Dave’s Blog: It’s Time For PA Practice In Puerto Rico

Puerto Rico is the last place that is part of the USA that does not allow PA practice. Why?

by Dave Mittman, PA, DFAAPA

I live in Florida but my soul is that of a New Yorker. It has been said that all New Yorkers are eventually a blend of each other. I believe that. That being said, NY is home to the largest population of people of Puerto Rican ancestry outside of the Commonwealth itself. When Hurricane Maria struck, I personally felt it. I know the people there. Obviously, my thoughts turned to healthcare and just who was going to provide it? Even the question of whether PAs could go down there to help? Let me explain…

If you don’t know, Puerto Rico has been experiencing a “brain drain” as physicians and nurses from there leave to make considerably more money on the mainland. Their economy has been hurting and the healthcare system had manpower shortages before the Hurricane. I can’t imagine that it will get better after. Imagine getting your degree, finishing residency and being able to make tens or even hundreds of thousands of dollars a year more for doing the same thing. It would be a challenge for any of us to stay. After Maria that challenge becomes something that can not be ignored.

Puerto Rico is the last place that is part of the USA that does not allow PA practice. Why? Most agree it is because of the pressure imposed by organized medicine. There are NPs there as they have legislation which is fairly new but they have problems also.

In a report issued January 2017 from the Health Policy Resource Center titled “Puerto Rico Healthcare Infrastructure Assessment”, this was said about PAs and NPs; “The health care provider shortage is exacerbated by a lack of midlevel providers like physician assistants (PAs) and nurse practitioners (NPs). PAs are not licensed to practice in Puerto Rico, and according to many respondents, physician groups have exerted ongoing pressure to maintain this arrangement. Some said that general practitioners worry about competition from PAs and the pressure this might create to further reduce reimbursement rates. By comparison, NPs face marginally better acceptance from the Puerto Rican medical community than PAs. Recently, Puerto Rico passed a law allowing NPs to practice, and several NP training institutions exist in the commonwealth. However, most graduates of these programs are either foreign students or Puerto Ricans intending to leave to practice elsewhere. Like physicians, bilingual nurses and NPs are in high demand on the US mainland and can earn significantly higher salaries there than in Puerto Rico”.

It’s time for PA legislation in Puerto Rico. It’s time to allow those that want to take some time and go down there to practice their profession the ability to do so. I know many of my PA friends over the years have wanted to, only to be told they were not wanted or needed. More than that let’s not settle for legislation that will tie our hands and not allow us to practice to the full extent of our education and clinical abilities. Let’s draft legislation for PA practice with OTP or as close to it as possible. We don’t need to hamper ourselves and this is a place that both needs and deserves PAs doing what we do best; providing medical care. Let’s look at what the NPs are trying to do and possibly work together and I hope all of us can team with the physicians there to provide the Island’s citizens with the healthcare they so desperately need.

It’s time for PA practice in Puerto Rico.


Dave Mittman has been a PA and later NP leader for thirty years. He co-founded the LIU PA Program student society, was President of the New York State Society of PAs from 1978-1979 and served on the American Academy of Physician Assistants (AAPA) Board of Directors from 1981-1983. Dave was also the first USAF Reserves PA permitted to practice. Dave spent 9 years in primary care in Brooklyn, N.Y. and left to begin a career in medical publishing with Physician Assistant Journal. Dave has also won the AAPA Public Education award for leading the march in Trenton NJ to establish PA practice. Dave left PA Journal to co-found Clinicians Publishing Group (1990) and Clinician Reviews Journal in 1991. Dave has authored papers in publications as diverse as “Chicken Soup for the Expectant Mothers Soul”, “U.S. Pharmacist”, “The British Medical Journal” and others. Dave¹s paper in the BMJ was the first internationally written paper written on PA practice. Dave and a few very close PA colleagues co-founded the PAs For Tomorrow”” in 2012 which is a new national professional organization representing and advocating for PAs in an different way. Dave as spoken at hundreds of NP and PA meetings and always has some interesting thoughts on the future of both professions. Most recently Dave has been busy launching another dream; Clinician 1, the first internet community for PAs and NPs. Dave is married to his sweetheart Bonnie for 32 years and has two wonderful children.

Wage Gap Between Female and Male PAs Persists

Despite 70% of PAs being female, they earn significantly less than their male counterparts, a new study has found.

A new study conducted by the AAPA and published this month in Women’s Health Issues has found that there is a glaring disparity between the salaries of male and female PAs. For every dollar a male PA earns, his female counterpart earns only 89 cents—though nearly 70% of all PAs are female.

“As a PA educator, I feel keenly the burden of student debt. One way to think about the impact of the gender pay gap is in the context of the $150,000 in student loans facing a typical PA upon graduation. A male PA earning $10,000 a year more than his female PA counterpart could use that extra money to pay off his student loan debt in 15 years. The disparate treatment of women in the PA profession is simply unacceptable,” L Gail Curtis, President and Chair of the AAPA Board of Directors, is quoted as saying.

While this 11% gap may be shocking to some, compensation disparities between males and females have persisted for decades, and despite years of progress in the fight against the gender wage gap, women continue to make less than their male counterparts for doing the same work in nearly all professions. According to the most recent data from the U.S. Bureau of Labor Statistics, on average, women’s earnings were only 82% of men’s.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

States Lift More Hurdles To Physician Assistants

Like nurse practitioners, barriers to PAs are falling for a variety of reasons, including a doctor shortage and general comfort patients have with being treated by someone other than a physician.

from Forbes

An unprecedented number of regulatory hurdles are falling for physician assistants seeking more autonomy in their efforts to treat patients. In some cases, states are easing barriers that in the past led to redundant tasks or slowed the ability of patients to get the care they needed in a timely fashion. Such changes to regulations or scope of practice laws are taking effect this year as the result of state legislative sessions completed this summer.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Certified PAs Enhance Hospice and Palliative Care

With the number of Certified PAs growing 44% in just six short years, this workforce can help meet the demand for medical providers in the area of palliative care.

from Psychiatric Times

Making end-of-life decisions is difficult, but something many will face. I am privileged to provide compassionate care to those confronting these decisions as they enter the unfamiliar territory of facing mortality. As the chief physician assistant (PA) in hospice and palliative medicine at Carl T. Hayden VA Medical Center in Phoenix, Ariz., I’m committed to treating those diagnosed with chronic progressive illnesses that have advanced and become more burdensome, without curative options. Most of my patients are male, typically aged 65 or older, and are part of a growing demographic that will rely on our expertise in the future.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Expanding the Role of PAs in the Treatment of Severe and Persistent Mental Illness

Patients with severe and persistent mental illness often face limited access to psychiatric and primary care—PAs could change that.

from JAAPA

Among mental health teams that care for patients with severe and persistent mental illness, a growing concern is patients’ limited access to psychiatric support. One contributing factor is a shortage of psychiatrists, especially in community-based and outpatient settings. Physician assistants historically have been used in settings with physician shortages.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Life as a Traveling PA

Curious about locum tenens work as a PA? Here’s a handy list of things you might want to know.

from All Things Physician Assistant

Danielle Kepics, the PA-C at the helm of All Thing Physician Assistant, has received a multitude of questions about being a traveling or “locums” PA. As a result, she has compiled an extensive FAQ to address these questions and share her experiences with others who are curious about or interested in becoming a traveling PA. Are you interested in locums PA roles?

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

New AMA Policy Opposes Autonomous State PA Boards

At the annual meeting of the AMA, held June 9-14, 2017, delegates passed a resolution opposing autonomous state PA boards.

from AAPA

At the annual meeting of the American Medical Association (AMA) held June 9-14, delegates passed a resolution opposing autonomous state PA boards. This resolution was introduced following AAPA’s House of Delegates approval of Optimal Team Practice (OTP) last month.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

Uncovering the “Hidden Value” of PAs

If a PA treats a patient but the service is billed under a physician’s NPI number, did the PA contribute any revenue to the practice?

from AAPA

If a PA performs a procedure but no one knows about it, did it really happen? If a PA treats a patient but the service is billed under a physician’s NPI number, or performs pre-op services that are covered under a global surgery payment, did the PA contribute any revenue to the practice? These kinds of questions are becoming increasingly relevant as health-care systems and public and private payers look to become more data-driven in their approach to determining the productivity and value of health professionals, and as healthcare transitions to fee-for-value reimbursement and rewarding quality.

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Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.

This Month, Everything Changed for PAs

After days of debate and years of dreaming, collaboration and study, an entire profession has embraced their future.

by Beth Smolko, MMS, PA-C

After days of debate and years of dreaming, collaboration and study, the resolution called “Optimal Team Practice” (OTP) came up for a vote in the American Academy of PAs (AAPA) House of Delegates (HOD). I remember hearing the Speaker call for all votes in favor and although there was a good response, I couldn’t tell if it was a majority. Then, the Speaker called for “all opposed” and there was silence. Pure, beautiful, silence. It was in that moment that an entire profession embraced their future.

In years past, a determined and legendary PA leader, David Mittman, started saying we needed Full Practice Authority/Responsibility in order for the PA profession to survive and thrive. Many PAs did not want to risk future PA legislation by angering physicians with FPA. We saw the fierce battles the NPs had to engage in and realized that we would have to fight the state Board of Medicine in almost every state without the same level of protection that comes from having your own state board (like nursing). As the years went on, we saw our nurse colleagues fight battle after battle, state after state, and even though the physician groups bemoaned their success, they didn’t cease to hire NPs. In the past year, it became clear that physician groups were actually preferentially hiring NPs due to the reduced administrative burden, over “dependent” practitioners like PAs. PAs who felt that physicians would continue to hire them due to PAs practicing in the same “medical model” or staying “in our place” were sadly mistaken. As physicians had increasingly become employees instead of solo practitioners, they no longer wanted the professional liability that comes from having to “supervise” another professional.

Almost two years ago, I led an advocacy team for primary care PAs (AFPPA) joining with the PAs for Tomorrow (PAFT) and Brian Sady (a passionate educator from Nevada who wrote a comprehensive white paper on FPA for PAs) to address PA practice authority. We worked diligently to create a resolution to bring to the 2016 AAPA HOD to introduce Full Practice Responsibility (FPR). There was vigorous debate on the house floor but ultimately the resolution was referred for further study. From this point, the HOD and AAPA Board of Directors (BOD) formed the Joint Task Force on the Future of PA Practice Authority (JTF). The JTF reflected the diversity found in our profession. It was made up of clinically practicing PAs, educators, state PA leaders, and two PAs who work for the Veterans Administration. It was a group that would have to come to consensus on ideas and language that would be best for our patients, our profession, and our stakeholders.

Over the past 10 months, the JTF worked with AAPA staff to create the most transparent and member-engagement driven process in our organization’s history. They sought to understand the wishes, needs, and will of their constituents. The concept was named Full Practice Authority and Responsibility (FPAR) and consisted of four “pillars”:

  1. Emphasize the PA profession’s continued commitment to team-based practice.
  2. Support the elimination of provisions in laws and regulations that require a PA to have and/or report a supervisory, collaborating, or other specific relationship with a physician in order to practice.
  3. Advocate for the establishment of autonomous state boards, with a voting membership comprised of a majority of PAs, to license, regulate, and discipline PAs.
  4. Ensure that PAs are eligible to be reimbursed directly by public and private insurance.

A survey was released on FPAR with over 12,000 PAs responding and over 71% in favor of the concept. The AAPA held calls with state chapters, specialty organizations, students, program directors, PA Administrators, past presidents and a variety of other PA leaders, as well as external stakeholders to field questions and explain the concept of FPAR. The AAPA also received thousands of emails, comments on social media, and letters regarding FPAR. PA leaders met with multiple physician organizations to discuss the proposal under consideration. By March, it appeared clear that this would be the way forward, but slow deliberation is the hallmark of PA leadership. During the Leadership and Advocacy Summit held in March 2017, we heard concerns from some attendees, including PA educators, which led to rethinking the name and some of the language originally proposed by the task force. As the pillars would directly impact AAPA’s Model State Legislation, they were added to the guidelines document as opposed to creating a “stand alone” resolution. The pillars were given a new name — “Optimal Team Practice” (OTP). This change in language gave some assurance to PAs that felt teamwork was important to emphasize. They wanted it to be clear that PAs weren’t going “rogue”, but rather wanted to be better teammates by not burdening any other teammate with “supervision”.

So, once again, I found myself on the floor of the HOD last week, asking for my colleagues to consider the future of our profession and the impact OTP would have on patient access to care. And after two days of debate, it ended in silence… followed by cheers, tears, and emotion unlike anything I’ve ever seen from our profession. It was a moment that changed everything – how PAs see themselves as a profession, where we belong in the healthcare landscape, and how we can expand access to care for our patients.


Beth Smolko is a certified PA with experience in primary care and occupational health and wellness. While in PA school, Beth volunteered in a mobile medical unit in Tucson, AZ which ignited her passion for bringing quality medical care to the underserved outside the walls of a clinic. Beth is a recognized leader in primary care with professional roles that include: Director-at-Large, American Academy of PAs (AAPA); Past President of the Association of Family Practice Physician Assistants (AFPPA); PA Representative at the 2013 and 2014 World Hepatitis Day meetings held at the White House; HCV Testing Recommendations Implementation Panel – Healthcare Providers (Centers for Disease Control). Participant representing PAs in the discussion on the Implementation of Hepatitis C Screening Recommendations for Patients born between 1945-65; Preceptor for George Washington University, Franklin Pierce and Salus University PA Programs. Preceptor for LECOM. Preceptor for University of Michigan Nurse Practitioner program; Guest lecturer for Mary Baldwin – Murphy Deming and George Washington University PA program speaking on “Pulmonary Disease” and “Family Medicine”; President and Founder of The Heart of Medicine, a non-profit connecting healthcare providers with patients desperately in need of care in Haiti.

Disclaimer: The viewpoint expressed in this article is the opinion of the author and is not necessarily the viewpoint of the owners or employees at Healthcare Staffing Innovations, LLC.