The Coalition recognizes the valuable contributions of the physician assistant (PA) profession and believes that physician assistants should function in an integrated practice arrangement with practicing, licensed physicians. Duties should not be delegated to a physician assistant for which the supervising physician does not have the appropriate educational training and current competence. The Coalition encourages health professionals to work together as clinically integrated teams in the best interest of patients. Patients are best served by a health care team led by a physician.

Regulation and Scope of Practice
The regulation of the scope of practice of physician assistants varies from state to state and is determined through state licensing requirements. Many states now allow the scope of practice to be determined at the practice level rather the state. States also commonly do not have uniform scope of practice regulations but address scope of practice on an issue-by-issue basis. State laws regarding the practice of physician assistants address issues concerning the use of “licensure” as a regulatory term, authority to prescribe, determination of scope of practice, adaptability of supervision requirements, determination of co-signature requirements, and maximum number of PAs a physician can supervise at one time. All states have passed legislation regarding the use of the term “licensure” to describe the process by which the state authorizes PAs to practice.

Currently, six states (AL, AR, GA, IA, KY, WV) limit the prescriptive authority of physician assistants at the state level. Kentucky does not allow PAs to prescribe or administer any schedule drugs, while the other six do not allow PAs to prescribe Schedule II medications.¹ Oklahoma allows the state board to define the scope of prescriptions PAs may prescribe.² Prescriptive authority is determined at the practice level by the supervising physician for the other 44 states and DC.³

There are 37 states that allow for the determination of scope of practice to be jointly established through a written agreement between the supervising physician and PA at the practice level. The remaining 13 states (AL, FL, GA, IA, KY, MD, MS, OK, PA, SC, VA, WA, WI, WV) and DC require the scope of practice for PAs determined by law or the state’s medical board on an individual basis.4 Similarly, 27 states and the District of Columbia (AK, AR, AZ, CT, DE, DC, FL, GA, HI, ID, IL, ME, MD, MA, MI, MN, NM, NY, NC, ND, OR, RI, SD, WA, WV, WI, WY) allow for co-signature requirements for PAs to be determined at the practice level by the supervising physician. The remaining 33 states have state regulations regarding co-signature requirements.5

Additionally, 20 states (AL, AK, CO, FL, ID, IA, KS, KY, ME, MS, MO, MT, NE, NV, OR, PA, SC, TN, VA, WV) have laws determining the means by which responsible supervision of a physician over PAs is accomplished, while the other 30 states and DC allow this to be decided at the state regulatory level. Finally, 36 states and the District of Columbia have state laws limiting the number of PAs that one physician may supervise at a time. The limits vary from state to state but generally allows between two to seven PAs per one supervising physician. The other 14 states (AK, AR, CT, ME, MA, MT, MS, MI, MN, NC, ND, RI, TN, VT) do not have any limits.6

Future Issues
Due to the current physician shortage, states are seeking to adjust scope of practice regulations of PAs to fill the physician supply gaps. A number of states have introduced legislation aiming to expand scope of practice relationships from supervisory to “collaborative.”

Resources:

1 American Medical Association. (2018). “Physician assistant scope of practice.” Web.
2 Kaiser Family Foundation. (2015). “Physician Assistant Scope of Practice Laws.” Web.
3 American Medical Association. (2018). “Physician assistant scope of practice.” Web.
4 Scope of Practice Policy. (2018). “Physician Assistants Overview.” Web.
5 American Medical Association. (2018). “Physician assistant scope of practice.” Web.
6 Barton Associates. (2018). “PA Scope of Practice Laws.” Web.

The Coalition recognizes the evolving complexity and proliferation of pharmaceutical agents and the important role pharmacists play in the delivery of high-quality health care. The pharmacy professional and physician can and should work collaboratively so that their combined expertise is used to optimize the therapeutic effect of pharmaceutical agents in patient care. The Coalition opposes state legislation allowing pharmacists to dispense medication beyond the expiration of the original prescription for other than emergency purposes. Although the Coalition believes that pharmacists’ right of conscientious objection should be reasonably accommodated to safeguard the patient-physician relationship, government policies must protect patients’ rights to obtain legally prescribed and medically indicated treatments in a timely manner. The pharmacist’s refusal to fill a prescription must be discussed with the physician (or his/her representative) and the patient, and the prescription must be returned to its source.

Further, the Coalition believes that only licensed doctors of medicine, osteopathy, dentistry, and podiatry should have the statutory authority to prescribe drugs. Pharmacists should not alter a prescription written by a physician, except in an integrated practice supervised by a physician or when permitted by state law. The Coalition believes that independent prescription authority for pharmacists will further fragment the American health care system and will undermine the national goals of integrated, accountable care.

Regulation and Scope of Practice
The regulation of the scope of practice of pharmacists varies from state to state and is determined through state legislation or Departments of Health, Boards of Pharmacy, or other governing bodies authorized by the state. Scope of practice regulations generally target drug dispensing and administration of clinical services. Within these areas, state laws regarding pharmacist practice address issues such as prescriptive authority, authority to monitor or modify patient medication therapy, prescription or administration of clinical services such as vaccines, flu shots, contraception, etc. without a prescription, or instruction or interpretation of laboratory testing.

There are a variety of methods through which scope of practice adjustments can be implemented. States can authorize pharmacists to dispense drugs after independently prescribing them, after entering into a collaborative practice agreement under which the pharmacist operates under authority delegated by another licensed practitioner with prescribing authority (i.e. a physician), under “standing orders” issued by the state, or based on other predetermined state authorized protocols. Forty-eight states and the District of Columbia allow for collaborative practice agreements; Oklahoma and Alabama remain as the only states without collaborative practice agreements expanding pharmacist authority.1

All fifty states and the District of Columbia allow pharmacists to administer vaccinations; however, states have limitations based on age, type of immunization, consent of a parent or guardian, and/or required authorization. Some of the pharmacist-administered immunizations include influenza, zoster, Tdap/Td, pneumococcal, or HPV. All states and the District of Columbia authorize pharmacists to administer the influenza vaccine. Nineteen states (AL, AK, CA, CT, GA, HI, ID, LA, MA, MT, NH, NJ, OK, OR, SD, TN, UT, WA, WY) allow pharmacists to prescribe and administer these vaccines independently while the other 31 states (AZ, AR, CO, DE, FL, IL, IN, IA, KS, KY, ME, MD, MI, MN, MS, MO, NE, NV, NM, NC, ND, OH, PA, RI, SC, TX, VT, VA, WV, WI) and the District of Columbia allow pharmacists to administer flu shots through collaborative practice agreements, standing orders, prescriptions from authorized providers, or other protocols. Further, five states (AZ, KY, NJ, NY, OR) expand pharmacist vaccine administration authority in the case of a public health state of emergency.2

All states permit standing orders to allow pharmacists to dispense naloxone,3 with five states (CA, DE, MA, NY, OR) requiring pharmacists to participate in naloxone administration programs prior to obtaining authorization.4 Many of these states also allow pharmacists to distribute naloxone without a prescription.

Six states (CA, CO, HI, MD, NM, OR) also have regulations allowing pharmacists to prescribe and/or administer oral contraception, including self-administered hormonal contraceptives and emergency contraception drug therapy. Tennessee and Washington state allow pharmacists to prescribe oral contraception only. New Hampshire passed legislation allowing physicians to issue standing orders to allow pharmacists the authority to prescribe contraception.5

Future Issues
Expansion of pharmacist scope of practice is expected to continue across states. The Centers for Medicare and Medicaid Services (CMS) issued guidance regarding state flexibility to expand scope of pharmacy practice using collaborative practice agreements, standing orders, or other predetermined protocols. These recommendations focus on the administration of naloxone in response to the nationwide opioid epidemic, tobacco cessation drug therapy, and emergency contraception.

Resources

1 CMS Center for Medicaid and CHIP Services. (2017, January 17). CMCS Informational Bulletin. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib011717.pdf
2 American Medical Association. (2016). Pharmacist Administered Immunizations: Authorizations by State. Chicago, IL: Author.
3 National Alliance of State Pharmacy Associations. (2018). Naloxone Access in Community Pharmacies. Retrieved from https://naspa.us/resource/naloxone-access-community-pharmacies/
4 CMS Center for Medicaid and CHIP Services. (2017, January 17). CMCS Informational Bulletin. Retrieved from https://www.medicaid.gov/federal-policy-guidance/downloads/cib011717.pdf
5 Kaiser Family Foundation. (2017). Oral Contraception Pills. Retrieved from https://www.kff.org/womens-health-policy/fact-sheet/oral-contraceptive-pills/

The Coalition believes that naturopathic theory and practice are not based upon knowledge widely accepted by the scientific community. Naturopathic education does not prepare practitioners to properly and accurately diagnose or provide appropriate treatment, safely or effectively prescribe medications, perform physicals for school or employment, or perform surgical procedures. The Coalition opposes an expansion of naturopaths’ scope of practice in the 20 states and DC that provide licensing for naturopathic practitioners. A naturopath must not be allowed, under any circumstances, to use the title “physician,” nor should a naturopath be considered a “primary care physician.”

Regulation and Scope of Practice
The regulation of the practice of naturopathy varies from state to state. Both South Carolina and Tennessee explicitly prohibit the practice of naturopathy, while 20 states and DC have laws that license naturopathic providers. To receive a license to practice naturopathic medicine in those 20 states and DC, practitioners are required to graduate from an accredited four-year residential naturopathic school and pass a postdoctoral board examination. Licensed naturopathic providers must fulfill state-mandated continuing education requirements annually and follow a specific scope of practice defined by their state’s law.5

State laws regarding the practice of naturopathy address prescribing authority, surgical authority, the ability to order tests, and use of the term “physician.” While most states allow for naturopathic providers to have prescribing authority, they are not allowed to prescribe controlled substances aside from New Hampshire and Washington, which both allow limited exceptions for certain drugs.6,7 The majority of states allow a naturopath to prescribe and administer nonprescription natural therapeutic substances, drugs and therapies.8

Aside from prescribing authority, the extent of what licensed naturopathic providers can do differs widely among states. Twelve states (CA, CO, HI, KS, ME, MN, MA, MT, NH, OR, UT, and VT) and DC allow naturopaths to provide minor surgeries. While definitions of minor surgeries vary, they typically refer to the repair, care and suturing of superficial lacerations and abrasions and the removal of foreign bodies located in superficial tissue.9 Additionally, 11 states (CA, CO, MA, MD, ME, MN, MT, ND, NH, UT, and VT) allow naturopathic providers to order diagnostic tests. Finally, seven states (AZ, HI, MA, MT, OR, UT, and VT) allow naturopathic providers to use the term “physician;” however, this is expressly prohibited in seven states (AK, CA, CO, KS, MD, ME, and ND) and DC.10

References:

5 “Regulated States & Regulatory Authorities.” American Association of Naturopathic Physicians. Web.
6 N.H.R.S.A. § 328-E:4
7 R.C.W. § 18.36A.020
8 N.D.C.C. § 43-58
9 C.R.S. § 12-37.3-105
10 “State law chart: Naturopathic licensure and scope of practice.” American Medical Association. Web.