FTC Staff Comment to the Professional Licensure Division of the Iowa Department of Public Health Regarding -- In the Proposed New Rules of the Iowa Board of Physician Assistants -- the Definition of Physician Supervision of A Physician Assistant

UNITED STATES OF AMERICA
FEDERAL TRADE COMMISSION
WASHINGTON, D.C. 20580
Office of Policy Planning
Bureau of Competition
Bureau of Economics
December 20, 2016
Via USPS and email to susan.reynolds@idph.iowa.gov
Susan Reynolds
Professional Licensure Division
Department of Public Health
Lucas State Office Building
Des Moines, Iowa 50319-0075
RE: Iowa Board of Physician Assistants, Proposed New Rules: 645—327.8:
Definition of physician supervision of a physician assistant1
The staffs of the Federal Trade Commission’s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition (“FTC staff”) 2 appreciate the opportunity to respond to
the request for public comments on the Iowa Board of Physician Assistants’ (“PA Board”)
proposed rule, “Definition of physician supervision of a physician assistant” (“Proposed Rule”).3
Iowa patients would likely benefit if physician assistants (“PAs”) in Iowa can practice
with as few restrictions as possible, consistent with their education, training, skills, and
experience. PAs can provide more choice among health care providers, leading to more
accessible, affordable, safe, and effective health care. Thus, FTC Staff support the PA Board’s
initiative to comply with its legislative mandate to establish specific minimum standards or a
definition of supervision 4 while maintaining maximum flexibility at the practice level to allow
physician-owned practices, hospitals, clinics, and other practice sites to best employ PAs’
capabilities in a safe manner.
Specifically, the Proposed Rule would maintain the statutory and regulatory status quo by
allowing supervising physicians and PAs flexibility to determine, implement, and document the
appropriate level of supervision at the practice site. Based on FTC staff’s prior examination of
the impact of professional regulations on health care provider competition, we believe the
Proposed Rule would allow Iowa physicians and health care facilities to employ and deploy PAs
in the most efficient and effective manner, consistent with patient safety.
In contrast, the PA Board’s previously proposed regulations, and the regulations adopted
by the Iowa Board of Medicine (“BOM”), appear to limit such flexibility and impose potentially
new and more costly supervision requirements.5 Absent evidence of public health or safety
concerns about the care that PAs and their supervising physicians provide under current laws and
regulations, we believe the PA Board’s Proposed Rule would likely preserve competition and

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maintain and improve access to needed health care services for Iowa patients, particularly in
medically underserved areas.6
I. 	INTEREST AND EXPERIENCE OF THE FTC
The FTC is charged with preventing unfair methods of competition and unfair or
deceptive acts or practices in or affecting commerce.7 Competition is at the core of America’s
economy,8 and vigorous competition among sellers in an open marketplace gives consumers the
benefits of lower prices, higher quality products and services, and greater innovation. Because of
the importance of health care competition to the economy and consumer welfare, anticompetitive
conduct in health care markets has long been a key focus of FTC law enforcement,9 research,10
and advocacy.11
FTC staff have submitted many comments, and published a policy paper, explaining that
competition and consumers benefit if advanced practice registered nurses (“APRNs”) can
practice free of supervision requirements that are not justified by legitimate patient health and
safety concerns.12 Although FTC staff have not previously submitted comments focused
specifically on PA supervision and scope of practice issues, our APRN comments and the APRN
policy paper have suggested that a similar interplay between competition and scope of practice
regulation may apply to PAs as well.13 This prior FTC staff work informs the review of proposed
regulations in Iowa concerning PAs. The link between APRN and PA scope of practice
regulation and how it may affect competition and consumers is further supported by the Centers
for Medicare and Medicaid Services (“CMS”), which recently proposed regulatory revisions to
eliminate certain language that had treated PAs differently than APRNs. CMS suggested that
APRNs and PAs should be treated similarly with respect to their scope of practice, stating “PAs
are trained on a medical model that is similar in content, if not duration, to that of physicians.
Further, PA training and education is comparable in many ways to that of APRNs and in some
ways, more extensive.”14
II. 	BACKGROUND
A. 	Overview of the PA Profession
The PA profession emerged in the 1960s to address primary care physician shortages, as
well as to train military veterans who were corpsmen and medics to provide medical care under
physician oversight.15 PAs are educated in the medical model in master’s level accredited
programs, with the typical program of didactic and clinical education lasting 27 continuous
months and including approximately 2,000 hours of supervised clinical practice.16
Approximately 108,000 PAs practice across all medical and surgical specialties nationwide, with
about 30,000 PAs in primary care practice.17
PAs constitute ten percent of the primary care work force and nine percent of clinicians
in community health centers, and play a significant role in staffing federally designated rural
health clinics.18 The Bureau of Labor Statistics projects that the PA profession will grow over 30
percent by 2024.19 At the same time, the Association of American Medical Colleges (“AAMC”)
projects significant physician shortages in both primary and specialty care by 2025.20 The
AAMC also reported that Iowa ranked 42 nd among the states in the number of active physicians
per 100,000 people, 45th in the total number of active patient care physicians, and that 38 percent

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of Iowa’s active physicians were over the age of 60.21 Thus, it appears that encouraging the
greater use of PAs could help to alleviate these projected physician shortages in the U.S.
generally and Iowa specifically.
B. 	Background on PA Statutes and Regulations in Iowa
In 1988, the Iowa legislature created the PA Board and moved regulatory authority from
the BOM to the PA Board.22 In taking this action, the Iowa legislature granted PAs a certain
degree of regulatory autonomy over their profession, subject to specific supervisory requirements
mandated by the legislature.23
Iowa law requires that PAs be licensed and allows PAs to perform certain medical
services under a physician’s supervision. A physician cannot supervise more than five PAs at the
same time. Several restrictions have eased over time, including an increase in the number of PAs
whom a physician can supervise from two to five. The statute requires the PA Board to adopt
rules “requiring a licensed physician assistant to be supervised by physicians” and states that a
“ licensed physician assistant shall perform only those services for which the licensed physician
assistant is qualified by training or not prohibited by the board.”24
1. 	PA Board Regulations
The PA Board has adopted various regulations to implement the broad statutory
requirements, as well as additional specifications governing the relationship between physicians
and PAs. Existing PA Board regulations define “supervision” as follows:
[A] supervising physician retains ultimate responsibility for patient care, although
a physician need not be physically present at each activity of the physician
assistant or be specifically consulted before each delegated task is performed.
Supervision shall not be construed as requiring the physical presence of the
supervising physician at the place where such services are rendered except insofar
as the physical presence is expressly required by these rules or by Iowa Code
chapter 148C.25
Existing regulations also require that PAs pass a national certification exam and identify
their supervising physicians on board-approved forms before practicing in Iowa and when
renewing their license. The regulations incorporate the statutory requirements that at least one
physician must supervise a PA and that a physician cannot supervise more than five PAs at the
same time. The regulations specify that it is the PA’s and physician’s responsibility to ensure
adequate supervision, and if the designated supervisor is not available, the PA cannot practice
unless a substitute physician can supervise during that time. The regulations require both the PA
and the physician to know and comply with the supervision provisions and to review the PA’s
patient care on an ongoing basis, as appropriate based on the clinical condition of the patient.26
Neither Iowa law nor existing PA Board rules require a supervising physician to review
every chart or visit, and the rules allow for the review of patient care in person or via telephone
or other telecommunication means. If physician signatures are necessary as part of supervision,
the rules permit electronic signatures if certain safeguards are in place.27 The regulations set forth

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the types of medical services a physician can delegate to a PA and state that “the ultimate role of
the physician assistant cannot be rigidly defined because of the variations in practice
requirements due to geographic, economic, and sociologic factors.”28
The PA Board regulations also set forth specific requirements for remote medical sites,
which are defined as practice locations at which the supervising physician is present less than 50
percent of the time. For remote medical sites, the supervising physician must visit the remote site
at least every two weeks, or less frequently under special circumstances that require notification
to the PA Board.29
2. 	New legislative charge to both PA Board and BOM in 2015
In 2015, the legislature adopted a provision known as Senate File 505 (“SF505”), which
states:
The boards of medicine and physician assistants shall jointly adopt rules pursuant
to chapter 17A to establish specific minimum standards or a definition of
supervision for appropriate supervision of physician assistants by physicians. The
boards shall jointly file notices of intended action pursuant to section 17A.4,
subsection 1, paragraph “a”, on or before February 1, 2016, for adoption of such
rules.30 [Emphasis added].
In compliance with SF505, subcommittees of both the BOM and the PA Board worked
together to develop a proposed regulation and issued notices of proposed rulemaking to set
minimum standards for physician supervision of PAs.31 In response to public comments, both
boards issued identical amended proposed rules – ARC 2531C by the PA Board and ARC 2532C
by the BOM.32
The BOM adopted ARC 2532C, the amended rule, which we discuss below. The BOM
press release and other actions suggest that – despite legislative language that seems to require a
jointly adopted rule – the BOM appears to consider its rule effective and enforceable33 even
without a parallel rule adopted by the PA Board.34
The PA Board received additional comments on ARC 2531C, held another hearing on
June 3, 2016, and held two subsequent board meetings to discuss ARC 2531C.35 Based on the
public comments, the PA Board expressed concern that ARC 2531C (and ARC 2532C, the
identical version adopted by the BOM) would have significant adverse effects and would be
likely to negatively impact access to care for Iowans.36 As a result, the PA Board has issued and
seeks public comment on the Proposed Rule.37
III. 	THE PA BOARD’S CURRENTLY PROPOSED RULE
The PA Board’s Proposed Rule expands upon the existing definition of physician
supervision in the PA Board’s current rules, without specifying additional minimum standards of
supervision. The Proposed Rule states:

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327.8(1) Definition of supervision. Supervision means an ongoing process by
which a supervising physician and physician assistant jointly ensure that the
medical services provided by the physician assistant are appropriate. A
supervising physician retains ultimate responsibility for patient care. A physician
need not be physically present at each activity of the physician assistant or be
specifically consulted before each delegated task is performed. Supervision shall
not be construed as requiring the physical presence of the supervising physician at
the place where such services are rendered except insofar as the physical presence
is expressly required by Iowa Code chapter 148C.
327.8(2) Additional elements of supervision.
a. Supervision must be tailored to the individual practice setting and take into
account the experience of both the physician and physician assistant.
b. Individual practice requirements must guide how to best use health information
technology to enhance patient care by ensuring effective and timely
communication between physician and physician assistant.
c. The supervising physician and physician assistant must determine appropriate
methods of evaluation for each practice. This evaluation may include, but is not
limited to, review of delegated services, periodic chart review, and existing
evaluation tools as determined by the practice.
d. Both the supervising physician and physician assistant must review all of the
requirements of physician assistant licensure, practice, supervision and delegation
of medical services as set forth in the Iowa Code.38
IV. 	LIKELY IMPACT OF THE PA BOARD’S PROPOSED RULES
FTC staff recognize that certain professional licensure requirements and scope-of-
practice restrictions may be necessary to protect patients.39 Consistent with patient safety,
however, we have urged regulators and legislators to consider whether removing unnecessary
practice restrictions for non-physician providers may promote competition and benefit patients.40
With respect to the Proposed Rule, if PAs can better practice to the full extent of their education,
training, and abilities – as determined by their physician supervisors – health care consumers will
likely reap competitive benefits. Those gains would flow from an expanded supply of quality
health care providers, including improved access to health care, lower costs, and additional
innovation.41
When analyzing competition in various health care professions, FTC staff consistently
recommend that policy makers carefully examine purported safety justifications for restrictions
on health care practitioners – especially when the scope of practice for one health care profession
overlaps to some degree with that of another profession over which it exercises supervisory
authority. We have recommended that state legislators, regulators, and other policy decision
makers:
• 	Evaluate what, if any, pertinent evidence exists to maintain or add scope-of-practice
restrictions;
• 	Evaluate whether purported health and safety justifications are well founded; and

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• 	Consider whether less restrictive alternatives would protect patients without imposing
undue burdens on competition and undue limits on patients’ access to health care
services.42
FTC staff urge the PA Board, as well as the BOM,43 to apply a similar analytical
framework as they consider regulations governing physician supervision of PAs. We recognize
that Iowa law requires PAs to practice under the supervision of physicians. This requirement
gives supervising physicians some control over PAs’ ability to access the health care
marketplace, including for services where those PAs may compete with physicians.44 But
regulations to implement this legislative requirement can, and should, minimize restrictions that
are not justified by legitimate patient safety concerns. Even well-intentioned laws and
regulations may include unnecessary or overbroad restrictions, including those that may limit
competition or frustrate the development of innovative and effective models of team-based
health care.45 Such undue restrictions on health care services can raise costs or prices to patients
or third-party payers, limit access to important health care services, or both, without providing
countervailing consumer protection benefits.
The PA Board’s Proposed Rule, which would promote greater flexibility and avoid a
“one size fits all” approach, likely will enable physician-owned practices and clinics, as well as
institutional health care providers, to continue to deploy PAs efficiently and effectively in a
variety of patient care situations.46 The Proposed Rule appears to comply with the statutory
mandate in that it provides a more detailed definition of supervision, and does so without
creating additional rigid supervision rules that could increase costs and decrease access.
Moreover, unlike the previous proposal by the PA Board (ARC 2531C), which was adopted by
the BOM (ARC 2532C), the Proposed Rule is unlikely to create confusion or uncertainty as to
the regulations with which PAs and physicians must comply.
V. 	LIKELY IMPACT OF THE PA BOARD’S PREVIOUSLY PROPOSED
ARC 2531C AND THE BOM’S ADOPTED ARC 2532C
SF505 appears to contemplate that both the BOM and the PA Board will adopt identical
rules. Therefore, we think it is useful to highlight some questions and concerns related to the PA
Board’s previously proposed ARC 2531C, which the BOM adopted as ARC 2532C (hereinafter
collectively referred to as “ARC 2532C”). ARC 2532C would mirror the PA Board’s current
definitions of supervision and remote medical sites.47 ARC 2532C would also set forth minimum
standards of supervision, which appear to impose additional requirements and restrictions
compared to the existing supervisory relationship between physicians and the PAs they
supervise. For example, the new BOM regulations would prescribe how or when certain
supervisory functions must take place, such as face-to-face meetings and chart reviews.48 As
explained below, FTC staff question whether these additional supervisory requirements are
necessary.
In addition to our substantive concerns about ARC 2532C, FTC staff also note an
important procedural concern. We understand that ARC 2532C, as well as the Proposed Rule,
would be considered additional rules that would not replace or supersede the PA Board’s
currently codified regulations. Because some of the language in ARC 2532C is similar to that of

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current PA Board regulations, but is not identical,49 this layering of old and new requirements
may confuse and impose costs on supervisory physicians, health care institutions, and PAs.50
A. 	Face-to-Face Meetings
ARC 2532C would require at least one supervising physician to meet face-to-face with
each PA a minimum of twice annually.51 Neither the Iowa statutes nor the current PA Board
regulations require face-to-face meetings, with the exception of certain requirements for PAs
working in remote medical sites.
FTC staff query whether there is evidence to support a requirement that formal face-to-
face meetings are necessary to address any legitimate health or safety concerns with respect to
the large number of PAs who collaborate routinely with physicians. The large majority of Iowa
PAs work in physicians’ offices, clinics, hospitals, and other health care settings where PAs and
their supervising physicians interact regularly, discussing cases and issues as they occur.52 Public
comments indicate that physicians, clinics, hospitals, and PAs are concerned that compliance
with an additional face-to-face meeting requirement would add costs in terms of time, potential
travel, documentation, reduced patient visits, and lost revenue.53 They also raise concerns about
how compliance might be achieved. For example, faculty from the Carver College of Medicine
at the University of Iowa noted that University of Iowa Health Care’s (“UIHC”) 75 physician
assistants “generally have immediate access to a staff physician for consultation at the time of
the patient visit, so that PA supervision is accomplished in a manner similar to supervision of
resident and fellow physicians.” Yet, UIHC did not think this system would “technically meet
the requirements in the proposed rule, so additional meetings would be required.”54
With respect to PAs practicing at remote sites, the current PA Board regulations already
require the supervising physician to visit a remote site at least every two weeks in order “to
provide additional medical direction, medical services and consultation.”55 The BOM’s press
release regarding ARC 2532C appears to suggest that, with respect to remote clinics, the two
new required face-to-face meetings would be in addition to the 26 currently required visits for
PAs practicing in remote clinics.56 If so, FTC staff question whether there is a substantiated
health or safety rationale for imposing this additional requirement. We also respectfully suggest
that in-person, face-to-face meetings should not be mandated by legislation or regulation. Absent
demonstrable evidence that face-to-face meetings are necessary to promote health care quality
and protect patients, the supervising physician and supervised PA should have flexibility to
determine the most effective and efficient way to maintain an appropriate supervisory
relationship.57
Even if the intent is to substitute two required face-to-face meetings per year for PAs
practicing at remote sites and thereby eliminate the 26 current site visits, FTC staff note that 28
states and the District of Columbia impose no on-site or face-to-face meeting requirements for
the supervision of PAs.58 Similarly, in 2014, CMS also eliminated biweekly onsite physician
visits to critical access hospitals (“CAHs”), rural health clinics (“RHCs”), and federally qualified
health centers (“FQHCs”).59 In response to comments on the proposed rule implementing that
change, CMS noted that:

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specifying a precise timeframe for a physician to visit the CAH, RHC, or FQHC,
and provide the general oversight required . . .would not guarantee better health
care. With the development of technology such as telemedicine, we believe a
CAH, RHC, or FQHC should have the flexibility to use a variety of ways and
timeframes for physician(s) to provide the necessary medical direction and
oversight.60
CMS also estimated that removal of the on-site provision would produce estimated annual
savings of approximately nearly $75.6 million for CAHs, RHCs, and FQHCs.61
If the BOM and the PA Board nevertheless decide there is a legitimate and substantiated
justification to keep the face-to-face requirement, FTC staff urge the PA Board and the BOM to
consider whether meetings via telecommunications or video conferencing could address any
purported health and safety concerns, while minimizing the costs and burdens for a supervising
physician to travel to a remote clinic.62 FTC staff have submitted a number of comments
supporting the increased use of telehealth by various types of health care providers under
appropriate circumstances,63 and we respectfully suggest to the BOM and the PA Board that
telehealth consultations might be adequate substitutes for some or all visits at the remote sites.
B. 	Chart Reviews
ARC 2532C would require that “[e]ach supervising physician shall conduct and
document an ongoing review of a representative sample of the physician assistant’s patient charts
encompassing the scope of the physician assistant’s practice provided under the physician’s
supervision and discuss the findings of the reviews with the physician assistant.” It appears that
this chart review requirement would be a completely new imposition for most PAs and
physicians in Iowa. Chart review is now required only for Iowa PAs with less than one year of
experience when practicing in a remote site.64
Twenty-eight states and the District of Columbia have no comparable chart review
requirement.65 Similarly, CMS, during its rulemaking to eliminate specified onsite visits to
CAHs, RHCs, and FQHCs also chose to eliminate a specified timeframe for reviewing charts.
CMS noted that it would instead allow for periodic review to provide these health care entities
“with the flexibility to manage patient care activities in such a way as to maximize staff time to
provide patient access to quality care in rural and remote areas.”66
This new chart review requirement could be a confusing and costly provision, depending
on whether it adds new chart review and documentation obligations beyond existing
requirements for physicians, hospitals, and other health care entities in connection with physician
supervision of PAs. Public comments submitted in response to the proposed rules raised these
types of concerns. Many organizations (e.g., physician practices, clinics, hospitals) noted they
already have chart review systems in place – some on a daily basis, and often via electronic
health records – but it is unclear what else ARC 2532C might require.67 They wondered, for
example, whether organizations would have to implement entirely new systems for chart
reviews, and whether a supervising physician would need to set aside time on “an ongoing basis”
to talk to the PA and formally discuss chart reviews even when the supervising physician had

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reviewed the course of action, agreed with everything, and initialed the chart at the time of care.
In many of these organizations, if there is a question about treatment, it is handled “in the
moment,” and it is unclear how ARC 2532C would require this be documented.68
VI. 	CONCLUSION
FTC staff support the PA Board’s efforts to comply with the legislative mandate in
SF505 by providing a definition of “physician supervision” without the additional burdens
contained in previously noticed rules or those in ARC 2532C, unless there is substantiated health
and safety evidence supporting such requirements. Those additional burdens could decrease
access to care and potentially increase health care costs for Iowa consumers, as well as to
physicians and health care institutions that employ PAs. Accordingly, we encourage the PA
Board to continue its efforts, including continued collaboration with the BOM to jointly adopt
the PA Board’s Proposed Rule, to improve access to care for Iowa patients as effectively and
efficiently as possible.
Respectfully submitted,
Tara Isa Koslov, Acting Director
Office of Policy Planning
Ginger Jin, Director
Bureau of Economics
Deborah Feinstein, Director
Bureau of Competition
1 ARC 2832C, Amended Notice of Intended Action, 39 Iowa Admin. Bull. 1108 (Dec. 7, 2016) (to be codified at
I OWA ADMIN. CODE r. 645-327.8(1) & (2), http://idph.iowa.gov/Portals/1/userfiles/26/PA/SECOND%20
AMENDED%20NOTICE%20OF%20INTENDED%20ACTION%20-%20IAC%20327_8.pdf (establishing
definition of physician supervision of a physician assistant). According to its agenda, the PA Board adopted this
version at its November 15, 2016 meeting. Iowa Bd. of Physician Assistants, Agenda (Nov. 15, 2016),
http://idph.iowa.gov/Portals/1/Meetings/MeetingFiles/13/Agendas/4eec981c-0db4-4c26-aba8-ada213aad4a3.pdf.
2 This letter expresses the views of staff in the Federal Trade Commission’s Office of Policy Planning, Bureau of
Economics, and Bureau of Competition. The letter does not necessarily represent the views of the Federal Trade
Commission or of any individual Commissioner. The Commission, however, has authorized us to submit these
comments.
3 ARC 2832C, Amended Notice of Intended Action, supra note 1.
4 See discussion concerning statutory and regulatory background, infra at Section II.B.2.
5 38 Iowa Admin. Bull. 2169, 2162 (May 11, 2016) (PA Board proposed ARC 2531C and Notice of PA Board’s
June 3, 2016, Public Hearing on the proposed regulations).
6 See generally I NST. OF M ED., T HE FUTURE OF N URSING: LEADING CHANGE , ADVANCING H EALTH (2011),
https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health [hereinafter IOM

10
FUTURE OF N URSING REPORT]; see id. at 98 (noting that the “growing use of APRNs and physician assistants has
helped ease access bottlenecks, reduce waiting times, increase patient satisfaction, and free physicians to handle
more complex cases.”); O FFICE OF T ECH. ASSESSMENT, U.S. CONG., H EALTH T ECH. CASE S TUDY 37, N URSE
P RACTITIONERS, P HYSICIAN A SSISTANTS, AND CERTIFIED N URSE - M IDWIVES : A P OLICY A NALYSIS 39 (1986),
https://www.princeton.edu/~ota/disk2/1986/8615/8615.PDF (“Most observers conclude that most primary care
traditionally provided by physicians can be delivered by [nurse practitioners and physician assistants].”).
7 15 U.S.C. § 45.
8 Standard Oil Co. v. Fed. Trade Comm’n, 340 U.S. 231, 248 (1951) (“The heart of our national economic policy
long has been faith in the value of competition.”).
9 See, e.g., Competition in the Health Care Marketplace, FED. T RADE COMM ’N, https://www.ftc.gov/tips-advice/
competition-guidance/industry-guidance/health-care.
10 See, e.g., FED. T RADE COMM ’N & U.S. D EP’ T OF J USTICE , I MPROVING H EALTH C ARE : A D OSE OF COMPETITION
(2004), https://www.ftc.gov/sites/default/files/documents/reports/improving-health-care-dose-competition-report-
federal-trade-commission-and-department-justice/040723healthcarerpt.pdf.
11 FTC and staff advocacy may consist of letters or comments addressing specific policy issues, Commission or staff
testimony before legislative or regulatory bodies, amicus briefs, or reports. See, e.g., Comment from FTC Staff to
La. State Representative Timothy G. Burns (May 1, 2009), https://www.ftc.gov/system/files/documents/
advocacy_documents/ftc-staff-comment-louisiana-house-representatives-concerning-louisiana-house-bill-687-
practice/v090009louisianadentistry.pdf (regarding proposed restrictions on mobile dentistry); Joint Comment from
the FTC and DOJ to the Ill. Task Force on Health Planning Reform (Sept. 15, 2008), https://www.ftc.gov/sites/
default/files/documents/advocacy_documents/ftc-and-department-justice-written-testimony-illinois-task-force-
health-planning-reform-concerning/v080018illconlaws.pdf (concerning Illinois certificate of need laws); Brief of
Amicus Curiae Federal Trade Commission, in Support of Appellants and Urging Reversal, In re Ciprofloxacin
Hydrochloride Antitrust Litig., 544 F.3d 1323 (Fed. Cir. 2008) (No. 2008-1097), https://www.ftc.gov/sites/
default/files/documents/advocacy_documents/ftc-amicus-curiae-brief-re-ciprofloxacin-hydrochloride-antitrust-
litigation-concerning-drug-patent/080129cipro.pdf; FTC & DOJ, IMPROVING H EALTH C ARE , supra note 10.
12 See, e.g., Fed. Trade Comm’n Staff, Policy Perspectives: Competition and the Regulation of Advanced Practice
Nurses (2014), https://www.ftc.gov/system/files/documents/reports/policy-perspectives-competition-regulation-
advanced-practice-nurses/140307aprnpolicypaper.pdf; Comment from FTC Staff to the Dep’t of Veterans Affairs
(July 25, 2016), https://www.ftc.gov/system/files/documents/advocacy_documents/comment-staff-ftc-office-policy-
planning-bureau-competition-bureau-economics-department-veterans/160725vastaffcomm1.pdf [hereinafter
Comment to the VA] (regarding proposed rule on APRNs); Comment from FTC Staff to W. Va. State Senator Kent
Leonhardt (Feb. 2016), https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-comment-senate-
west-virginia-concerning-competitive-impact-wv-senate-bill-516-regulation/160212westvirginiacomment.pdf
[hereinafter Comment to the Hon. Kent Leonhardt] (regarding legislation on APRNs); Comment from FTC Staff to
the S.C. State Representative Jenny A. Horne (Nov. 2, 2015), https://www.ftc.gov/system/files/documents/
advocacy_documents/ftc-staff-comment-south-carolina-representative-jenny.horne-regarding-house-bill-3508-3078-
advanced-practice-registered-nurse-regulations/151103scaprn.pdf (regarding legislation on APRNs); Comment from
FTC Staff to the Mo. State Representative Jeanne Kirkton 5 n.11 (Apr. 21, 2015), https://www.ftc.gov/system/files/
documents/advocacy_documents/ftc-staff-comment-representative-jeanne-kirkton-missouri-house-representatives-
regarding-competitive/150422missourihouse.pdf [hereinafter Comment to the Hon. Jeanne Kirkton] (regarding
collaborative practice arrangements between physicians and APRNs); Comment from FTC Staff to Mass. State
Representative Kay Khan (Jan. 17, 2014), https://www.ftc.gov/sites/default/files/documents/advocacy_documents/
ftc-staff-comment-massachusetts-house-representatives-regarding-house-bill-6-h.2009-concerning-supervisory-
requirements-nurse-practitioners-nurse-anesthetists/140123massachusettnursesletter.pdf (regarding supervisory
requirements for nurse practitioners and nurse anesthetists).
13 See, e.g., FTC Staff, Policy Perspectives, supra note 12, at 8 n.32 (noting the policy paper “does not discuss
Physician Assistants (PA) scope of practice issues, although PAs and APRNs typically are subject to similar types of
rules”); Comment to the Hon. Jeanne Kirkton, supra note 12 (FTC staff noted that Missouri “HB633, as approved
by the Committee of Professional Registration and Licensing on March 12, 2015, would amend the statute to also
include physician assistants and . . . [a]lthough these comments and our March 2014 policy paper refer specifically

11
to APRNs, we also encourage the legislature to consider our comments, and scrutinize available health and safety
evidence, as it evaluates whether and how to impose mandatory collaborative practice arrangements on physician
assistants.”). See generally Edward S. Sekscenski et al., State Practice Environments and the Supply of Physician
Assistants, Nurse Practitioners, and Certified Nurse-Midwives, 331 N. E NGL. J. M ED. 1266 (1994) (noting that
proposals to increase access to primary care often consider expanding the role of both APRNs and PAs); see also
IOM FUTURE OF N URSING REPORT, supra note 5, at 88, 97-98.
14 Medicare and Medicaid Programs; Hospital and Critical Access Hospital Changes To Promote Innovation,
Flexibility, and Improvement in Patient Care, 81 Fed. Reg. 39,448, 39,452 (proposed June 16, 2016) (to be codified
at 42 C.F.R. pt. 482, 485).
15 See Nat’l Governors Ass’n, The Role of Physician Assistants in Health Care Delivery (2014),
https://www.nga.org/files/live/sites/NGA/files/pdf/2014/1409TheRoleOfPhysicianAssistants.pdf; Kaiser Comm’n
on Medicaid and the Uninsured, Kaiser Family Found., Improving Access to Adult Primary Care in Medicaid:
Exploring the Potential Role of Nurse Practitioners and Physician Assistants (Mar. 2011),
https://kaiserfamilyfoundation.files.wordpress.com/2013/01/8167.pdf.
16 Am. Acad. of Physician Assistants, PA Education: Preparation for Excellence (Dec. 2016), https://www.aapa.org/
WorkArea/DownloadAsset.aspx?id=580.
17 Nat’l Governors Ass’n, supra note 15 (citing statistics and information from Primary Care Workforce Facts and
Stats No. 3., AGENCY FOR H EALTHCARE RESEARCH & Q UALITY (last updated Oct. 2014), http://www.ahrq.gov/
research/findings/factsheets/primary/pcwork3/index.html; Ctrs. for Medicare & Medicaid Servs., Rural Health
Clinic (Jan. 2016), https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/
MLNProducts/downloads/RuralHlthClinfctsht.pdf).
18 Nat’l Governors Ass’n, supra note 15, at 2 & nn. 6-7 (again citing statistics and information from AHRQ and
CMS); Kaiser Comm’n on Medicaid and the Uninsured, supra note 15, at 3 (noting that “NPs and PAs are more
likely than primary care physicians to practice in underserved areas and to care for large numbers of minority
patients, Medicaid beneficiaries, and uninsured patients” and noting “that these clinicians perform as well as
physicians on important clinical outcome measures” for primary care).
19 Employment Projections, Fastest Growing Occupations, B UREAU OF L ABOR STATISTICS (last updated Apr., 16,
2016), http://data.bls.gov/cgi-bin/print.pl/emp/ep_table_103.htm.
20 See Sarah Mann, AAMC Research Confirms Looming Physician Shortage, ASS’N OF AM . M ED. COLLS. (Sept. 27,
2016), https://news.aamc.org/medical-education/article/aamc-research-physician-shortage/ (AAMC summary based
on a 2016 update to a 2015 report by IHS Inc., Life Sciences Division, which AAMC commissioned). The AAMC
projects the U.S. “will face a shortage of between 61,700 and 94,700 physicians by 2025, with particularly large
shortfalls in certain surgical specialties.” By 2025, projected shortages for primary care physicians range from
14,900 to 35,600 and for surgeons, both general and specialty, from 25,200 to 33,200. The AAMC noted the
“primary factors driving demand are population growth and an increase in older Americans,” with the population
expected to grow by approximately 8.6 percent and the population of those over 65 years of age expected to increase
by 41 percent. Because those over 65 years of age “tend to require more specialized care than younger populations,
the shortage in certain specialties . . . will not keep pace with demand.” Id. Ass’n of Am. Med. Colls., Physician
Shortages to Worsen Without Increases in Residency Training (n.d.), https://www.aamc.org/download/150584/data/
physician_shortages_factsheet.pdf; B UREAU OF H EALTH P ROFESSIONS, H EALTH RESOURCES & SERVS. ADMIN., T HE
P HYSICIAN W ORKFORCE : P ROJECTIONS AND RESEARCH INTO CURRENT I SSUES A FFECTING SUPPLY AND D EMAND 70-
72, ex. 51-52 (2008), https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/physiciansupplyissues.pdf
(HRSA’s most recent workforce report on physician supply and demand, projecting increased shortages of both
primary care physicians and specialists).
21 Ass’n of Am. Med. Colls., Iowa Physician Workforce Profile (2015), https://www.aamc.org/download/447176/
data/iowaprofile.pdf.
22 Physician Assistants, Title IV, I OWA CODE §148C (2016) (includes reference to the 1988 Act establishing the
Board of Physician Assistants).

12
23 FTC staff have suggested that licensed professionals not be granted the authority to regulate those with whom
they compete. See, e.g., Comment to the Hon. Kent Leonhardt, supra note 12 (noting that “we strongly suggest that
it may be problematic to have independent regulatory boards dominated by medical doctors and doctors of
osteopathy serve as regulators of APRN prescribing”); Comment from FTC Staff to the Miss. State Representative
Mark Formby (Mar. 22, 2011), https://www.ftc.gov/sites/default/files/documents/advocacy_documents/ftc-staff-
letter-honorable-mark-formby-mississippi-house-representatives-concerning-mississippi/110322mississippipbm.pdf
(noting that because pharmacists and pharmacy benefit managers (PBMs) “have a competitive, and at times,
adversarial relationship, we are concerned that giving the pharmacy board regulatory power over PBMs may create
tensions and conflicts of interest for the pharmacy board,” may increase prescription drug prices and reduce
competition within the state, and that “the antitrust laws recognize that there is a real danger that regulatory boards
composed of market participants may pursue their own interests rather than those of the state”); N.C. State Bd. of
Dental Exam’rs v. FTC, 135 S. Ct. 1101 (2015). See also B UREAU OF H EALTH P ROFESSIONS, H EALTH RESOURCES
AND SERVICES ADMIN., THE P ROFESSIONAL P RACTICE E NVIRONMENT OF D ENTAL H YGIENISTS IN THE F IFTY STATES
AND THE D ISTRICT OF COLUMBIA, 2001, at 80-81 (2004), http://docplayer.net/13728482-The-professional-practice-
environment-of-dental-hygienists-in-the-fifty-states-and-the-district-of-columbia-2001-april-2004.html (“Dental
hygiene is idiosyncratic in that most health professions are self-regulated. Dental hygiene is largely under the
purview of dentistry. This is not true for similarly situated medical professionals who are principally self-
regulated”). See generally id. at 73 (noting “[t]he dental hygiene profession has progressed less quickly than most
other health professions. This is largely due to the regulation of the profession of dentistry, a condition that is
unusual in health regulation since most other professions are provided with autonomy in governing their
constituents.”).
24 I OWA CODE § 148C.3. Section 148C.3(6) also states that the PA Board “shall adopt rules pursuant to this section
after consultation with the board of medicine.”
25 I OWA ADMIN. CODE r. 645-326.1, Definitions.
26 r. 645-326.8(1)-(4), Supervision Requirements.
27 r. 645-326.8(4)c.(1), (2).
28 r. 645-327.1(1), Duties.
29 r. 645-327.4, Remote Medical Site. The PA at a remote site must have practiced for at least one year or if less than
one year, then the PA must have practiced for at least six months, worked with the supervising physician at the same
location for at least three months, and the supervising physician must review patient care at least weekly and sign all
patient charts unless there is documentation that the PA directly consulted with the physician for a specific patient.
Finally, there is an exception to these stringent requirements if a physician and PA provide a written statement to the
PA Board that the PA is qualified to provide the needed medical services and that the medical care will be
unavailable at the remote site unless the PA is allowed to practice there. The physician still must make weekly visits
and sign all charts unless direct consultation has occurred.
30 S.F. 505, 86th Gen. Assemb. 1st Session, div. XXXI, sec. 113 (Iowa 2015). This appears to be the only provision
in Iowa law addressing directly the authority of the BOM to adopt rules concerning PAs, as opposed to
disqualification or discipline of MDs related to PA supervision.
31 38 Iowa Admin. Bull. 1415 (Jan. 20, 2016) (BOM’s originally proposed rule, ARC 2372C ); 38 Iowa Admin.
Bull. 1521 (Feb. 17, 2016) (PA Board’s originally proposed rule, ARC 2417C).
32 38 Iowa Admin. Bull. 2169 (May 11, 2016) (PA’s proposed amended rule, ARC 2531C); 38 Iowa Admin. Bull.
2190 (May 11, 2016) (BOM’s adopted amended rule, ARC 2532C). It is unclear whether the BOM took into
account additional public comments on the amended rule.
33 See Iowa Board of Medicine website page (stating the rule becomes effective June 15, 2016). Iowa Code, Rules,
Policy, I OWA B D. OF M ED., http://medicalboard.iowa.gov/iowa_code/index.html; Press Release, Iowa Bd. of Med.,
New Rule Establishes Minimum Standards for Supervision of Physician Assistants (Aug. 18, 2016),
http://medicalboard.iowa.gov/Board%20News/2016/Press%20release%20-%20New%20rule%20establishes%20
minimum%20standards%20for%20supervision%20of%20physician%20assistants%20-%20August%2018%20
2016.pdf (stating the rule is effective).

13
34 See Iowa Bd. of Med., Teleconference Meeting Open Minutes (Apr. 15, 2016), http://medicalboard.iowa.gov/
Minutes/2016/PubMin%204-15-16%20Tele.pdf.pdf (adopting rule and suggesting it would be effective on June 15,
2016, “presuming the Board of Physician Assistants follows suit”).
35 38 Iowa Admin. Bull. 2162 (May 11, 2016) (Notice of PA Board’s June 3, 2016, Public Hearing on ARC 2531C).
The additional board meetings took place on July 20, 2016 and October 19, 2016. The Proposed Rule was suggested
at the PA Board meeting on October 19, 2016. The PA Board thereafter drafted the Proposed Rule, and voted to
issue this proposal for public comment via a November 15, 2016 teleconference.
36 ARC 2832C, Amended Notice of Intended Action, supra note 1.
37 Id.
38 Id.
39 For example, licensure requirements or scope-of-practice restrictions may sometimes offer an efficient response to
certain types of market failure arising in professional services markets. See C AROLYN COX & SUSAN F OSTER , FED.
T RADE COMM ’N, T HE COSTS AND B ENEFITS OF O CCUPATIONAL REGULATION 5–6 (1990), https://www.ftc.gov/
system/files/documents/reports/costs-benefits-occupational-regulation/cox_foster_-_occupational_licensing.pdf.
40 See, e.g., Comment to the Hon. Jeanne Kirkton, supra note 12, at 5 n.11(encouraging the Missouri “legislature to
consider our comments, and scrutinize available health and safety evidence, as it evaluates whether and how to
impose mandatory collaborative practice arrangements on physician assistants”). See also discussion of FTC
comments supra at notes 12 and 13 and accompanying text.
41 See, e.g., CHRISTINE E. E IBNER ET AL., RAND, CONTROLLING H EALTH C ARE SPENDING IN M ASSACHUSETTS: AN
ANALYSIS OF O PTIONS 103-104 (2009), http://www.rand.org/content/dam/rand/pubs/technical_reports/2009/
RAND_TR733.pdf (suggesting concrete savings that might be associated with expanded APRN and PA scope of
practice, due to the lower costs and prices that tend to be associated with services delivered by PAs and APRNs:
“between 2010 and 2020, Massachusetts could save $4.2 to $8.4 billion through greater reliance on NPs and PAs in
the delivery of primary care”); Edward J. Timmons, Healthcare License Turf Wars: The Effects of Expanded Nurse
Practitioner and Physician Assistant Scope of Practice on Medicaid Patient Access 17-18 (Mercatus Working
Paper, 2016) https://www.mercatus.org/system/files/Timmons-Scope-of-Practice-v2.pdf (finding broader scope of
practice for PAs is correlated with less expensive “outpatient care (an 11.8 to 14.4 percent reduction, depending on
specification) without negatively affecting access to health care” . . . and that the “results of this paper, combined
with findings of other researchers, suggest that broader scope of practice for NPs and PAs has little effect on the
quality of care delivered, increases access to health care, and also potentially reduces the costs of providing health
care to patients.”); Morris M. Kleiner, et al., Relaxing Occupation Licensing Requirements: Analyzing Wages and
Prices for a Medical Service, 59 J. L. & E CON. 261, 286 (2016) (study of the costs associated with regulation of
APRNs, finding “more rigid regulations increase the price of a well-child visit by 3-16 percent” but found no impact
on infant mortality or malpractice claims, suggesting relaxing regulations was unlikely to have adverse medical
outcomes).
42 See Barriers to Entrepreneurship: Examining the Anti-Trust Implications of Occupational Licensing: Hearing
Before the H. Comm. on Small Bus., 113th Cong. 1–3 (2014) (statement of Fed. Trade Comm’n on Competition and
the Potential Costs and Benefits of Professional Licensure), https://www.ftc.gov/public-statements/2014/07/
prepared-statement-federal-trade-commission-competition-potential-costs; Comment to the Hon. Jeanne Kirkton,
supra note 12, at 5 n.11; Comment to the VA, supra note 12, at 2. It is unclear what, if any, health and safety
concerns that ARC 2532C, the BOM’s adopted rule, would address.
43 It is our understanding that because the PA Board is proposing a regulation that differs from the one adopted by
the BOM, the two Boards must reconcile their differences and adopt parallel rules to comply with the statutory
mandate. See discussion of legislative and regulatory background, supra at Section II.B.
44 I OWA CODE § 148C.3, Licensure (2016); I OWA ADMIN. CODE r. 645-326.8 (148C), Supervision Requirements
(2016). See also discussion of legislative and regulatory background, supra at Section II.B.
45 See FTC Staff, Policy Perspectives, supra note 12, at 37.

14
46 Current Iowa statutes and regulations appear to permit such flexibility. Importantly, we are not aware of any
studies or other evidence that would lead to concerns with how the current supervision requirements are being
implemented, or the quality and safety of health care services delivered to patients by supervised PAs.
47 Compare ARC 2532C, 653-21.4(1) Definitions with, I OWA ADMIN. CODE r. 645-326.1. Definitions.
48 ARC 2532C, 653-21.4 (2), Minimum Standards, 653-21.4(2)b. Face-To-Face Meetings; and 653-21.4(2)e. Chart
Reviews.
49 Compare ARC 2532C, 653-21.4, Specific Minimum Standards for Appropriate Supervision of a Physician
Assistant by a Physician with, I OWA ADMIN. CODE r. 645-326.8 (specifying supervision requirements); ARC 2532C,
653-21.4(2)a. Review of Requirements with, I OWA ADMIN. CODE r. 645-326.8(4) (PA and supervising physician are
each responsible for knowing and complying with the supervision provisions of these rules); ARC 2532C, 653-
21.4(2)c. Assessment of Education, Training, Skills, And Experience with, I OWA ADMIN. CODE r. 645-327.1 Duties
and 327.1(1) (the supervising physician must have sufficient training or experience with the delegated tasks and
must determine the PA’s proficiency and competence); ARC 2532C, 653-21.4(2) d. Communication, g. Timely
Consultation, and h. Alternate Supervision, with, I OWA ADMIN. CODE r. 645-326.8(4), 645-326.8(4)a. and b.(PA
cannot practice if supervision is unavailable and supervisor and PA must review patient care on an ongoing basis as
indicated by the clinical condition of the patient, which can occur in person, by telephone or by other
telecommunicative means); ARC 2532C, 653-21.4(3), Amendment with, I OWA CODE § 148C.3.1. (specifying only
that the PA “board shall adopt rules to govern the licensure of physician assistants”); and ARC 2532C, 653-21.4(4)
Joint Waiver or Variance with, I OWA ADMIN. C ODE r. 645-327.4(1)c. and 327.4(2) (specifying when the PA Board
may permit variances with respect to care provided at a remote site). But cf. ARC 2532C, 653-21.4(2)f., Delegated
Services, which expressly incorporates by reference one of the PA Board’s existing regulations (stating in part: “The
medical services and medical tasks delegated to and provided by the physician assistant shall be in compliance with
645—subrule 327.1(1).”).
50 See, e.g., Comments from Faculty of the Dept. of Physician Assistant Studies & Services, Carver College of
Medicine, University of Iowa to the Iowa Bd. of Physician Assistants (Jan. 19, 2016; April 20, 2016) (explaining
that University of Iowa Health Care (“UIHC”) has “a pre-existing chart review QI in place in each department for all
providers (physicians, PA’s, ARNP’s, etc.) . . . but that system would not meet the chart review requirements of the
proposed rule, so supervising physicians would have to specifically add more chart review time to go over PA
charts”). See also public comments referenced, infra, at note 54; Comment from Libby Coyte, PA, former chair,
lowa Bd. of Physician Assistants and former member, Iowa Bd. of Med. to lowa Bd. of Physician Assistants (Mar.
8, 2016) (noting “rules 327.8(b-J) are restatements of what is already in the PA rules but are more restrictive and
vary enough to be confusing to licensees”); Nat’l Governors Ass’n, supra note 15, at 11 (noting state policy should
consider whether “[u]nclear statutes or regulations may inadvertently limit PAs’ ability to participate in innovations”
and that “[o]verly strict statutes or regulations may interfere with physicians’ ability to delegate tasks to PAs”).
51 ARC 2532C states:
At least one supervising physician shall meet face-to-face with each physician assistant a
minimum of twice annually. If the physician assistant is practicing at a remote site, both meetings
shall be at the remote site. Each party shall ensure that the face-to-face meetings are documented.
The meetings are for the purpose of discussing topics deemed appropriate by the physician or the
physician assistant, including supervision requirements, assessment of education, training, skills,
and experience, review of delegated services, and medical services provided by the physician
assistant.
52 See, e.g., American Academy of PAs, Iowa PA Practice Profile (2015), https://www.aapa.org/WorkArea/
DownloadAsset.aspx?id=1610 (approximately 64% of PAs are employed by a physician group or solo practice,
26.4% practice in hospital settings, and 41.1% practice in rural areas); Comments from Paul A. James, MD, Chair,
Dept. of Family Medicine, Carver College of Medicine, University of Iowa to the Iowa Bd. of Medicine (Mar. 9,
2016) (stating the proposed minimum standards are not necessary and noting that at the Family Medicine Clinic at
the University of lowa Hospitals and Clinics there are over 20 supervising physicians for two highly trained PAs,
who “are under the direct observation of physicians every day, seeking guidance or reassurance in the course of
caring for patients”).

15
53 See, e.g., Comment from American Academy of PAs to Bd. of Physician Assistants (June 2, 2016) (public
comment on ARC 2531C) (noting economic impact analysis conducted jointly with the Iowa Society of Physician
Assistants estimates a $2.9 million burden on Iowa’s healthcare system and a loss of approximately 44,500 patient
encounters).
54 See, e.g., Comments from Faculty of the Dept. of Physician Assistant Studies & Services, supra note 50 (UIHC
estimated that the originally proposed rules would have cost UIHC $502,200 for the 75 PAs it employs; its updated
cost estimate to implement ARC 2532C projected $315,000 in additional costs per year); Iowa Bd. of Physician
Assistants, Jobs Impact Analysis: ARC 2417C (Mar. 3, 2016) (although the Job Impact Analysis conclusions were
based on the original rule, there were 84 comments from PAs, physicians, and hospitals in response to the survey,
many of which raised concerns about what perceived need was being addressed by the proposed rules and how or
whether existing review systems would meet the requirements of the proposed rules. For example, one hospital
(comment No. 76) noted “Because our mid-levels work side-by-side with our physicians their work is being
evaluated on an on-going basis. Additional formal chart review beyond the chart review we already provide would
essentially [be] an exercise in pushing additional paper around in order to meet requirement and would not improve
quality.”). ARC 2532C also does not appear to contemplate any flexibility to the requirement for face-to-face
meetings based on the PA’s experience and training, how long the PA and physician have worked together, diverse
circumstances and clinical needs, new models of consultation and supervision, or new technologies or institutional
resources.
55 I OWA ADMIN. CODE r. 645-327.4(2).
56 Press Release, Iowa Bd. of Med., supra note 33.
57 See discussion infra at notes 58-63 and accompanying text (discussing the costs associated with such face-to-face
meeting requirements, the fact that many states and CMS do not have such requirements, and the potential use of
telehealth or other innovations in health care delivery that might be stymied by such requirements). Increasingly,
telehealth is being used successfully to facilitate supervision and collaboration among health care providers, as well
as for the direct provision of health care services. See, e.g., Comment from FTC Staff to the Delaware Bd. of
Occupational Therapy Practice (Aug. 3, 2016), https://www.ftc.gov/system/files/documents/advocacy_documents/
ftc-staff-comment-delaware-board-occupational-therapy-concerning-its-proposed-telehealth-regulation/
v160014_delaware_ot_proposed_advocacy.pdf (noting proposed telehealth regulation would likely enhance
competition and improve access to occupational therapy services by “not imposing rigid and unwarranted in-person
care and supervision requirements”); Brian J. Miller, et al., Commentary, Telemedicine and the Sharing Economy:
The “Uber” for Healthcare, 22 AM . J. M ANAGED C ARE , Dec. 2016, at 294, 295 (noting that telehealth platforms can
“expand access to general medical services by reaching out to consumers in underserved areas and providing access
to highly specialized consult services . . . [and] that physicians have successfully practiced telemedicine for over 100
years by using the telephone to conduct physician-to-physician consults, diagnose and treat patients, prescribe
medications, and order diagnostic tests”).
58 Am. Acad. of Physician Assistants, Six Key Elements of a Modern PA Practice Act (Oct. 26, 2016),
https://www.aapa.org/WorkArea/DownloadAsset.aspx?id=799 (chart of status for all states and the District of
Columbia). South Dakota became the 28 th state (29 th including DC) when its Board of Medical and Osteopathic
Examiners (“SDBOME”) repealed its remote site visit requirement in September 2016. S.D. Bd. of Med. &
Osteopathic Examiners, Notice of New Rules (Sept. 2016), http://www.sdbmoe.gov/sites/default/files/
Notice%20of%20New%20Rules.pdf (SDBOME explained changes to its regulations concerning PAs, noting they
removed the requirement that a supervising physician must visit each PA practice location every 90 days; eliminated
the required in-person meeting as a condition of the supervision agreement; and allow the Physician/PA team to
determine the best supervision arrangement).
59 Medicare and Medicaid Programs; Regulatory Provisions To Promote Program Efficiency, Transparency, and
Burden Reduction; Part II, Final Rule, 79 Fed. Reg. 27,106, 27,131 (May 12, 2014) (to be codified at 42 CFR pt.
413, 416, 440, 442, 482, 483, 485, 486, 491, 493), https://www.gpo.gov/fdsys/pkg/FR-2014-05-12/pdf/2014-
10687.pdf [hereinafter CMS 2014 Burden Reduction].
60 CMS 2014 Burden Reduction, supra note 59, at 27,131.
61 Id. at 27,150 (CMS estimated a total annual savings of $75,639,190 million by eliminating face-to-face visits and
specified chart reviews for CAHs, RHCs, and FQHCs).

16
62 See, e.g., Id. at 27,131 & 27,149-50 (discussing both out-of-pocket costs and loss of patient encounters resulting
from inflexible face-to-face meeting requirements); Comment from Nancy Bucklew, President, lowa Ass’n of Rural
Health Clinics to Bd. of Physician Assistants (Mar. 9, 2016) (“requiring face to face meetings prevents RHCs from
fully utilizing our PAs for tele-emergency and tele-psychiatry to the detriment of our patients”).
63 See, e.g., Comment from FTC Staff to the Delaware Board of Speech/Language Pathologists, Audiologists and
Hearing Aid Dispensers (Nov. 29, 2016), https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-
staff-comment-delaware-board-speech/language-pathologists-audiologists-hearing-aid-dispensers-regarding-its-
proposed-revisions-its/161130_ftc_dealers_final_.pdf (commenting positively on the board’s proposal “to remove
existing restrictions on service by telecommunication and allow licensees to determine whether telepractice is an
appropriate level of care, . . . which could enhance consumer choice by providing an alternative to in-person care,
potentially reducing travel expenditures, increasing access to care, and increasing competition, as well as suggesting
additional procompetitive steps the board might consider); Comment from FTC Staff to the Del. Bd. of
Dietetics/Nutrition (Aug. 16, 2016), https://www.ftc.gov/system/files/documents/advocacy_documents/ftc-staff-
comment-delaware-board-dietetics/nutrition-regarding-its-proposed-telehealth-regulation/staff_comment_
delaware_diet_telehealth_signed.pdf (same, but noting the proposed rules would limit flexibility by requiring all
initial evaluations to be performed face-to-face and not through telehealth); Comment from FTC Staff to Steve
Thompson, Representative, Alaska State Legislature (Mar. 25, 2016), https://www.ftc.gov/system/files/documents/
advocacy_documents/ftc-staff-comment-alaska-state-legislature-regarding-telehealth-provisions-senate-bill-74-
which/160328alaskatelehealthcomment.pdf (noting telehealth provisions that eliminate the in-state requirement for
Alaska-licensed physicians appear to be a procompetitive improvement in the law and likely would expand the
supply of telehealth providers, promote competition, and increase access to safe and cost-effective care, as well as
reduce transportation costs for Alaska patients and providers).
64 I OWA ADMIN. CODE r. 645-327.4 b(4).
65 Am. Acad. of Physician Assistants, supra note 58.
66 CMS 2014 Burden Reduction, supra note 59, at 27,131. See also id. at 27,133 (CMS noted if “the applicable State
law does not require a record review or cosignature, or both, by a collaborating physician, then CMS does not
require such periodic record review” and that there is no CMS “regulatory requirement for the review of records to
be performed onsite and in person”).
67 See discussion supra at notes 50 and 54 and accompanying text.
68 See UIHC Comment and other public comments discussed supra at notes 53 and 54 and accompanying text.