New Law: Physician Assistant Collaborative Practice

 

To:	Rural Chief Executive Officers, Chief Medical Officers, Chief Nursing Officers, Legal Counsel and Government Affairs Leaders
Staff Contact:	Katerina LaMarche, JD, Policy Director katerinal@wsha.org | (206) 216-2505Mary Storace, Policy Analyst marys@wsha.org | (206) 577-1838
Subject:	New Law: Physician Assistant Collaborative Practice

Purpose

The purpose of this bulletin is to provide hospitals with information about ESHB 2041 (2024), which replaces the physician assistant (PA) supervision model and practice agreements. The new law, within Chapter 18.71A RCW, creates a collaborative practice model that uses collaboration agreements for physician assistants in Washington State. The new law harmonizes PA practice in Washington with PA practice in Oregon and Idaho.

Applicability/Scope

Effective January 1, 2025, Chapter 18.71A RCW applies to entities that employ or contract with physicians and PAs.

Recommendation

1. Review this bulletin, ESHB 2041, and Chapter 18.71A RCW.
2. Review the model collaboration agreement created by the Washington Medical Commission (WMC).
3. Update PA practice agreements to collaboration agreements. A PA must enter into a collaboration agreement no later than the date on which the PA’s license is due for renewal or July 1, 2025, whichever is later. A PA or their employer must make the collaboration agreement available upon the request of the WMC.
4. Review reimbursement practices for PAs.
5. Review and assess policies and documentation, including insurance and liability considerations for PAs practicing under collaboration agreements.

Beginning January 1, 2025 – ESHB 2041 Highlights:

1. Replaces the supervision model implemented through based on practice agreements with a collaborative practice model for most PAs. The collaborative practice model utilizes collaboration agreements (RCW 71A.120).
2. Authorizes collaborative practice for PAs who have over 4,000 hours of postgraduate clinical experience and 2,000 hours of specialty experience. PAs are supervised by physicians until that point (RCW 71A.030).
3. Makes changes to PA scope of practice. PA’s scope of practice mirrors their participating physician’s or the group of physicians that the PA is working with in that specialty area(s) or department. PAs who have 10 years or 20,000 hours of specialty experience can work outside the scope of their participating physician(s) if they continue to obtain continuing medical education in that specialty and they are working in a medically underserved or rural area (RCW 71A.030).
4. Removes the physician to PA ratio. A PA, physician, or employer may participate in more than one collaboration agreement if the physician or employer is reasonably able to fulfill the duties and responsibilities in each agreement (RCW 71A.120).
5. Authorizes direct pay/reimbursement for PA-provided care (RCW 43.835).
6. Removes physician liability for the care provided by Pas to patients. PAs are legally responsible for their medical decisions (RCW 71A.050).
7. Maintains signing and attestation requirements for PAs, but as related to the physician assistant’s participating physician or physician group (RCW 71A.090).

Overview

1. Collaboration Agreements Process:

a. Beginning January 1, 2025, a PA must enter into a collaboration agreement no later than the date on which the PA’s license is due for renewal or July 1, 2025, whichever is later. A PA practicing under a practice agreement that was entered into before July 1, 2025, may continue to practice under the practice agreement until the PA enters into a collaboration agreement. Beginning July 1, 2025, all PAs will sign collaboration agreements rather than practice agreements (RCW 71A.120). The WMC’s model collaboration agreement can be completed currently with a notation that it will convert to a collaboration agreement on January 1, 2025.

b. Prior to entering into a collaboration agreement, the participating physician or physicians, their employer, or their designee must verify a PA’s credentials. If medical credentials are satisfactory, the collaboration agreement process can begin. A collaboration agreement must be in written or electronic form and describe the manner in which a PA will be supervised by, or collaborate with, at least one physician.

c. The collaboration agreement must be available either electronically or on paper at the PA’s primary location of practice and made available to the commission upon request.

d. A “collaboration agreement” is written agreement that describes the manner in which the PA is supervised by or collaborates with at least one physician, and that is signed by the PA and one or more physicians or the PA’s employer.

Collaboration agreements are “tiered” based on whether the PA requires supervision or whether the PA can engage in collaborative practice:

i.  Supervised PAs:

1. 1. 1. 1. PAs must work under the supervision of a participating physician if they have fewer than 4,000 hours of postgraduate clinical practice, as described in the collaboration agreement and determined at the practice site. See collaboration agreement requirements below.
         2. If a PA changes specialties after completing 4,000 hours of postgraduate clinical practice, the first 2,000 hours of postgraduate clinical practice in the new specialty must be completed under the supervision of a participating physician, as described in the collaboration agreement and determined at the practice site. See collaboration agreement requirements below.

ii.  Collaborative PAs: If a PA has met the hours requirements above, they can practice collaboratively, meaning they can interact with, consult with, or refer to a physician or other appropriate members of the health care team as indicated by the patient’s condition, the education, experience, and competencies of the PA, and the standard of care.

e.  Nothing in RCW 71A.120 shall be construed as prohibiting PAs from owning their own practice or clinic.

f.  Whenever a PA is practicing in a manner inconsistent with the collaboration agreement, the WMC may take disciplinary action under chapter 130RCW. Whenever a physician is subject to disciplinary action under chapter 18.130 RCW related to the practice of a PA, the case must be referred to the appropriate disciplining authority.

2. Collaboration Agreement Requirements:

Collaborative agreements are required by statute to include specific elements. See RCW 18.71A.120 for complete information.

a.  The signature of the PA, at least one participating physician, and the PA’s employer (e.g., a medical director or other scope appropriate clinician who is authorized to enter into the collaboration agreement with a PA on behalf of the facility, group, clinic, or other organization that employs the PA). If a participating physician is not a signatory to the collaboration agreement, the participating physician must be provided notice of the agreement and an opportunity to decline participation. Entering into the agreement remains voluntary and a physician may not be compelled to participate as a condition of employment. The protections of RCW 70.075 still apply to any participating physician or employer who reports to the commission acts of retaliation or reprisal for declining to sign a collaboration agreement;

b.  A description of the duties and responsibilities of the PA and the participating physician or physicians. If the PA is working with an anesthesiologist who is acting as a participating physician, and the PA’s duties include delivering general or intrathecal anesthesia, the collaboration must include evidence of adequate education and training in the delivery of the type of anesthesia being delivered;

c.  A description of the supervision requirements for PAs with less than 4,000 hours of postgraduate clinical practice or 2,000 hours of specialty practice and the collaboration requirements for PAs who have met that threshold;

d.  A process between the PA and participating physician or physicians for communication, availability, and decision making when providing medical treatment to a patient or in the event of an acute health care crisis not previously covered by the collaboration agreement;

e.  If there is only one participating physician identified in the collaboration agreement, a protocol for designating another participating physician for consultation in situations in which the physician is not available;

f.  If the physician assistant has not met the required hours for collaborative practice and is working under the supervision of a participating physician, in accordance with RCW 18.71A.030, a plan for how the physician assistant will be supervised;

g.  An attestation by the PA of the number of postgraduate clinical practice hours completed, including those completed in a chosen specialty, when the physician assistant signs the collaboration agreement;

h.  The PA or participating physician must provide written notice at least thirty days prior to the termination. The PA or participating physician may terminate the collaboration agreement immediately due to good faith concerns regarding unprofessional conduct or failure to practice medicine while exercising reasonable skill and safety; and

i.  A description of expanded scope of practice if the PA meets the scope of practice exception.

3.  Scope of Practice:

a.  Effective January 1, 2025, a PA may practice in any area of medicine or surgery as long as the practice is not beyond the scope of expertise and clinical practice of the participating physician or physicians or the group of physicians within the department or specialty areas in which the PA practices. In other words, the PA’s scope of practice mirrors the participating physician’s or the group of physicians that the PA is working with in that specialty area(s) or department. The participating physician or physicians, or the PA’s employer, and the PA shall determine which procedures may be performed and the degree of autonomy under which the procedure is performed (RCW 71A.030).

b.  Exception: PAs who have 10 years or 20,000 hours of specialty experience can work outside the specialty of their participating physician(s) if they continue to obtain continuing medical education in that specialty and they are working in a medically underserved or rural area. This expanded scope must be described in a collaboration agreement.

4.  PA Reimbursement

RCW 48.43.835 authorizes insurance carriers to reimburse employers of PAs, including hospitals, for services covered and rendered by licensed PAs. The bill does not affect PA reimbursement rates. Reimbursement for PA services must be made when rendered within a PAs scope of practice and if the health care service ordered or performed by a PA would have been covered if it had been performed by a physician. Carriers are prohibited from imposing practice or other requirements that are more restrictive than state laws or regulations which govern PAs.

Background

During the public health emergency, Governor Inslee issued proclamation 20-32, effective from March 2020 until October 2022, which permitted PAs to practice with increased autonomy and without a practice agreement signed by a supervising physician. Following the rescission of the proclamation, PAs worked with legislators to codify the change allowed during the pandemic.

WSHA’s 2024 New Law Implementation Guide

Please visit WSHA’s new law implementation guide online. The Government Affairs team is hard at work preparing resources and information on the high priority bills that passed in 2024 to help members implement the new laws, as well as links to resources such as this bulletin. In addition, you will find the Government Affairs team’s schedule for release of upcoming resources on other laws and additional resources for implementation.

References

ESHB 2041 – Session Law

Model Collaboration Agreement – Washington Medical Commission

Chapter 48.43 RCW – Insurance Reform

Chapter 80, Laws of 2020 – Physician Assistants, Various Provisions

Chapter 18.71A RCW – Physician Assistant Statute