Physician Assistant Autonomy: Exploring States Without Physician Supervision

While all U.S. states require PAs to operate under some degree of physician oversight, a growing number are easing restrictions by eliminating mandated physician supervision—particularly for experienced PAs:

• Iowa, Montana, New Hampshire, North Dakota, Utah, Wyoming — These states have modernized their laws to allow PAs to practice without direct physician supervision. Instead, PAs collaborate within the healthcare team based on their competence and experience; this environment is often termed “optimal” or “advanced” scope of practice (ncbi.nlm.nih.gov, timesunion.com).

• Arizona (2023 update) — PAs with 8,000+ hours of clinical practice, certified by the state board, can now practice via a collaborative—not supervisory—agreement (mica-insurance.com).

• During the COVID-19 pandemic, states like Oklahoma and Minnesota temporarily relaxed supervision mandates for PAs in emergency roles and even for regular practice — signaling recognition of PAs’ capacity to operate autonomously (en.wikipedia.org).

These reforms reflect mounting evidence that PAs deliver safe, effective care in an autonomous role while helping address physician shortages—especially in rural and underserved communities (timesunion.com).

Prescriptive Authority for Physician Assistants

General Findings:

• Most states (44 of 50) permit PAs to prescribe controlled substances (Schedules II–V) and non-controlled legend drugs (ama-assn.org).

• Exceptions & limitations:

• No Schedule II prescribing in AL, AR, GA, HI, IA, and WV.

• Legend drug restrictions in Kentucky.

• Other states (AR, GA, IA, KY, MO, OK, WV) impose specific limits or require supervising physician approval on certain drugs (ama-assn.org, mica-insurance.com).

What “full prescribing authority” means:

PAs with full prescribing rights can order medications across all therapeutic classes—non-controlled, controlled (II–V), devices, and supplies—according to state law. Restrictions in some states may limit dosage, duration, or require additional physician sign-off.

Requirements to Practice & Prescribe Independently

1. Clinical Experience

States eliminating supervision typically require a set number of hours of clinical experience:

• Arizona: 8,000 hours of clinical PA practice to shift from supervision to collaboration (mica-insurance.com).

• New York proposal: likewise, 8,000 hours in primary care/hospitalized settings qualifies PAs to practice collaboratively, not independently (timesunion.com).

2. Collaborative Agreements

Even without direct supervision, most states mandate a formal collaborative agreement with a physician:

• Defines communication methods (in-person, telemedicine).

• Details scope, chart review, consultation frequency.

• Varies by state: Monthly meetings, telecommunication availability, or chart reviews may be required.

3. Chart Reviews & Oversight

• Many states require periodic chart reviews, such as monthly or quarterly, to ensure standardized care.

• In some (e.g., Mississippi, Missouri, Nebraska), new PAs must undergo more intensive oversight during transition to independent practice.

Why States Are Easing Supervision — And Why Caution Remains

Pros:

• Improved access to care in underserved areas.

• Evidence of safety: During COVID deregulation, care outcomes remained safe and effective (timesunion.com, ama-assn.org).

• Support from PA advocates who note modern PA training equips providers for elevated autonomy (timesunion.com).

Cons:

• Some physicians express concern that PAs may overprescribe or misdiagnose without physician oversight (timesunion.com).

• Critics worry that removing physician supervision could reduce safeguards and quality assurance — especially for complex or chronic conditions.

Looking Ahead

The trend toward broadening PA practice and prescribing authority continues:

• More states are considering legislation to transition from supervision to collaborative practice for experienced PAs.

• Ongoing proposals (e.g., New York) aim to quantify experience thresholds like 8,000 clinical hours before allowing unsupervised collaborative practice (timesunion.com).

• This places greater emphasis on outcomes research to ensure such autonomy preserves patient safety and care quality.

Conclusion

• Prescriptive authority: In most of the U.S., PAs may prescribe Schedules II–V and legend drugs, though a few states maintain controlled prescribing limitations.

• Supervision to collaboration: States like IA, MT, NH, ND, UT, WY—and now Arizona (for experienced PAs)—allow PAs to transition into collaborative practice without direct physician supervision.

• Requirements: Key prerequisites include significant clinical hours, formal collaborative agreements, ongoing chart review, and communication mechanisms.

• Balanced approach: Regulators support increased PA autonomy to improve access, but many healthcare stakeholders urge continuing safeguards via oversight and evaluation.