Physician Assistants (PAs) in Kentucky: The Fight for Full Prescriptive Authority

The U.S. is currently experiencing the first waves of a physician shortage—a problem which is projected to intensify. As the country’s population grows and ages, the Association of American Medical Colleges (April 2019) predicted that the increase in the demand for doctors will result in a shortage of somewhere between about 50,000 and 122,000 physicians within the next 13 years.

This shortage is already affecting some areas more than others. So far, rural areas are feeling it the most, according to the Health Resources and Services Administration. To measure the issue, the organization has identified 7,200 regions, called the Health Professional Shortage Areas, in which there is an insufficient number of physicians. A disproportionate fraction, nearly 60 percent, are located in the country’s rural regions.

Kentucky is experiencing the shortage more than other states. According to the University of Kentucky College of Medicine, the state ranks 36th among states for all physicians per 100,000 people and 40th for primary care physicians. And although 40 percent of Kentuckians live in rural areas, only 17 percent of primary care physicians practice in rural zones.

Andrew Rutherford, a Kentucky PA and current vice president of the Kentucky Academy of Physicians Assistants (KAPA), practiced in rural western Kentucky in the small community of Trigg County. As a PA, Rutherford shares many of the same duties of a doctor, such as diagnosing illnesses, ordering and interpreting tests, and developing treatment plans—but he does not have the same authority as a doctor. He explained how the shortage of primary care physicians is affecting rural Kentuckians.

“Cities like Cuvington and Cincinnati are full of providers, full of urgent treatment centers, full of primary care providers. There are always physicians around for PAs if they really need something signed [for a patient], and there’s all this access to care,” he said.

“But in Trigg County, they only had a couple of primary care physicians, and so if they were on vacation or out of town, patients didn’t really have a lot of people to go to,” he said. “As a PA practicing out there, I only had really one physician I could go to if I needed them to sign [a prescription].”

Rutherford said it wasn’t unusual for a patient to come see him for something as routine as prescribing a diabetes treatment, like Lyrica, but if the physician was out of town, he wouldn’t be able to help them. “I couldn’t write it for them, so I’d have to send the patients to the emergency department just so they could get the prescription written by the physician over there,” he said.

Healthcare teams in these areas can’t seem to find enough primary care physicians to meet the demands of Kentucky’s rural population, and the burden of the shortage falls on the patients. This scenario is common not only in Trigg County, but in countries throughout western, eastern and southern Kentucky. As the population ages and grows, this problem will only get worse.

One way to address the shortage of physicians in Kentucky is to give PAs full prescriptive authority, which is the ability of a medical professional to prescribe patients “scheduled” or “controlled” drugs.

Over the last 30 years, most states have independently updated their laws to do so, and today, PAs have the ability to independently prescribe patients with controlled drugs in 49 states. Kentucky is the one final outlier. The Bluegrass State is the last remaining state in which PAs can only prescribe non-controlled medications.

KAPA, the organization in which Rutherford currently holds the role of vice president, is at the helm of the effort to grant PAs more authority. It has been tirelessly pushing such legislation over the last five years, but so far, its efforts have been to no avail. There have been baby steps taken to grant PAs more authority since 2015, but House Bill 93, which would give PAs full prescriptive authority to prescribe controlled substances, was shot down once again by Kentucky Senate Leadership in 2019 to the disappointment of KAPA and much of the medical community in Kentucky.

Those from outside the medical community may make the mistake of assuming that the pursuit of becoming a PA is quick and easy compared to becoming a full-fledged doctor, perhaps because of the word “assistant.” In reality, becoming a PA is not an easy feat by any stretch of the imagination. In Kentucky, PAs spend about six to eight years to become licensed and go through extensive training in pharmacology and pharmacotherapeutics.

“The big thing we’re asking for at this point is recognition that we’ve been taught. We’re educated [in] how to prescribe these medicines,” Rutherford said.

Once permission has been given, no state has ever overturned the decision to let PAs prescribe controlled medications, yet even with the shortage of doctors projected to increase and a tremendous effort to change the state law, Kentucky still won’t budge, begging the question: what is the story behind the resistance?

One major aspect of the resistance is related to the national opioid problem. The U.S. has been tallying steady increases in opioid-related deaths over the last 20 years, but saw a frightening spike in such deaths between 2015 and 2017, skyrocketing from around 30,000 deaths to more than 47,000 (National Institute of Health “Overdose Death Rates,” Jan. 2019).

“Unfortunately, the opioid epidemic is huge throughout the U.S., but Kentucky has been hit very hard,” Rutherford said.

According to the National Institute on Drug Abuse, there were 1,160 reported opioid-related deaths in Kentucky in 2017, a rate of about 18 deaths per 100,000 people, compared to the national average rate of about 14.6 deaths per 100,000.

These statistics encompass street heroin as well as prescription opioids, like fentanyl and oxycodone, which are available legally by prescription. While opioid pain relievers are safe when prescribed by a physician and taken for short periods of time, their abuse can lead to addiction and death.

Rutherford explained that the resistance against KAPA’s efforts to increase PAs’ prescriptive authority is rooted in the fear that loosening PAs’ restrictions will translate to a greater number of Kentuckians suffering from opioid addiction.

“I would say that the opioid epidemic is the foremost resistance to passing this [bill], which we’re very understanding of,” he said. “A lot of our legislators and concerned people are trying to be good stewards. They’re afraid that increased PA authority would lead to more controlled substance prescriptions.”

KAPA acknowledges that these concerns are valid and understandable, but wants the community to understand some misconceptions about the issue.

Rutherford says that KAPA’s goal is not to give PAs the authority to prescribe more opioids. In fact, last year, the organization changed its objective to reflect the community’s concern about the opioid epidemic by removing schedule II narcotics from its agenda.

“The opioid epidemic has shown that the number of deaths has been going down drastically and physicians in Kentucky have been writing for much less opioids,” he said. “It’s something that a lot of physicians tout very highly, that opioid prescribing of physicians is actually going down quite a bit. And we would say we are part of that group whose prescription of opioids is going down.”

Reports back up Rutherford’s claims. Contrary to popular belief that physicians are increasing their rates of opioid prescription in Kentucky, the 2017 rate represented a more than a 36 percent decrease from its peak in 2011.

And more good news: the opioid crisis has actually taken a turn for the better in recent years, and quite a significant one at that. While the battle against the epidemic in Kentucky is nowhere near over, a report from the Kentucky Office of Drug Control Policy (“2018 Overdose Fatality Report,” July 2019) showed that the state had 233 fewer drug deaths in 2018 than in 2017, which is the first time the annual death toll has decreased since 2013.

Another misconception that Rutherford wants to address is the perception that PAs are seeking full, independent autonomy from doctors. Rutherford clarified that while PAs are seeking “full prescriptive authority,” that doesn’t mean they will operate independently of their physicians.

“There’s this concern that we may try to break away from our physician-led team model,” he said, “but even our national group, the American Association of Physicians Assistants (AAPA), their first pillar talks about a physician-led team,” he said.

“I think that’s one of those things we have to educate more people on is that we as PAs are actually already making the medical decision to prescribe, it’s just that someone else [the physician] has to sign it,” he said.

“What passing HB 93 would allow is for the PA and the physician who they work with to decide what kind of controlled substances are pertinent to that practice and what the PA could write,” he explained. And as a result, citizens of Kentucky would have a much wider access to the proper medical care that they need.

To those who are concerned about allowing PAs too much freedom, Rutherford added that by giving Kentucky PAs full prescriptive authority, they would also be held to a higher accountability. “We would still fall underneath the same jurisdiction … we’d be monitored exactly the same as the physicians are,” he said.

The health of Kentuckians and even the future progress of the opioid crisis are dependent on the state’s ability to address the projected increase in demand for healthcare professionals. As the Kentucky population grows and ages, it will be a continued challenge for the community to meet the shortage of qualified medical care professionals, especially if Kentucky fails to grant its PAs full prescriptive authority.

“Kentucky really needs healthcare providers. We have three PA schools in the state that train really good providers, but they’re choosing to leave Kentucky because they wanted to be in a less restrictive state,” Rutherford said.

As KAPA’s president, Dr. Laurie Garner told Kentucky Today last year, “If the Kentucky General Assembly does not allow PA prescriptive authority, Kentucky PAs will not be able to participate in this expanded opportunity to treat patients with opioid addictions. Given the significant healthcare provider shortage in the state, that would be a tragic missed opportunity.”