No state currently allows physician assistants to practice with the same level of independence that some states grant nurse practitioners. Every state requires PAs to maintain some form of legal relationship with a physician, though how much oversight that actually involves varies enormously. A handful of states have recently moved toward what the PA profession calls “optimal team practice,” which removes many traditional supervision requirements and gives PAs far more day-to-day autonomy.
The landscape is shifting fast. Several states have passed major scope-of-practice reforms since 2020, and the terminology can be confusing. Here’s what the different levels of PA practice authority actually look like and which states offer the most autonomy.
Why “Independent Practice” Is Misleading for PAs
When people search for PA independent practice, they’re usually thinking of the model available to nurse practitioners in about half the country: hanging your own shingle, seeing patients, prescribing medications, and billing insurance without any required physician relationship. That model does not exist for PAs in any state. Even the most permissive states still require PAs to have a defined relationship with a physician or physician-led entity, though that relationship may involve very little direct oversight in practice.
The American Academy of PAs has pushed for what it calls “optimal team practice,” or OTP. Under OTP, PAs work collaboratively with physicians but without a formal supervisory agreement, mandatory chart reviews, or restrictions on the number of PAs a physician can oversee. It’s not full independence, but it’s a significant step away from the traditional model where a specific physician must sign off on a PA’s work.
States With the Most PA Autonomy
North Dakota became one of the first states to dramatically expand PA autonomy when it passed legislation allowing experienced PAs to practice without a traditional collaborative agreement. Wyoming similarly defines supervision loosely: a physician needs to be available for consultation, but contact by phone or other telecommunications counts as adequate availability. The physician doesn’t need to be on-site or review every decision.
Other states that have adopted OTP-style frameworks or significantly reduced oversight requirements include Utah, which removed its collaborative agreement mandate, and Connecticut, which shifted from a supervisory to a collaborative model. South Dakota, Indiana, and West Virginia have also modernized their PA practice laws in recent years. In West Virginia, “collaboration” is defined as overseeing PA activities and accepting responsibility for their medical services, but this doesn’t require the physician to be physically present or approve individual clinical decisions.
The common thread in these states is that PAs can evaluate patients, diagnose conditions, develop treatment plans, and prescribe medications with substantial clinical freedom. The physician relationship functions more like a safety net than a chain of command.
How Supervision Differs From Collaboration
State laws generally fall into two categories: supervision and collaboration. The practical difference matters more than it might sound.
In supervision states (the majority), a designated physician is responsible for directing and controlling the PA’s clinical activities. In Iowa, for example, the supervising physician “retains ultimate responsibility for patient care,” though the physician doesn’t need to be physically present for each task. Louisiana defines it as “responsible direction and control.” Oklahoma requires the supervising physician to oversee and accept responsibility for the PA’s medical services. These states may also cap how many PAs a single physician can supervise or require periodic chart reviews.
Collaboration states use softer language. Illinois, for instance, specifies that collaboration “shall not be construed to necessarily require the personal presence of the collaborating physician” as long as the PA can reach them by phone or electronically. Alaska requires at least monthly contact between the PA and collaborating physician to review performance, patient care, and health records. In practice, a PA in a collaboration state might go weeks working autonomously, touching base with their collaborating physician periodically rather than getting approval for day-to-day decisions.
Prescribing Authority by State
Prescribing power is often the biggest concern for PAs looking at practice authority, since it directly affects what patients you can treat. Forty-four states and Washington, D.C. authorize PAs to prescribe controlled substances in schedules II through V, which covers everything from opioid painkillers and stimulants to lower-risk medications like certain anti-anxiety drugs and cough suppressants. Five states limit PAs to schedules III through V, excluding the most tightly controlled substances. Kentucky stands alone as the only state where PAs cannot prescribe controlled medications at all.
Even in states with broad prescribing authority, some require a physician co-signature for certain controlled substances or limit the quantity that can be prescribed at one time. The specifics vary enough that PAs relocating to a new state should check their state medical board’s current rules before assuming their prescribing scope carries over.
What’s Driving the Push for More Autonomy
Rural healthcare access is the engine behind most of these legislative changes. When a community has one physician and three PAs, requiring that physician to personally review every chart or co-sign every prescription creates bottlenecks that delay patient care. States with large rural populations have generally moved faster to loosen PA oversight requirements.
The COVID-19 pandemic also accelerated changes. Several states issued emergency orders expanding PA practice authority during the public health emergency, and some later made those expansions permanent. The logic was straightforward: if PAs could safely practice with reduced oversight during a crisis, the oversight requirements may have been unnecessarily restrictive to begin with.
The American Medical Association has pushed back against these expansions, maintaining that PAs should function under the direction and supervision of physicians. The AMA’s position is that this protects patient safety and ensures appropriate clinical oversight. PA advocacy groups counter that decades of outcomes data show PAs deliver safe, effective care and that outdated supervision laws primarily create administrative burdens rather than meaningful quality checks.
How to Check Your State’s Current Rules
PA practice authority is a moving target. Multiple states introduce or pass new legislation each year, and what was accurate two years ago may already be outdated. Your most reliable source is your state medical board’s website, which will list current statutes and regulations governing PA practice. The American Academy of PAs also maintains a state-by-state advocacy tracker that shows where legislation is pending or recently passed.
If you’re a PA considering relocation or a student choosing where to practice, look beyond the label of “supervision” or “collaboration.” Check the details: How many PAs can one physician oversee? Are chart reviews required, and how often? Can you prescribe schedule II substances? Is the physician required to be on-site, or is phone availability enough? These specifics shape your daily practice far more than the broad category your state falls into.