Physician assistant (PA) supervision requirements are one of the most rapidly evolving areas of healthcare regulation. Over the past five years, a growing number of states have moved away from traditional supervision models toward collaborative and independent practice frameworks. For healthcare businesses employing PAs across multiple states, keeping up with these changes is essential to maintaining compliance and optimizing your care delivery model.
The Three Major Practice Models
PA practice authority generally falls into one of three categories, though the specific rules within each category vary significantly from state to state.
1. Supervisory Agreement States
In these states, PAs must practice under the direct supervision of a licensed physician. The physician must be available for consultation, chart review, and in some cases, must be physically present in the same facility during a certain percentage of practice hours.
- The supervising physician is legally responsible for the PA's clinical work
- Written supervision agreements must be filed with the state medical board
- Physician-to-PA ratios are often limited (commonly 2:1 to 4:1)
- Chart review requirements may mandate the physician review a percentage of patient encounters
2. Collaborative Agreement States
Collaborative agreement states require PAs to maintain a formal relationship with a collaborating physician, but the arrangement is less restrictive than traditional supervision. The physician does not need to be on-site, and the PA generally has more autonomy in clinical decision-making.
- The collaborative agreement outlines the scope of practice and consultation protocols
- The collaborating physician is available by phone or teleconference rather than on-site
- Chart review requirements are typically less frequent
- Some states allow collaborative relationships to be established at the practice level rather than individually
3. Optimal Team Practice (OTP) States
The American Academy of Physician Associates (AAPA) has championed the Optimal Team Practice model, which eliminates the requirement for a formal supervisory or collaborative agreement. Instead, PAs practice as members of a healthcare team with a collaborative relationship that does not require a specific written agreement with a designated physician.
As of 2025, more than a dozen states have adopted some form of Optimal Team Practice, and several more have legislation pending. This represents the most significant shift in PA practice authority in decades.
State-by-State Highlights
The following overview covers notable states and their current approach to PA supervision. This is not exhaustive, and you should always verify current regulations with each state's licensing board before making operational decisions.
States with Full Practice Authority or OTP
- North Dakota was among the first states to grant PAs full independent practice authority with no required supervisory agreement
- Wyoming allows PAs to practice without a collaborative agreement after meeting experience thresholds
- Utah adopted OTP legislation allowing PAs to practice without a designated supervising physician
- Indiana moved to a collaborative practice model that closely mirrors OTP principles
States with Collaborative Agreement Requirements
- California transitioned from a supervision model to a collaborative agreement model under AB 890 for nurse practitioners, and has modernized PA practice authority through subsequent legislation
- New York requires a written collaborative agreement and maintains specific protocols for prescriptive authority
- Illinois requires a collaborative agreement but has expanded PA prescriptive authority significantly
States with Traditional Supervision
- Texas maintains a physician supervision requirement with specific delegation protocols
- Georgia requires a job description agreement and limits the physician-to-PA ratio
- Ohio requires a supervision agreement and has specific rules about on-site physician availability
Recent Legislative Changes
The trend toward expanded PA practice authority has accelerated, particularly since the COVID-19 pandemic demonstrated that PAs can safely deliver a wide range of services with greater autonomy. Several notable legislative changes have occurred in 2024 and 2025:
- Multiple states have reduced or eliminated physician-to-PA ratios, recognizing that rigid ratios do not reflect the realities of modern team-based care
- Prescriptive authority expansion continues, with more states allowing PAs to prescribe Schedule II controlled substances independently
- Telehealth provisions have been updated in many states to clarify that supervisory or collaborative relationships can be maintained remotely
- Interstate compacts are being explored to allow PAs licensed in one state to practice in others under similar rules
What This Means for Healthcare Businesses
For healthcare companies employing PAs across multiple states, these varying requirements create significant operational complexity. Each state where you operate may require a different type of agreement, a different physician-to-PA ratio, and different documentation.
Key operational considerations include:
- Collaborating physician coverage: You need licensed physicians available in every state where your PAs practice, even if those physicians are not providing direct patient care
- Agreement management: Supervisory and collaborative agreements must be kept current and filed with the appropriate state boards
- Scope of practice alignment: Your clinical protocols must reflect the specific scope of practice allowed for PAs in each state
- Credentialing and privileging: Each facility and insurance panel has its own requirements for PA credentialing that must align with state law
Staying current with PA supervision requirements is not a one-time exercise. The regulatory landscape is changing year over year, and healthcare businesses must have systems in place to monitor legislative developments and update their compliance programs accordingly. Foundry PC tracks these changes across all 50 states and can help ensure your PA practice agreements remain compliant as the law evolves.