Indiana's physician assistants received a collective shot in the arm earlier this month when their authority to prescribe medicine to patients became effective.
The profession had long lobbied lawmakers for the right before the Legislature relented with the passage of House Bill 1241 this year. July 1 officially marked the milestone in which Indiana became the last state in the nation to grant prescribing powers to physician assistants.
"It's the right thing to do," said Dr. John Lucich, director of Butler University's physician assistant program. "We were able to show, based on the experience of other states, that this was not going to be a bad thing, and that this sort of system actually works."
Hoosier doctors historically opposed the measure, arguing that if physician assistants could prescribe medicine, they would establish competing medical facilities with only loose supervision from doctors. They were concerned that quality and consistency of care would suffer as well.
But a few stipulations included in the legislation seemed to have alleviated fears. A supervising physician must be either present at the location where services are performed by physician assistants or must be immediately available for consultation and in the county or contiguous county of the hospital or health care facility.
Further, physician assistants must have completed 30 hours of pharmacology training and been employed for one year before they can prescribe medicine. Even then, controlled substances prescribed by a physician assistant are limited to a seven-day supply.
"With those guidelines, everyone seems to be happy about it," said Dr. Vidya Kora, president of the Indiana State Medical Association. "We didn't want a situation where a physician was in Indianapolis and supervising someone in Evansville."
Physician assistants typically receive more than two years of training. Many schools require incoming physician assistant students to have a bachelor's degree, although Butler will admit students with as little as two years of completed coursework.
The private Indianapolis university, which accepts about 50 physician assistant students a year, is making the transition from a two-year to a three-year program and will graduate its first class under the master's format in 2008.
The only other school in the state offering a physician assistant program is the University of Saint Francis in Fort Wayne.
Like medical students, they undergo lectures and labs in basic medical sciences and do clinical rotations in various medical fields. Most work in hospitals examining, diagnosing and treating patients, which can include interpreting tests, assisting surgeons and prescribing medicine. The doctors they work for must review their work within 24 hours.
Butler graduates already are trained to prescribe drugs, because many seek employment out of state, said Lucich, who doubts the legislation will have any effect on his program.
What Lucich does anticipate is more job opportunities in the state, since doctors interesting in lightening their workloads are beginning to contact him about prospects. Physician assistants in Indiana earn an average of $62,150 a year.
The state would have to nearly double its number of physician assistants to catch up with the national average. There are 680 physician assistants in Indiana, according to the U.S. Bureau of Labor Statistics, or one for every 9,200 state residents.
Nationally, there are 64,000, or one for every 4,700 residents. Medical experts do not foresee such a drastic increase in the number hired by doctors.
Even so, Steve Jacobs, a physician assistant at the Indiana University Health Center on the Bloomington campus and legislative co-chairman of the Indiana Academy of Physician Assistants, suspects the profession will become more appealing here.
"Being at Indiana University in Indiana, we have a lot of students who aspire to be PAs but go on to a PA program in another state, and those individuals are not returning," he said. "I think now we'll see individuals stay, return and come to Indiana."
Retail clinic concerns
A study by the Alexandria, Va.-based American Academy of Physician Assistants bolstered arguments for prescribing authority.
The poll of more than 1,000 adults conducted by Opinion Research Corp. in New Jersey found that 80 percent of patients would see a physician assistant for a routine visit if their primary doctor were unavailable.
Moreover, 50 of Indiana's 92 counties, including parts of Marion, are designated medically underserved by the Indiana State Department of Health. Under a doctor's guidance, physician assistants may be able to provide accessible health care in areas, particularly the rural parts of the state, where there is limited access, Jacobs argued.
Before the current legislation passed, doctors feared physician assistants would set up competing medical facilities, such as the quick-service clinics inside retail stores. The clinics in Indiana are staffed mainly by nurse practitioners, who already can prescribe medicine here.
Nonetheless, the proliferation of instore clinics being opened by retail giants is coming under increased scrutiny by the American Medical Association. The AMA's policymaking House of Delegates, meeting in Chicago in late June, said it would ask state and federal agencies to launch widespread investigations into the fast-growing patient- care model.
The AMA is concerned that the lack of regulation at retail clinics might be fostering liability concerns, health risks and potential conflicts of interest between the clinics' nurse practitioners who order prescriptions and the pharmacies that fill them. The clinic is often near the pharmacy counter in those retail stores.
The AMA is reacting to moves by Wal-Mart and drugstore chains Walgreen and CVS to bring thousands of retail clinics to consumers in the coming years. They argue that increased regulation would decrease access to care by putting more burdens on the facilities.
Clinics fill a void for patients needing treatment for minor ailments, conceded Kora at the ISMA. But he's more concerned about those with multiple medical problems who might visit the facilities for primary care.
"We want patients to be established with their physicians and have continuity of care," he said. "There is too much fragmentation. That is neither good for the patient or physician."
Meanwhile, physician assistants must complete a Controlled Substance Registration application before they can prescribe medication. The form is available on the Medical Licensing Board of Indiana Web site.