State licensure procedures for PAs (physician assistants) vary significantly, as does the average time necessary for states to process a PA license. This article discusses these variations and presents evidence that states with the highest number of extra requirements for PA licensure tend to have longer license processing times. It also includes an analysis showing that states with modernized PA practice laws (e.g., laws that allow PAs to practice to the full extent of their education and experience) tend to have fewer extra licensure requirements. Finally, this article discusses potential benefits of reducing extra PA licensure requirements, including mitigation of health care practitioner shortages without compromising patient safety and greater adoption of the Uniform Application (UA) for PAs.
PAs (physician assistants), like other health care practitioners, are licensed by the state in which they practice. PAs seeking licensure submit an application, pay fees, and provide proof of graduation from an accredited PA program and passage of the Physician Assistant National Certifying Examination (PANCE) administered by the National Commission on Certification of Physician Assistants (NCCPA). A criminal background check and information regarding prior practice are also generally required.
However, many states have extra — and often burdensome — licensure requirements, including personal interviews, identification of a supervising or collaborating physician, submission of letters of recommendation or other supplemental forms, board approval of the PA's practice agreement, passage of a jurisprudence examination, and/or direct action by board members to either ratify or approve licensure. These extra requirements — and the time it takes for state licensing boards to process a PA's request for licensure — vary widely from state to state.
In 2016 and 2017, the American Academy of PAs (AAPA) sought information from state licensing boards on the overall use of extra PA licensure requirements, as well as the estimated time necessary for licensing boards to process a typical PA license. The goal of this research was to determine which licensing boards had the highest number of licensure requirements for PAs and whether these boards also had the longest processing times for licensure. AAPA also sought to determine whether states with the most modernized PA practice laws (e.g., those which allow PAs to practice to the full extent of their education and experience) were among those with fewer extra licensure requirements.
AAPA policy supports a simple approach to PA licensure. Applicants who meet a state's qualifications should be issued a license, and there should be no extra steps which slow the licensure process without enhancing public safety.1 This is similar to the Federation of State Medical Boards' (FSMB) policy, which supports licensure procedures for physicians that do not include extraneous steps.2 This article will discuss the variations in PA licensure procedures among the states, show how these differences may be connected to a state's PA practice laws, and provide arguments for creating a system of PA licensure which protects the public while reducing extra requirements.
Background on the PA Profession
The first PA educational program was established in 1965 by Duke University's then-chairman of the Department of Medicine, Dr. Eugene A. Stead, Jr.3 This new profession was created to increase patient access to health care and create civilian jobs for the thousands of returning service personnel who had gained significant medical training and experience while in the military.4 Students in the inaugural program completed a course of study which was based on the medical school model and included 12 months of science education and 15 months of clinical instruction.5
The first PA students — all former U.S. Navy corpsmen — graduated in 1967.6,7 However, there were no laws or regulations in North Carolina which addressed PA practice or licensure aside from a ruling by the state's Attorney General that PAs could perform medical services under physician delegation and supervision.3 As interest in PAs spread to other states, the federal government contracted with Duke University's Department of Community Health Sciences to create model legislation for the uniform regulation of PAs. The model allowed PAs to perform any “act, task or function . . . at the direction and under the supervision of a physician licensed by the Board of Medical Examiners.”3 The proposal was adopted by the North Carolina General Assembly in 1971, and it became a model for other states seeking to regulate this new profession.3
Today, there are more than 123,000 PAs, and the typical PA educational program, which generally requires basic science pre-requisite courses and a bachelor's degree, now lasts for three academic years, with PA students completing an average of 2,000 hours of supervised clinical practice prior to graduation.8 PAs are licensed in every state, the District of Columbia, and every U.S. territory with the exception of Puerto Rico. In most jurisdictions, PAs are licensed by the medical licensing board. In these cases, the medical board includes a designated PA seat, has an established PA advisory committee or council, or both. Seven states license PAs under separate osteopathic medical boards if they are supervised by or collaborate with an osteopathic physician.
Eight states have distinct PA boards. Three of these boards, located in California, Michigan and Texas, must seek final approval from the medical board for rulemaking and various other regulatory functions. Four of the other five PA boards, in Arizona, Massachusetts, Rhode Island and Utah, have full authority over PA licensure, practice, regulation and discipline. The Iowa PA board has full authority over PA licensure and discipline, but regulations related to some aspects of PA practice must be jointly approved by the medical board.
In July 2016, AAPA sought information from state licensing boards to verify whether any of the following items beyond an application, standard documentation, and fees were required for PA licensure:
Identification of a supervising or collaborating physician
Submission of letters of recommendation or other supplemental forms besides transcripts
Board approval of the PA's practice agreement
Passage of a jurisprudence examination
Direct action by board members to either ratify or approve licensure
For the purposes of this analysis, these are referred to as “extra requirements.” This inquiry focused on uncomplicated license applications only — those without “yes” answers to questions related to criminal history or past disciplinary action. AAPA also verified with each board the average time to process a PA license application.
Much of the information sought by AAPA was available in statutes, regulations, or on the licensing boards' web sites. However, AAPA staff also contacted several boards directly to supplement or clarify this information. Once assembled, the results were shared within AAPA's community of PAs who serve on state licensing boards (PA regulators). These individuals provided additional information and clarification regarding a handful of provisions.
From July 2016 until July 2017, AAPA staff tracked changes in PA licensure procedures as they occurred. At the end of the one-year tracking period, AAPA again accessed state licensing boards' web sites and the relevant statutes and regulations for the most up-to-date information on licensure procedures. As in 2016, AAPA staff contacted individual licensing boards for clarification and updated PA license processing times. They also consulted with PA regulators for additional information.
AAPA sought to ensure accuracy and consistency in collecting this information. However, there were instances in which corrections were made after the initial information requests, either by PA regulators or through additional communication with licensing board staff. There were also a handful of instances in which different information was obtained via board staff or resources from one year to the next, even though no legislative or regulatory change had occurred. AAPA's process for gathering this information often relied on estimates or interpretations regarding procedures and timelines. The subjective nature of some of this information may have resulted in seemingly unexplained changes between 2016 and 2017, particularly as it relates to estimated license processing times. The discussion which follows notes these changes only if they were a direct result of amendments to laws, regulations, or board policies or procedures.
AAPA's research and subsequent analysis resulted in two significant findings. First, licensing boards with a higher number of extra requirements for PA applicants generally take longer to issue a license. Second, states with modernized PA practice laws tend to have fewer extra licensure requirements and, therefore, tend to take less time to issue a license.
AAPA's 2016 and 2017 surveys found that 11 licensing boards had no extra PA licensure requirements. Maryland is included in this list because even though it requires board approval of both a PA's practice agreement and final licensure if the PA will be performing “advanced duties,” this does not apply to all PAs. “Advanced duties” are defined by the Maryland Board of Physicians as “medical acts that require additional training beyond the basic physician assistant education program required for licensure” to include “(c)osmetic procedures, lumbar punctures, central or arterial line insertions, endoscopic procedures, (and) stress testing.”9 The remaining 47 boards which license PAs have at least one extra requirement.
Personal Interviews. Six licensing boards required all applicants for PA licensure to undergo an in-person or telephone interview in 2016. Notably, these states did not have the same requirement for physician licensure. This number decreased to five in 2017 due to Mississippi's removal of its interview requirement.
Physician Identification. Fifteen licensing boards required PAs to identify a supervising or collaborating physician as a condition of licensure in 2016. This requirement is different — and more onerous — than the requirement in many states that a PA identify a supervising or collaborating physician prior to beginning practice, as it requires a PA to be employed before a license may be issued. This number decreased to 14 in 2017 due to Virginia's elimination of this requirement.
Letters of Recommendation. In 2016, 21 licensing boards required every applicant to provide at least one letter of recommendation or form other than a transcript to be filled out and returned by a school, instructor or former employer. Such letters or documentation were also required for physicians regulated by all but three of these boards. While South Dakota requires a letter of recommendation at the board's discretion and Colorado requires a letter of recommendation if the applicant was previously licensed in another jurisdiction, these boards were not included in this category because the requirements do not apply to all PAs. This number decreased to 19 in 2017 due to both Florida boards' elimination of this requirement.
Approval of the PA's Practice Agreement. In 2016 and 2017, eight licensing boards required approval of an applicant's practice agreement as a condition of licensure. In Maryland, a PA's practice agreement must be approved prior to licensure only if the PA will be performing advanced duties; however, it was not included in this category because the requirement does not apply to all PAs. Like the physician identification requirement, this requirement means a PA must be employed prior to becoming licensed.
Jurisprudence Examination. In 2016 and 2017, 10 licensing boards required applicants to take and pass an examination on state laws and regulations, or jurisprudence exam. Applicants in Arkansas must sign an affidavit stating that they have read the PA practice act and associated regulations; however, it was not included in this category because an actual examination is not required for licensure.
Direct Action by Board Members Required for Licensure. In 2016 and 2017, 23 boards were required to ratify licensing decisions before they became final, though much of the review process is handled administratively. Such ratification typically occurs at regularly scheduled board meetings.
Twelve boards were required in 2016 to review and approve every PA license, a process which, like ratification, generally occurs at regularly scheduled board meetings. Maryland only requires such approval if the PA will be providing advanced duties, so it is not included in this category. This number decreased to 11 in 2017 due to changes in Texas licensing procedures.
Twenty-two licensing boards allowed PAs to become licensed as an administrative action, without board member ratification or approval. Maryland is included in this category because it allows administrative approval of licenses for PAs who will not be performing advanced duties. This number increased to 23 in 2017, when Texas began to allow administrative license approval.
Average Length of Time for Licensure. Most licensing boards avoided quoting a definitive processing timeline, even for uncomplicated applications, opting instead to provide an average range of time for licensure. These ranges are categorized here as “short,” “medium,” and “long.” Average time ranges did not change significantly between 2016 and 2017 unless specifically noted.
Nine boards reported short average licensure times — as little as two weeks. As of 2017, five10 of these boards were among those which did not require any extra requirements, and only two required specific board ratification or approval for licensure. Put differently, the boards with the shortest estimated processing time for licensure also tended to have few to no extra requirements and were likely to process, approve and issue licenses as an administrative function.
Twenty-seven boards reported medium average licensure times in 2016, with a fastest possible license processing time of three or four weeks. This number increased to 28 in 2017 due to Texas's changed procedures, which reduced the expected processing time from approximately 16 weeks to four weeks. As of 2017, five of these boards had no extra requirements. In all but two of the remaining boards in this category, board members had to ratify or approve licensure; however, in 10 of these states, this was the only extra requirement. Thirteen boards in this category had two or more extra requirements. In other words, PAs licensed by boards that fell in the middle in terms of license processing time seemed to fall in the middle in terms of extra requirements.
Twenty-one boards reported long average licensure times in 2016, with a fastest possible license processing time of six weeks or longer. This category had the most variation in reported average processing times, with the longest reported time being 16 weeks or more. This number decreased to 20 in 2017 due to Texas's change in procedures. As of 2017, all but one of the boards reporting long estimated processing times had at least one extra requirement, and 11 had two or more. Seventeen of these boards had at least one of the rarer extra requirements, such as personal interviews, physician identification, letters of recommendation or other forms, approval of practice agreements, and jurisprudence exams. In other words, the licensing boards with the longest average processing times tended to have the highest number of extra requirements.
Practice Environment. AAPA also evaluated whether there was a relationship between boards' licensure procedures and processing times and the corresponding state's practice environment for PAs. Much like licensure laws, PA practice laws vary from state to state. AAPA tracks six components of PA laws and regulations, referred to as the Six Key Elements of a Modern PA Practice Act (key elements), the presence of which indicate enhanced ability for PAs to practice in a particular state.11 They include:
Using “licensure” as the regulatory term
Full prescriptive authority, including Schedule II–V controlled medications
Determination of scope of practice at the practice level
Adaptable collaboration requirements, including allowing decisions about practice location, physician proximity, and timing and manner of PA-physician interaction to be determined by the practice
Allowing chart co-signature to be determined at the practice level
Allowing a physician to practice with an unrestricted number of PAs
The key elements serve as a metric for determining how effectively PAs are able to provide care to patients in each state. When the licensing information collected from state regulatory boards in 2017 was compared with AAPA's tracking of the key elements during the same time, it appears states that had more of the key elements also tended to have fewer extra licensure requirements.12 For instance, four of the seven states with all six key elements had one or no extra requirements. Eight of the 14 states with five key elements had one or no extra requirements. Eight of the 15 states with four key elements had one or no extra requirements, two of the seven states with three key elements had one or no extra requirements, and two of the six states with two key elements had one or no extra requirements. However, this correlation was not absolute: The two states that had only one key element (Iowa and West Virginia) had zero and one extra requirement, respectively. (See Table 1.)
Similarly, states with more key elements tended to have faster license processing times than did states with fewer key elements. Only two of the seven states with six key elements quoted a long average licensing timeline (six weeks or longer). Likewise, four of the 14 states with five key elements, five of the 15 states with four key elements, four of the seven states with three key elements, and one of the two states with one key element estimated a long average processing time. States with two key elements were the outlier from this pattern — only one of these states quoted this longer timeline, with the majority falling into the medium category of average processing times. Still, it appears that states with more modernized PA practice laws are generally also home to boards that have fewer extra requirements for PA licensure and can also issue a license faster than states with more restrictive practice laws. (See Table 2.)
It is also worth considering whether the establishment of autonomous PA boards results in fewer extra requirements for PA licensure. When compared with states that regulate PAs solely through their medical or osteopathic medical boards, the information collected by AAPA shows that the eight states with separate PA boards tended to have fewer extra requirements and faster average licensing times. In both 2016 and 2017, five of the PA boards had no extra requirements. Two PA boards had one extra requirement, and one had two extra requirements. This means a strong majority of PA boards had no extra requirements, compared with under a quarter of all boards.
Likewise, PA boards tended to have faster license processing times than other boards. Four of the PA boards quoted average processing times of as little as two weeks, two PA boards quoted a three-week average, and three PA boards quoted a four-week average. Put differently, half of the PA boards could issue a license in two weeks, but less than one-fifth of all boards estimated that they could do the same. None of the PA boards reported average processing times of six weeks or longer, though over one third of all boards reported average processing times within that range.
There are several possible explanations for why PA licensure has fewer extra requirements and takes less time when handled by PA boards. First, members of PA boards are often either PAs themselves or physicians who are familiar with PA education and practice. This may reduce the need for extraneous documentation to evaluate a PA's eligibility for licensure. Additionally, PA boards usually have the authority to adopt regulations, including those related to licensure procedures. Even in the three states that do not have a fully autonomous PA board, the mere existence of a separate PA board allows PAs to have a greater than typical role in crafting — and enforcing — the standards to which they are held. This may lead such boards to reject extra licensure requirements which have no clear public benefit.
States should consider following the lead of PA boards by reducing extra requirements and shortening licensure times for PAs, for several reasons. First, faster PA licensure can improve overall health care delivery. Numerous studies have shown that PAs increase access to health care in primary care and specialty settings.13,14,15 Studies have also shown that PAs provide quality care while decreasing overall health care costs.16,17,18,19 Removing administrative delays associated with PA licensure allows states to maximize these benefits by enabling PAs to practice more quickly and encouraging more PAs to seek a license in the state.
Additionally, licensure relies on state resources, which are often scarce. Requiring every PA to undergo additional scrutiny takes up valuable staff and board time. Several studies have found that PAs provide safe care to patients.20,21 One such study showed that over a 17-year period, just over three percent of PAs made a malpractice payment, compared to 37% of physicians.22 Moreover, the percentage of PAs who make a malpractice payment remains extremely small whether a PA practices in a state with extra licensure requirements or one with none. According to the National Practitioner Data Bank, an average of 0.10% of PAs in states with three to five additional requirements made a malpractice payment in 2017, compared to an average of 0.15% of PAs in states with no additional requirements.23 This data shows that on the whole, PAs are providing safe patient care and little, if any, benefit is derived from the imposition of extra licensure requirements.
Finally, a more standardized licensure process for PAs would make it easier for states to adopt FSMB's Uniform Application (UA) for PA Licensure, modeled after the UA used by physicians. The UA for PAs is accepted by the Oklahoma Board of Medical Licensure and Supervision, the Maine Board of Licensure in Medicine, the Maine Board of Osteopathic Licensure, the Washington Medical Commission, and the Montana Board of Medical Examiners. Additional licensing boards are expected to follow. Wider adoption of the UA for PAs would make it significantly easier for PAs in these states to become licensed in the event they relocate or opt to practice in more than one state.
Many states' licensure procedures create barriers or delays for qualified PAs who are newly entering the workforce or beginning practice in a new state. AAPA's analysis suggests the existence of these barriers may also indicate a state's PA laws do not allow PAs to practice to the full extent of their education and experience. These combined limitations on the PA profession may impact patient access to care, which is especially concerning in states experiencing health care provider shortages. They also appear to have little, if any, effect on patient safety. As such, states should evaluate whether their current licensure procedures are a barrier to PAs becoming licensed and, if so, determine how they may promote the best use of available health care workforce resources. (See Table 3.)
Author's Note: In August 2018, AAPA compiled updated information from state licensure boards regarding extra requirements and average license processing times. Since 2017, the New Mexico Board of Osteopathic Medicine has eliminated all of its extra licensure requirements and the South Carolina Board of Medical Examiners has eliminated its letters of recommendation requirement.
About the Author
Erika E. Miller is Director of Constituent Organization Outreach and Advocacy at the American Academy of Physician Assistants.