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Barriers for PAs volunteering to serve indigent populations

Lack of liability coverage and authorization requirements for supervision can create legal barriers for PAs who want to volunteer. The good news: Some states are amending their laws so that PAs can volunteer legally.

Clair Talmadge, PA-C, MMSc; Virginia Joslin, PA-C, MPH

Clair Talmadge wrote this article while she was a student in the PA program at Emory University, Atlanta, Ga. Virginia Joslin is the director of the program and assisted with the clarification of current barriers to volunteerism by PAs. The authors have indicated no relationships to disclose relating to the content of this article.

   If you prefer to view this article in PDF form, click here.

Nationwide, the growing number of uninsured people, including immigrants and refugees, is creating gaps in the delivery of health care. The United States Census Bureau estimated that 45 million persons were living without health insurance in 2003, an increase from 43.6 million in 2002.1 The national poverty rate has also risen from 12.1% in 2002 to 12.5% in 2003.1 Barriers between quality health care and the uninsured and indigent populations are having an increasingly significant impact on the nation’s health. Over the past 3 years, mortality risk in the uninsured population was found to be 25% higher than in those with insurance, contributing to 18,000 unnecessary deaths each year.2-4

Volunteerism

Healthy People 2010: Objectives for Improving Health identifies access to care as one of the most significant causes of health disparities in America. It also cites the increasing number of uninsured people as a major contributing factor.5

In response to this trend, the free clinic movement and volunteerism are emerging as innovative ways to improve access to care. Approximately 1,000 free clinics, which provide both preventive and primary care for indigent populations and the working poor at reduced or no cost, have opened nationwide. Because minimal funding is available from state and national organizations, free clinics rely almost exclusively on private donations, gifts in kind, and the volunteer support of health care professionals. By donating professional services, clinicians are able to extend a high standard of care to uninsured or underinsured persons whose financial burdens might otherwise prevent them from seeking treatment. Collectively, the value of goods and professional services donated to the free clinic network is estimated to be worth more than $3 billion annually and to reach 3.5 million of the uninsured.6

PAs are a valuable asset to the health care delivery teams for underserved populations and represent a potential pool of health care providers to volunteer in free clinic settings. PAs are trained in the medical model that offers a level of competence and a team approach to medicine that are optimal for extending the reach of quality health care to underserved populations. States that include provisions for supervision in remote sites or in areas that are designated as Health Professional Shortage Areas (HPSAs) broaden the capability of the physicianPA team to deliver quality care in areas that otherwise may not have access to primary care providers.7-10

The AAPA has estimated that out of the 61,000 PAs currently eligible to practice, 42% are working in primary care.11 A breakdown of the types of communities served by PAs in 2002 indicates that 41% are working in urban and innercity communities, and 22% work among rural populations.12 Incentives for PAs to work in rural areas have increased the number in practice from 6,700 in 1996 to more than 10,000 in 2002.12,13 This means that an estimated one in five PAs is within reach of rural and medically underserved communities (MUCs) with recognized impediments to accessing primary care. The potential is even greater for innercity PAs to reach indigent populations who may not meet federal and state criteria for HPSA/MUC status. For example, an indigent person could live within 30 miles of a primary health care provider but still be significantly underserved from a medical, financial, and cultural standpoint—and remain unable to access the usual systems of care. Integrating the physician-PA team model into these same underserved areas through volunteerism could have an even greater impact on improving access to care.

Despite such potential, however, volunteering may not be an option for PAs. Depending on where they practice, the same state laws of supervision that help the physician-PA model overcome barriers in practice could actually create other barriers when applied to the volunteer setting. Both liability protection and authorization to practice become primary concerns for PAs who want to volunteer.

Liability protection

For most clinicians, providing health care in the volunteer setting is facilitated by state and federal legislation that reduces the risk of malpractice liability while volunteering. Historically, Good Samaritan immunity has provided some assurance against malpractice suits for health care providers, including PAs, who respond to those in need of emergency assistance.14 In some states, Good Samaritan legislation includes nonemergent settings in order to provide the same type of coverage in a volunteer or free clinic. For example, in Virginia, licensed health care professionals may be exempt from liability for civil damages resulting from care rendered in a clinic that delivers health care services without charge.15 Other states have enacted charitable immunity laws that provide volunteer protection by raising the standard of care at which the clinician may be held liable. They indemnify the clinician as a government employee, or they offer special volunteer licensure and malpractice coverage for retired physicians. In 1997, Congress passed the Volunteer Protection Act and, more recently in 2004, the Free Clinics Federal Tort Claims Act (FTCA) Medical Malpractice Program, both of which are designed to provide liability coverage for any clinician, including PAs, in the volunteer and free clinic settings.16,17 All but seven states—Alaska, California, Massachusetts, Nebraska, New Mexico, New York, and Vermont—have enacted charitable immunity laws alongside the federal legislation programs in order to reduce the risk of malpractice suits, as an incentive for qualified clinicians to volunteer professional services.18

The legal requirements for maintaining liability coverage are based on verification that the provider is not compensated for the services rendered and that the duties performed remain within the limits of the provider’s licensed laws of practice. While PAs may be included in the category of clinicians who are eligible for state and federal liability coverage, they should take care to maintain all components of their authorization to practice in the free clinic or volunteer setting as well.


Rural PA of the Year Teresa Nielsen, who volunteered to train ambulance crew members.

Authorization to practice

Because the physician-PA relationship is one of interdependence, supervision is one of the cornerstones of the PA profession and its regulating state laws. All state laws stipulate that the care provided by the PA is physician-delegated, within the state-approved scope of practice, and supervised by a board-approved physician. While supervision is considered continuous, the amount of time required for the supervising physician to be physically present during the services rendered by the PA varies among states. In all states, the supervising physician must be readily available for consultation by radio, telephone, or telecommunications during the PA’s time of service.7 Some states define additional parameters for supervision by requiring that the physician be on site to supervise a specified percentage of practice time, ranging from 20% in Nebraska to 75% in South Carolina.7 Other states may designate a number of days per week or month that the physician must be physically present in order to provide consultation and monitor quality of care.

In rural areas, some state laws stipulate remote-site supervision in order to better utilize the PA in practice settings that meet HPSA or MUC status. Remote-site supervision addresses this need and thus is an important factor in improving access to care in patient populations located far from medical services. By definition, however, remote sites do not include medically underserved inner-city populations. In some states, remotesite supervision can be even more restrictive. The facility may be required to have been approved by the Board of Medical Examiners for the state where the physician routinely practices at least 25% of the time. The physician may also be required to be physically present twice a week and available to review charts daily. This is the case in Georgia, for example. In the volunteer or free clinic setting, maintaining all of the legal requirements for supervision within the governing state may not be possible for both members of the physician-PA team. As a result, most states do not authorize PAs to provide volunteer care unless their supervising physician is also involved and the services rendered occur within the practice agreement approved by the state.

Authorization to volunteer

A few states have laws that define supervision and delegation in the volunteer setting and thus authorize PAs to provide volunteer service.19 For example, in Indiana the supervising physician can delegate authority so that the PA can provide both charitable and migrant health care.20 In Alaska, a statute grants immunity for civil damages if the PA is volunteering health care services.21 Three states offer special volunteer licensure for PAs, but each has different criteria. Virginia allows PAs to apply for a restricted volunteer license that permits them to volunteer in free clinics approved by the board.22 North Carolina offers a limited volunteer license for licensed PAs who are not currently practicing in North Carolina but who want to volunteer in clinics for indigent patients.23 In Wyoming, a similar license is available for PAs—but only for those who are retired—who choose to volunteer in nonprofit health care facilities that serve lowincome, uninsured patients.24

All of these commendable options authorize the PA to participate in volunteer service, but the number of states implementing volunteer provisions or licensure for PAs is minimal. Additionally, the process and criteria for obtaining authorization to volunteer in each of these states differ and require the PA to have the foresight to submit applications and await board approval.

Disaster response

Some states have provisions for PAs to participate in disaster and emergency situations, primarily by defining supervision in this setting. Several states* have adopted the AAPA model legislation recommendations for disaster response so that PAs can legally render emergency care in a state or local disaster under the supervision that is available, with the understanding that in some cases there may be none.25,26 South Carolina approaches disaster response by including provisions in the state law to provide liability protection to all health care providers, including PAs, by waiving licensing requirements during a state emergency.27 Regardless of whether disaster response language addresses liability concerns or parameters for supervision, these laws permit PAs to render emergency care that is outside of the PA’s approved practice setting without necessitating the protocol of board notification and approval of alternative supervision.25

*Alabama (AC540X7), Arizona (AS322501), Arkansas (AC248), California (CC3502.5), Delaware (CD24170021.1.2), Idaho (IS22.01.03), Iowa (IC148C.4), Kansas (KA652891), Kentucky (KRS311.862), Louisiana (LRS 37:1360.31), Maryland (CM10.32.03.15), Minnesota (MHR147A.23), North Carolina (21NCAC 32S.0118), Oregon (ORS401.651), South Carolina (SCC,Section 444570), and Wyoming (WS3326103).

The PA laws in California and New York facilitate PA participation in a variety of health care settings, including disaster response and volunteer service. In these states, any licensed PA can be supervised by any licensed physician without board notification or approval. This allows the greatest amount of flexibility in the professional setting.26 The PA is able to extend the same standards of excellence as the normal, state-approved scope of practice but can do so under the supervision of any physician and in any agreed upon location, including remote sites or the disaster and emergency field. During the terrorist attacks on September 11, 2001, for example, PAs practicing in the state of New York were immediately and fully utilized on medical relief units because they could be supervised by physicians who were involved in rescue efforts.28 In the volunteer setting, state laws authorizing this definition of physician-PA supervision would be ideal. The PA would be able to provide care in free clinics, on migrant farm camps, or in underserved areas as long as a licensed physician was involved and willing to delegate and supervise. In the nation’s efforts to improve access to care through volunteerism, this legislation would assure that PAs, who are highly competent primary care providers and already established in rural and underserved areas, remain a valuable part of these health care delivery teams.


Humanitarian PA of the Year Sandra Hoyman working in a migrant camp.

Conclusion

During a time when the nation must improve access to health care, state laws should not create barriers for PAs who choose to help. The rising number of the uninsured is having a significant impact on morbidity and mortality rates and mandates the need for quality health care to reach indigent populations. Providing a mechanism for PAs to contribute to these efforts by volunteering in free clinics and underserved areas with the supervision of any licensed physician is essential. State laws that define the parameters for PAs in the volunteer setting facilitate the process of enacting these services. Further, state laws allowing any licensed physician to supervise a PA without board notification would assure that the quality care provided in daily practice would also be delivered in the volunteer setting. 

As PAs we should become advocates for initiating the changes that will allow us to expand our efforts to practice in underserved areas. The AAPA provides assistance by defining language for model state laws that can be adopted into statutes.29 In addition, AAPA provides a summary of state regulations with links to each state’s medical board for detailed review of the statutes and regulations already in practice.30 Constituent chapters can help incorporate AAPA language into law by communicating the need for change to state legislators and partners in professional medical organizations. PAs can assist with the efforts of their state chapters by becoming involved on the state legislative and governmental affairs committees and by discussing these barriers with their supervising physicians. The common goal is to maintain a commitment to competence and supervision while allowing for the compassionate practice of volunteerism. Initiating changes in state laws that will facilitate this process will strengthen the ability of the PA profession to assist the nation in dismantling barriers between quality health care and those who are in need. 

Acknowledgement

Special thanks to Ann Davis, PA-C, for her significant contributions to this article and to the advancement of volunteerism in the PA profession. Her advocacy for legislative changes that allow PAs to expand their efforts by participating in disaster response or volunteer service is an inspiration to us all to help those in need. (See “Physician assistant volunteers belong in free clinics.”)

REFERENCES

  1. US Bureau of the Census. Income stable, poverty up, numbers of Americans with and without health insurance rise. Washington, DC: US Census Bureau Public Information Office; August 26, 2004. Press Release CB04-144.
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