Missouri State Rep. Tricia Derges is pushing a bill to give assistant physicians like herself a pathway to becoming fully licensed doctors in the state.
Not that Derges 鈥� among the highest-profile holders of the assistant physician license created in 2014 to ease a doctor shortage 鈥� is the most persuasive advocate right now.
Derges was indicted last year on of selling fake stem-cell treatments, illegally prescribing drugs and covid relief funds. Derges, who did not respond to multiple messages sent to her and her lawyer, has pleaded not guilty. But she has already been the Republican caucus, forced to move her legislative office into a , put on a for her narcotics license and denied the ability to run for reelection following her indictment. A trial is set for June.
Her personal tribulations have jeopardized an already contentious solution for states that struggle with gaps in primary health care. Even some early proponents now want to rein in the assistant physician license.
Assistant physicians 鈥� sometimes called associate physicians, and not to be confused with physician assistants 鈥� are medical school graduates who have not yet completed residency training. Similar licenses also now exist in Arizona, Arkansas, Kansas, and Utah. Virginia is considering and model legislation is making such licenses easier than ever for other state legislatures to adopt.
顿别谤驳别蝉鈥� would allow assistant physicians to become licensed 鈥� similar to doctors who have completed a residency 鈥� provided an assistant physician has practiced for five years with a collaborating physician, passed a licensure exam and completed certain training requirements.
Her bill would create a new path for training physicians. aims to scale back the license, though, and cap the number of years assistant physicians can practice until they funnel back into residency programs.
Dr. , a former state representative and orthopedic surgeon from Rolla, Missouri, proposed the original assistant physician legislation, the first of its kind in the nation.
Nearly every county in Missouri is short of primary care providers, according to the federal . It would take nearly to fill that void, but efforts to get doctors to practice in underserved areas have been 鈥渃hronically unsuccessful,鈥� Frederick said. At the same time, thousands of medical school graduates who apply for residency programs each year are not accepted 鈥� 9,155 applicants did not match to a program , or about 1 in 5 of the candidates, most coming from international medical schools.
The assistant physician license allows those medical school graduates to practice medicine in Missouri under a collaborative practice agreement with a physician, who is ultimately responsible for the care given, and on the condition that they do so in an underserved area. They can see patients, prescribe drugs and provide certain treatments, in much the same way as nurse practitioners or physician assistants 鈥� so-called midlevel practitioners, both of which have distinct master鈥檚-level training.
Frederick鈥檚 bill passed the same year it was introduced, a legislative feat he described as 鈥減retty remarkable.鈥�
The idea did have its detractors at the time. Chief among them was the Missouri Nurses Association, which argued the state鈥檚 were better suited to address primary care shortages. The association views the state鈥檚 rules for nurse practitioners 鈥渢he most severely restrictive in the nation.鈥�
Nationally, the American Medical Association, American Academy of Family Physicians and Accreditation Council for Graduate Medical Education also .
One initial supporter of the idea was Dr. , chief medical officer for Scotland County Hospital in rural Memphis, Missouri, and an executive committee member of the . Eight years after the law passed, however, Davis has no assistant physicians working with him, even though he said he has several openings that would benefit from them.
The challenge, Davis said, is Medicare will not reimburse for care provided by assistant physicians. Hospitals in rural areas on revenue from that public insurance program for Americans 65 and older. But for hospitals to get paid by Medicare for the work of an assistant physician, Davis said, the assistant physician would have to work under the direct supervision of a physician whose name would be used to submit the bill.
鈥淭hat doesn鈥檛 make much business sense,鈥� Davis said.
Frederick hopes that having more states create an assistant physician license will force the hand of the Centers for Medicare & Medicaid Services to start reimbursing for the work done by those clinicians. The American Legislative Exchange Council adopted after Frederick presented the idea at the conservative nonprofit鈥檚 summit last year.
Currently, Missouri has 348 active licenses for assistant physicians, including Dr. Trevor Cook, creator of the . Cook graduated in 2014 from the International American University medical school on the Caribbean island of St. Lucia.
鈥淯nfortunately, I was one of those many, many, many, many thousands of doctors that don鈥檛 match each year鈥� into a residency program, Cook said.
Cook has practiced at Downtown Urgent Care in St. Louis since 2018, a position he called rewarding. He is supportive of a pathway for assistant physicians to become fully licensed in Missouri, like the one proposed by Derges. As to the indictment, Cook said, one person鈥檚 actions are not representative of an entire group of practitioners.
A review of active assistant physician licenses in the state 鈥� including 顿别谤驳别蝉鈥� 鈥� found none under current disciplinary action. Two were previously under probation due to prior behavior.
Still, state doctor groups that initially supported the idea now want to cap the number of years someone can hold an assistant physician license, as other states have done. Under current Missouri law, assistant physicians can practice indefinitely.
鈥淎s with anything, you find out that people try to game the system and work an angle and get something that wasn鈥檛 intended out of something you did in good faith,鈥� Davis said.
Dr. , president of the American Academy of Family Physicians, said he already had concerns about the quality of care provided by assistant physicians, citing a 2018 JAMA article that found they had compared with their counterparts in residency programs. He said he鈥檚 doubtful about creating an alternative pathway to full physician licensure.
鈥淚 would personally have trouble supporting it without a lot more information to verify quality standards,鈥� Ransone said.
The American Medical Association favors a that would increase the number of residency positions in the U.S. by 14,000 over the next seven years.
Dr. , CEO of the American Osteopathic Association, didn鈥檛 shut the door on a role for assistant physicians but said he was skeptical: 鈥淲e have to be responsible to make sure that we鈥檝e put all the safeguards in with training and verification and monitoring, so that health care that is delivered by a physician is up to the standards that it should be.鈥�
Frederick called those concerns 鈥減urely turf protection鈥� amid what he said is a tremendous health care shortage.
鈥淲e have all these people that are highly trained,鈥� Frederick said. 鈥淲hy would you waste that resource?鈥�
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