For the past year, Optimal Team Practice (OTP) or, as it was initially known, Full Practice Authority and Responsibility (FPAR), has been a hot-button issue in the PA world.
The original FPAR proposal put forth by an AAPA joint task force, issued in December 2016, centered around four components:
- Team-Based Practice
- Elimination of Supervisory Agreement Requirements in Law/Regulation
- Creation of Autonomous State PA Boards
- PA Eligibility for Direct Reimbursement
We'll break down these components in just a bit. But, in short, the proposal was developed to try to make PAs as employable as nurse practitioners and to represent better the role PAs play in patient care. On its face, this effort sounds reasonable for any PA or future PA considering job prospects in down the road.
But, to understand all of the moving parts of this proposal (and trust me, it's worth your while to understand them), you have to understand the goals and potential consequences of each.
So, let's start there.
Why what behind the start of OTP?
From here on out, let's agree to call it OTP for the sake of consistency. Things are gonna get a little acronym crazy with the organizations involved, and I want to minimize confusion.
The four components of OTP all work towards the same end goals—allowing PAs to practice up to their full level of training and removing restrictions that can impede our ability to deliver care—but, they each work in a different way.
The first guideline focuses on a commitment to team-based practice. PAs are trained (and have always been trained) to work alongside physicians. This built-in collaboration is why many people are drawn to work in the profession, and it works tremendously well, particularly early on in your career as a PA, to help you grow into a better provider. So, team-based practice is at the core of what PAs do.
This commitment to continuing a collaborative PA-physician model has nothing to do with any recommended changes. Fundamentally, it's is emphasized as part of the proposal because of what people, including the American Medical Association (AMA), are about to object to in the next guideline.
The second point of the proposal calls for the elimination of the requirement for PAs to have a practice agreement with a specific physician. Stricter supervisory agreements typically mean that a physician takes responsibility for PA-provided care, which isn't exactly in line with the way we practice and can put physicians at risk.
Though many states have moved towards "collaborative" rather than "supervisory" agreements over time, currently every state but Michigan has some version of a supervisory obligation.
However, in 22 states and D.C., nurse practitioners are not required to have an agreement with a specific physician. So, if a practice is looking to grow and is concerned about the number of PAs a physician can legally supervise or a physician does not want to assume responsibility for the care given by another provider, it may be easier for employers to hire an NP rather than a PA.
Also, while PAs can have several supervising physicians, written agreements must be in place for all of these relationships, and state-mandated requirements must be met to comply with the law. This can get a little tricky if you work as a PA in private practice with one physician or when there is physician turnover.
Instead, the AAPA task force proposed that decisions on PA-physician collaboration be made at the practice level, which would make it easier for employers to hire and employ PAs and decrease the burden on both PAs and physicians to follow state-specific collaboration requirements.
As presented, this makes logical sense. Wouldn't it be more reasonable for the physician-PA team to decide what kind of collaboration an individual PA might need to succeed? Wouldn't that be different for a brand new PA versus a PA with 5 or 10 years of experience? That's not quite the entire story, but we'll get there soon.
The third component of OTP originally called for the creation of separate majority-PA boards to license, regulate, and discipline PAs. The revised version of OTP requests that PA regulation be done by either a separate majority-PA board or a state medical board that has both PAs and physicians who practice with PAs as members. Currently, the practice requirements of and restrictions on PAs are regulated by state medical or healing arts boards, typically comprised of physicians and a few attorneys.
Nurse practitioners, on the other hand, are under the purvue of their states' nursing boards overseen by, you guessed it, other nursing professionals.
This component is arguably less controversial than the second, but it does result in a decreased level of control over PAs by physicians at the institutional level.
Lastly, the proposal closes with a final, relatively simple guideline: authorize PAs to be directly reimbursed by all public and private insurers.
This one is pretty straightforward and represents a relic of PA practice. Currently, PAs are the only health professionals that bill Medicare who are not entitled to direct reimbursement. Nearly all third-party payers (private insurers and Medicare) reimburse for services and procedures provided by PAs, but they require that the payments to be made to the PA's employer.
Currently, charges for PA services are often billed under the name of the physician with whom the PA works. As a result, the care that PAs provide as well as their productivity can be cloaked and attributed to another provider.
This "hidden" work is problematic. As a PA, your metrics—including quality of care and billing—cannot be adequately evaluated from information pulled from electronic medical records or Medicare databases.
When Medicare tries to determine your patient outcomes or your employer tries to determine your "worth" based the revenue you generated, or if you try to obtain this information to present to a prospective employer, your work may be vastly undervalued.
[As an aside, did you know that Medicare reimburses PA work at 85% of the physician fee for the exact same service? Total BS.]
So, as presented by AAPA, these requests seem fairly reasonable based on the skill level of PAs and how PAs practice in the era of modern medicine.
But, there has been opposition, even within the PA realm, to the plan for OTP.
The potential problems with OTP
Remember the original FPAR proposal from December of 2016? After the task force developed the proposal, questions around OTP ("FPAR" at the time) were presented in a survey emailed to 102,101 PAs, retired PAs, and PA students in January of 2017. They were given three weeks to respond.
Of the respondents, 72% expressed support for the OTP proposal. But, only 12.6% of the individuals surveyed responded.
Also, remember the AAPA Joint Task Force that created the proposal? It was an 11 member committee that included a couple of PA program directors. But, AAPA didn't include the other three major PA organizations, PAEA (representing PA educational programs), ARC-PA (responsible for accrediting PA programs), or NCCPA (responsible for PA certification), in the development of the proposal.
This exclusion caused a rift with PAEA because the adoption of OTP could have a significant impact on PA education. If implemented as proposed, much of the burden of sorting out how future PAs are trained to practice more autonomously would be placed on PA programs. So, one can see why PAEA would be miffed not to be asked for input before the proposal was rolled out to the public.
In a comprehensive report issued in early May 2017, PAEA supported three of the four elements of OTP but objected to the proposal for the elimination of a legal relationship between PAs and physicians.
Currently, PA programs train future PAs for practicing collaboratively with physicians. In PAEA surveys of program directors, there was concern that the consequences of OTP could include increased content, length, and cost of PA programs as well as decreased applicant diversity and increased experience requirements for applicants.
Nationwide clinical training sites shortages are already an obstacle for both PA and other health professional programs. Finding preceptors and practices willing to devote more time to training students may be difficult. Additionally, there may be a downstream effect that could impact the available preceptor pool.
If PA students need to be trained for more independent practice, would preceptors with fewer years of experience or who haven't been trained to practice independently be qualified to help educate future PAs?
Many programs, already faced with clinical training site shortages, could also find it difficult to expand their clinical curricula. Additionally, if PA programs were longer, as they would likely need to be if training PAs for more independent practice was incorporated into the program, there is concern that programs could explore awarding a clinical doctorate.
This possibility leads down a serious rabbit hole.
If doctorates start to be awarded, would this become uniform among programs? If new graduate PAs have doctorates, would the expectation be that practicing PAs go back for an additional degree? If the doctorate is based on learning how to practice more autonomously, what would be the point of a PA who has experience getting one? Would employers come to expect PAs with a more advanced degree?
PAEA also cited concerns over how OTP would affect new graduate PAs. When the details of the original AAPA FPAR survey results were combed through, 481 of the 498 responses that mentioned "new graduates" discussed concerns about or advised against giving full practice authority for new PA grads.
In their 2016 Matriculating Student Survey, PAEA found that 91% of newly enrolled PA students considered the supervising physician relationship as "essential" or "very important" to their career path upon program graduation. OTP, PAEA argued, could "create an unsupportive environment that could compromise [new graduate] success, and, in some settings, patient safety."
OTP has the potential for unintended consequences in PA education, and PAEA brought these to light as part of the discussion.
Where does OTP stand now?
Following the PAEA report from May 8, 2017, AAPA held their annual meeting in late May. During the conference, a few revisions were made to the resolution language, which was ultimately supported by PAEA. The AAPA House of Delegates (HOD) approved the new OTP policy.
The AAPA HOD approval does not change any state laws or requirements. It is a policy that supports implementing the OTP changes at the state level. Individual state PA chapters will decide whether to pursue the recommendations in their state.
For the final proposal regarding direct reimbursement, AAPA will be working to advocate for Medicare to allow direct PA reimbursement and eliminate language regarding physician supervision when defining PA services.
In July of 2017, AAPA developed an "Early Career PA Commission" to create resources to educate new graduates and "early career" PAs about OTP and explore challenges that OTP could create for new grads in the transition from a student to a provider role.
In November of 2017, the AMA HOD passed a resolution referencing the AAPA HOD’s adoption of Optimal Team Practice and opposing “physician assistant independent practice” (AAPA has repeatedly emphasized that OTP is not about independent practice and that PAs remain committed to a team-based approach) and a second “opposing state and national level legislative efforts aimed at inappropriate scope of practice expansion of non-physician healthcare practitioners.”
For the record, the AMA has routinely opposed independent licensing of NPs as well.
This February, PAEA started work with the "OTP Impact on Education Task Force" to “address the implications of OTP for PA education and for new graduates as raised in the 2017 PAEA OTP Task Force Report.”
So, the "Four Orgs" (AAPA, PAEA, ARC-PA, and NCCPA) are relatively on the same page now regarding OTP, at least more than they were this time last year. But, the policy puts forth some complex issues and recommends some major changes to PA practice that will take some time and a lot of work to sort out.
If accomplished, the changes may have long-term consequences on the profession as well as on how we train PAs, but, they're also likely to take quite a while to come to fruition.
2017-18 Charges: Early Career Commission. AAPA, Jul 2017,
By the Numbers: Program Report 31. PAEA. http://paeaonline.org/wp-content/uploads/2016/12/faculty-directors-report20160218.pdf
By the Numbers: Student Report 1. PAEA, Jul 2017. Washington, DC: PAEA. doi: 10.17538/SR2017.0001. http://paeaonline.org/wp-content/uploads/2017/07/Student-Report-2017.pdf
Frequently Asked Questions: Optimal Team Practice. AAPA, Jan 2018. https://www.aapa.org/wp-content/uploads/2018/01/Core-FAQ.pdf
Full Practice Authority and Responsibility Survey Report Released. AAPA, Feb 28, 2017.
Guidelines for State Regulation of PAs. AAPA, Jun 2017.
Optimal Team Practice. AAPA, Jan 2017. https://www.aapa.org/advocacy-central/optimal-team-practice/?utm_source=aapa.org&utm_medium=news_central_post&utm_campaign=mem_otp
Optimal Team Practice. PAEA, https://paeaonline.org/optimal-team-practice/
Optimal Team Practice: The Right Prescriptions for All PAs? PAEA, OTP Task Force. May 8, 2017. http://paeaonline.org/wp-content/uploads/2017/05/PAEA-OTP-Task-Force-Report_2017_2.pdf
Third-Party Reimbursement for PAs. AAPA, Feb 2017.