Our respective associations, which together represent tens of thousands of physicians across the state of New York providing care to hundreds of thousands of patients each year, respectfully request the removal of a proposal in Subpart E of Part N of the Executive Budget Health & Mental Hygiene Budget bill (A.10007/S.9007) that would expand the authority of many physician assistants (PAs) to deliver care without the oversight and collaboration of a physician. We thank the State Legislature for rejecting similar proposals in previous years’ State Budgets, and ask you do so again.

PAs are undoubtedly an essential source of care delivery within our health care delivery system. However, we are very concerned that patients will be adversely impacted by completely removing the important oversight and coordination role which a trained physician plays in overseeing a patient’s care, particularly as it relates to the ordering of diagnostic tests, the evaluation of the effectiveness of various prescription medications and treatments and the ongoing assessment of the patient’s response to treatment. All of these oversight functions are essential safeguards in assuring that lesser trained professionals do not overlook important elements of the patient’s unique circumstances.

To address gaps in access to care, we believe that policymakers should begin by focusing on affirmative steps that can be taken to address the shortage of specialized physicians in various regions of the state. As a result of our challenging practice environment, New York continues to maintain the dubious distinction as one of the worst states in the country to be a doctor. This is the result of New York’s exorbitant liability costs, low Medicaid and other payor reimbursement, pervasive insurer hassles, and high overhead costs. This fundamentally impacts our ability to attract new physicians to New York State, and to retain the thousands we train each year.

Rather than exposing patients to diminished quality of care by expanding scope for various non-physicians, policymakers must work to improve New York’s practice environment by expanding medical student loan repayment opportunities and addressing the overwhelming administrative burden on medical care delivery such as reducing excessive prior authorization and data reporting requirements which has led directly to physicians retiring early due to “burnout” or relocating to other states. Making matters worse are the plethora of other Executive Budget proposals advanced this year that seek to balance the State Budget on the backs of New York’s dedicated physicians (including steep new costs for obtaining Excess Malpractice Insurance Coverage, and greatly diminished physicians rights in the State’s Independent Dispute Resolution system) that will adversely impact physician care delivery and make it harder to retain their services in New York State. Improving the practice environment, not worsening it, will help to keep physicians in New York instead of losing them to other states with better practice climates.

Expanding scopes of practice will not be the panacea some assert. Multiple studies show that when non-physicians are permitted to practice independently, this difference in training presents patient safety risks and increases health care costs. One study looking at 10 years of cost data on 33,000 patients by a South Mississippi accountable care organization (ACO) (ama-assn.org) found that care provided to patients exclusively by non-physicians (PAs and NPs) was much more expensive than the care delivered by physicians. This is because these non-physician providers ordered more tests and referred more patients to specialists and hospital emergency departments than physicians did. Unnecessary tests and referrals delay care and create stress for patients. The care provided by non-physicians was also determined to have lower quality rankings. Moreover, another study (ama-assn.org)) reported that NPs delivering emergency care without physician supervision or collaboration in the Veterans Health Administration (VHA) increase lengths of stay by 11% and raise 30-day preventable hospitalizations by 20% compared with emergency physicians.

Nor does scope of practice expansion actually translate to expanded access to primary care. Particularly noteworthy is a new study from Florida showing that NPs statutorily permitted to practice without physician supervision if practicing in the areas of family medicine, general pediatrics, or general internal medicine, were actually regularly practicing outside of these primary care areas. PubMed

It is impossible to state the importance of a physician’s comprehensive education and training to ensure quality patient care. Most physicians must complete 4 years of medical school plus 3-7 years of residency and fellowships, including 10,000-16,000 hours of clinical training before they are permitted to treat patients independently. Various milestones must be met as part of this training to help these young physicians learn to differentiate among the many possible diagnoses for any possible patient condition. This training is unlike any other healthcare provider. This extensive training makes physicians best suited to deliver, oversee and coordinate needed primary and specialized patient care. This role cannot be replaced by a non-physician without adverse consequences to patients and unnecessarily higher costs.

Surveys on patient sentiment report that 95% of patients believe it is important that a physician be involved with their diagnosis and treatment decisions, and that 91% say that a physician’s education and training are vital for optimal care.

Moreover, we note that last February the State Legislature and Governor implemented legislation enacted in 2024 to expand regulatory flexibility for PAs and to increase the services they could provide and coordinate, including ordering for durable medical equipment and collaborating with nurses on various standing order for patient treatment in hospitals. This newly enacted law must be evaluated for its effectiveness and its impact on patient safety before enacting more expansive measures that further removes the important oversight provided by physicians. Indeed, any measure to expand scope must be time-limited in duration and its further extension conditioned on the meeting of defined specific goals of expanding access to care.

We welcome a thoughtful discussion of individual measures that would help to address gaps in patient care across the State. However, we will not in a meaningful way address the gaps in access to care we face until measures are adopted to make New York’s practice environment more welcoming for physicians and other care providers.

In summary, this proposal will reduce patient safety by removing the essential coordination and oversight provided by physicians to ensure the delivery of quality patient care. We thank you for your past opposition and urge you to again oppose these provisions.