which represents doctors in the state

As physician assistants and other midlevel health professionals fill growing gaps in primary health care, turf battles are erupting in many states over what they can and can't do in medical practices.

One of the bitterest fights is in Kentucky, where physician assistants are lobbying the state legislature to repeal a law that says that for the first 18 months after certification, physician assistants are allowed to treat patients only when a supervising physician is on site. Being in phone contact isn't deemed sufficient.

The Kentucky Medical Association, which represents doctors in the state, says it is still evaluating the bill. But it helped push for an on-site requirement in 2003 and helped block two previous attempts to rescind the 18-month rule, on the grounds that physician assistants have far less experience than physicians and benefit from more supervision.

PAs, as they are known, are licensed to practice medicine as part of a physician-led team. Their "scope of practice" rules vary from state to state, but PAs can generally do whatever tasks the doctor delegates to them within those rules, including examining patients, prescribing medications, conducting rounds in hospitals—even closing surgical incisions—as needed. About 80% have master's degrees, with an average of 27 months of classroom and clinical work after college.

Demand for PAs has grown, particularly in primary care and rural areas, as more doctors choose to specialize and work in urban settings. That demand is expected to increase further when the federal health law next year extends coverage to millions more Americans, likely prompting many of them to seek care.

"Our focus is on the safety of the public," says David Bensema, the Kentucky Medical Association's board chairman, who likens the training PAs receive to that of third-year medical students. The doctors' group has also opposed attempts by nurse practitioners, optometrists and other nonphysicians to expand their scope of practice in Kentucky. A 2011 flier from the Kentucky Medical Association told state residents, "Not everyone in a white coat is a medical doctor."

The Kentucky Academy of Physician Assistants argues that no other state requires PAs to have 18 months of on-site supervision. (Colorado, the state with the next-longest mandate, requires supervision only for the first 1,000 hours). The Kentucky group also says the rule needlessly complicates patient care, especially in rural areas where doctors are stretched thin. The Kentucky Academy of Physician Assistants is planning a rally at the state capitol this week and has hired two lobbyists to make its case to hospitals, insurers and medical practices.

Some Kentucky physicians agree with the PAs. Naren James is the only primary-care doctor for two central-Kentucky clinics, 25 miles apart. He and his four PAs handled a total of 25,624 patient visits or calls at the two clinics last year. Two of the PAs can treat patients at one clinic while Dr. James is at the other. But the other two PAs can only work when and where Dr. James does, because they have been on the job less than 18 months.

If Dr. James is out sick, on vacation or treating patients elsewhere, he says he has to hire another doctor to fill in—not easy in rural Kentucky. If not, the two PAs have to stop working until he returns. "None of this makes clinical sense," says Dr. James.

"We're here to help distribute the workload," says Jeremy Caudill, a former pro football player who graduated from a PA program in June and works with Dr. James. But if the doctor is away, he says, "I can't even refill a prescription for blood-pressure medication that someone has been on for 10 years."

Across the country, such skirmishes are increasing, as nurse anesthetists, nurse midwives, psychologists and podiatrists seek more autonomy and authority—and often meet opposition from physician groups. In the past two years, more than 1,795 scope-of-practice bills were proposed, but only 349 were enacted, according to the National Conference of State Legislatures.

Some states are expanding what PAs can do. Ohio now allows them to prescribe physical therapy for patients, for example, and insert and remove chest tubes. Massachusetts allows PAs to bill patients and insurers directly for their services, generally at 85% of a doctor's rate. All 50 states allow PAs to write prescriptions, though not for controlled substances in Kentucky or Florida.

Many health-care experts say PAs will be in even greater demand when the Affordable Care Act expands insurance to 30 million more Americans next year. The Association of American Medical Colleges has warned that the supply of new doctors can't keep pace, due to limits on federal funding for medical residency programs, and estimates that the U.S. will face a shortage of more than 90,000 physicians by 2020, particularly in primary care and in rural areas.

The number of licensed PAs, meanwhile, has doubled in the past decade, to 86,500, and is likely to grow another 30% by 2020, according to the American Academy of Physician Assistants.