0361.2009.00252.x; R. Wells et al., Physician Assistants: Structured Clinical Examination,” Journal of Evaluation in Modernize Laws to Improve Rural Access, National Rural Clinical Practice 21, no. 5 (Oct. 2015): 971– 75, doi:10.1111/ Health Association, April 2018, www.ruralhealthweb.org jep.12418. (PDF); and Y. Xue et al., “Trends in Primary Care Provision to Medicare Beneficiaries by Physicians, Nurse Practitioners, 4.J. F. Cawley, E. A. Cawthon, and R. S. Hooker, “Origins of the or Physician Assistants: 2008 – 2014,” Journal of Primary Physician Assistant Movement in the United States,” JAAPA: Care and Community Health 8, no. 4 (Oct. 2017): 256 – 63, Official Journal of American Academy of Physician Assistants doi:10.1177/2150131917736634. 25, no. 12 (Dec. 2012): 36 – 42. 16.M. Rudberg, “Retail Clinics: An Opportunity for PAs and 5. Scope of Practice, American Assn. of Physician Assistants, PA NPs to Work Together,” Amer. Assn. of Physician Assistants, January 2017, www.aapa.org (PDF). www.aapa.org. 6.J. Coffman, I. Geyn, and K. Himmerick, California’s Primary 17.M. G. H. Laurant et al., “The Impact of Nonphysician Care Workforce: Current Supply, Characteristics, and Pipeline Clinicians: Do They Improve the Quality and Cost- of Trainees, Healthforce Center at UCSF, February 16, 2017, Effectiveness of Health Care Services?,” Medical Care healthforce.ucsf.edu (PDF). Research and Review 66, 6 suppl. (Dec. 2009): 36S – 89S, 7.Laws and Regulations Relating to the Practice of Physician doi:10.1177/1077558709346277; I. B. Wilson et al., “Quality of Assistants, Physician Assistant Board, www.pac.ca.gov (PDF). HIV Care Provided by Nurse Practitioners, Physician Assistants, and Physicians,” Annals of Internal Medicine 143, no. 10 (Nov. 8.The Six Key Elements of a Modern PA Practice Act, American 2005): 729 – 36, doi:10.7326/0003-4819-143-10-200511150- Assn. of Physician Assistants, July 2016, www.aapa.org (PDF). 00010; P. A. Ohman-Strickland et al., “Quality of Diabetes Care 9.Amer. Assn. of Physician Assistants, Six Key Elements. in Family Medicine Practices: Influence of Nurse-Practitioners and Physician’s Assistants,” Annals of Family Medicine 6, no. 1 10.M. R. Zerehi and E. Rathfon, Internists and Physician (Jan. 1, 2008): 14 – 22, doi:10.1370/afm.758; D. W. Roblin Assistants: Team-Based Primary Care, American College of et al., “Patient Satisfaction with Primary Care: Does Type of Physicians, 2010, www.acponline.org (PDF). Practitioner Matter?,” Medical Care 42, no. 6 (June 2004): 579 – 90, doi:10.1097/01.mlr.0000128005.27364.72; and 11.E. Rathfon and N. A. Schilligo, Osteopathic Physicians Usha Subramanian et al., “Treatment Decisions for Complex and Physician Assistants: Excellence in Team-Based Medicine, Patients: Differences Between Primary Care Physicians and American Osteopathic Assn. and American Academy of Mid-Level Providers,” American Journal of Managed Care 15, Physician Assistants, July 2013, www.aapa.org (PDF). no. 6 (June 2009): 373 – 80, www.ncbi.nlm.nih.gov. 12.For a summary of the bill’s contents, see “California 18.E. T. Kurtzman and B. S. Barnow, “Comparison of Nurse Improves Chart Co-Signature Requirements for PAs,” Practitioners, Physician Assistants, and Primary Care Physicians’ press release, American Assn. of Physician Assistants, Patterns of Practice and Quality of Care in Health Centers,” October 6, 2015, www.aapa.org and “New Law Addresses Medical Care 55, no. 6 (June 2017): 615 – 22, doi:10.1097/ Supervision, Documentation Requirements for Physician MLR.0000000000000689. Assistants,” press release, California Hospital Assn., October 20, 2015, www.calhospital.org. 19.S. S. Virani et al., “Comparative Effectiveness of Outpatient Cardiovascular Disease and Diabetes Care Delivery 13.P. Pittman et al., “NP and PA Privileging in Acute Care Between Advanced Practice Providers and Physician Providers Settings: Do Scope of Practice Laws Matter?,” Medical Care in Primary Care: Implications for Care Under the Affordable Research and Review (February 27, 2018): online ahead of Care Act,” American Heart Journal 181 (Nov. 2016): 74 – 82, print, doi:10.1177/1077558718760333. doi:10.1016/j.ahj.2016.07.020. 14.P. Shin, “The Health Care Safety Net: Community Health 20.J. P. Nabagiez et al., “Physician Assistant Home Visit Centers’ Vital Role,” National Institute for Healthcare Program to Reduce Hospital Readmissions,” Journal of Management Foundation, July 2016, www.nihcm.org; Thoracic and Cardiovascular Surgery 145, no. 1 (Jan. 2013): and M. Proser et al., “Community Health Centers at 225 – 33, doi:10.1016/j.jtcvs.2012.09.047. the Crossroads: Growth and Staffing Needs,” JAAPA: Official Journal of the American Academy of Physician Assistants 28, no. 4 (Apr. 2015): 49 – 53, doi:10.1097/01. JAA.0000460929.99918.e6. California’s Physician Assistants: How Scope of Practice Laws Impact Care 11 21.T. M. Capstack et al., “A Comparison of Conventional 28.J. N. Mafi et al., “Comparing Use of Low-Value Health and Expanded Physician Assistant Hospitalist Staffing Models Care Services Among Us Advanced Practice Clinicians and at a Community Hospital,” Journal of Clinical Outcomes Physicians,” Annals of Internal Medicine 165, no. 4 (2016): Managment 23, no. 10 (Oct. 2016): 455 – 61, 237– 44, doi:10.7326/M15-2152. www.turner-white.com (PDF). 29.See Third-Party Reimbursement for PAs, American Assn. 22.D. Pavlik et al., “Physician Assistant Management of Physician Assistants, April 2018, www.aapa.org (PDF). of Pediatric Patients in a General Community 30. NCCPA, 2017 Statistical Profile. Emergency Department: A Real World Analysis,” Pediatric Emergency Care 33, no. 1 (Jan. 2017): 31. Coffman, California’s Primary Care Workforce. 26 – 30, doi:10.1097/PEC.0000000000000949. 32. 2016 Statistical Profile of Certified Physician Assistants, 23.B. E. Glotzbecker et al., “Impact of Physician Assistants National Commission on Certification of Physician on the Outcomes of Patients with Acute Myelogenous Assistants (NCCPA), www.nccpa.net. Leukemia Receiving Chemotherapy in an Academic Medical 33.NCCPA, 2016 Statistical Profile. Center,” Journal of Oncology Practice 9, no. 5 (Sep. 1, 2013): e228 – 33, doi:10.1200/JOP.2012.000841. 34. 2016 Sunset Review Report, Physician Assistant Board, www.pac.ca.gov (PDF). 24.M. Moote et al., “PA-Driven VTE Risk Assessment Improves Compliance with Recommended Prophylaxis,” 35. 2017 Statistical Profile of Certified Physician Assistants, JAAPA: Official Journal of American Academy of Physician National Commission on Certification of Physician Assistants 23, no. 6 (June 2010): 27– 35, www.ncbi.nlm.nih.gov. Assistants, 2018, www.nccpa.net (PDF). 25.D. K. Costa et al., “Nurse Practitioner/Physician Assistant Staffing and Critical Care Mortality,” Chest 146, no. 6 (Dec. 2014): 1566 – 73, doi:10.1378/chest.14-0566. 26.J. Altschuler et al., “Estimating a Reasonable Patient Panel Size for Primary Care Physicians with Team-Based Task Delegation,” Annals of Family Medicine 10, no. 5 (Sep./Oct. 2012): 396 – 400, doi:10.1370/afm.1400. 27.D. W. Roblin et al., “Use of Midlevel Practitioners to Achieve Labor Cost Savings in the Primary Care Practice of an MCO,” Health Services Research 39, no. 3 (June 2004): 607– 26, doi:10.1111/j.1475-6773.2004.00247.x; C. Eibner et al., Controlling Health Care Spending in Massachusetts: An Analysis of Options, RAND Corporation, August 2009, www.rand.org (PDF); and H. Liu, “The Impact of Using Mid- Level Providers in Face-to-Face Primary Care on Health Care Utilization,” Medical Care 55, no. 1 (Jan. 2017): 12 – 18, doi:10.1097/MLR.0000000000000590. California Health Care Foundation 12