Missouri tried to fix its doctor shortage. Now the fix may need fixing.

Missouri state Rep. Tricia Derges is pushing a bill to give assistant physicians like herself a pathway to becoming fully licensed doctors in the state.

Not that Derges — among the highest-profile holders of the assistant physician license created in 2014 to ease a doctor shortage — is the most persuasive advocate right now.

Derges was indicted last year on charges accusing her of selling fake stem-cell treatments, illegally prescribing drugs, and fraudulently receiving covid relief funds. Derges, who did not respond to multiple messages sent to her and her lawyer, has pleaded not guilty. But she has already been kicked out of the Republican caucus, forced to move her legislative office into a Statehouse broom closet, put on a three-year probation for her narcotics license, and denied the ability to run for reelection as a Republican following her indictment. A trial is set for June.

Her personal tribulations have jeopardized an already contentious solution for states that struggle with gaps in primary healthcare. Even some early proponents now want to rein in the assistant physician license.

Assistant physicians — sometimes called associate physicians, and not to be confused with physician assistants — are medical school graduates who have not yet completed residency training. Similar licenses also now exist in Arizona, Arkansas, Kansas, and Utah. Virginia is considering adding one, and model legislation is making such licenses easier than ever for other state legislatures to adopt.

Derges’ proposed legislation would allow assistant physicians to become licensed — similar to doctors who have completed a residency — provided an assistant physician has practiced for five years with a collaborating physician, passed a licensure exam, and completed certain training requirements.

Her bill would create a new path for training physicians. Competing legislation aims to scale back the license, though, and cap the number of years assistant physicians can practice until they funnel back into residency programs.

Dr. Keith Frederick, a former state representative and orthopedic surgeon from Rolla, Missouri, proposed the original assistant physician legislation, the first of its kind in the nation.

Nearly every county in Missouri is short of primary care providers, according to the federal Health Services and Resources Administration. It’d take nearly 500 physicians to fill that void, but efforts to get doctors to practice in underserved areas have been “chronically unsuccessful,” Frederick said. At the same time, thousands of medical school graduates who apply for residency programs each year are not accepted — 9,155 applicants did not match to a program in 2021 alone, or about 1 in 5 of the candidates, most coming from international medical schools.

The assistant physician license allows those medical school graduates to practice medicine in Missouri under a collaborative practice agreement with a physician, who is ultimately responsible for the care given, and on the condition that they do so in an underserved area. They can see patients, prescribe drugs, and provide certain treatments, in much the same way as nurse practitioners or physician assistants — so-called midlevel practitioners, both of which have distinct master’s-level training.

Frederick’s bill passed the same year it was introduced, a legislative feat he described as “pretty remarkable.”

The idea did have its detractors at the time. Chief among them was the Missouri Nurses Association, which argued the state’s 12,000 nurse practitioners were better suited to address primary care shortages. The association views the state’s rules for nurse practitioners as among “the most severely restrictive in the nation.”

Nationally, the American Medical Association, American Academy of Family Physicians, and Accreditation Council for Graduate Medical Education also opposed the license.

One initial supporter of the idea was Dr. Jeff Davis, chief medical officer for Scotland County Hospital in rural Memphis, Missouri, and an executive committee member of the Missouri Association of Osteopathic Physicians and Surgeons. Eight years after the law passed, however, Davis has no assistant physicians working with him, even though he said he has several openings that would benefit from them.

The challenge, Davis said, is Medicare will not reimburse for care provided by assistant physicians. Hospitals in rural areas often depend on revenue from that public insurance program for Americans 65 and older. But for hospitals to get paid by Medicare for the work of an assistant physician, Davis said, the assistant physician would have to work under the direct supervision of a physician whose name would be used to submit the bill.

“That doesn’t make much business sense,” Davis said.

Frederick hopes that having more states create an assistant physician license will force the hand of the Centers for Medicare & Medicaid Services to start reimbursing for the work done by those clinicians. The American Legislative Exchange Council adopted model associate physician legislation after Frederick presented the idea at the conservative nonprofit’s summit last year.

Currently, Missouri has 348 active licenses for assistant physicians, including Dr. Trevor Cook, creator of the Association of Medical Doctor Assistant Physicians. Cook graduated in 2014 from the International American University medical school on the Caribbean island of St. Lucia.

“Unfortunately, I was one of those many, many, many, many thousands of doctors that don’t match each year” into a residency program, Cook said.

Cook has practiced at Downtown Urgent Care in St. Louis since 2018, a position he called rewarding. He is supportive of a pathway for assistant physicians to become fully licensed in Missouri, like the one proposed by Derges. As to the indictment, Cook said, one person’s actions are not representative of an entire group of practitioners.

A review of active assistant physician licenses in the state — including Derges’ — found none under current disciplinary action. Two were previously under probation due to prior behavior.

Still, state doctor groups that initially supported the idea now want to cap the number of years someone can hold an assistant physician license, as other states have done. Under current Missouri law, assistant physicians can practice indefinitely.

“As with anything, you find out that people try to game the system and work an angle and get something that wasn’t intended out of something you did in good faith,” Davis said.

Dr. Sterling Ransone, president of the American Academy of Family Physicians, said he already had concerns about the quality of care provided by assistant physicians, citing a 2018 JAMA article that found they had lagging test scores compared with their counterparts in residency programs. He said he’s doubtful about creating an alternative pathway to full physician licensure.

“I would personally have trouble supporting it without a lot more information to verify quality standards,” Ransone said.

The American Medical Association favors a bill in Congress that would increase the number of residency positions in the U.S. by 14,000 over the next seven years.

Dr. Kevin Klauer, CEO of the American Osteopathic Association, didn’t shut the door on a role for assistant physicians but said he was skeptical: “We have to be responsible to make sure that we’ve put all the safeguards in with training and verification and monitoring, so that healthcare that is delivered by a physician is up to the standards that it should be.”

Frederick called those concerns “purely turf protection” amid what he said is a tremendous healthcare shortage.

“We have all these people that are highly trained,” Frederick said. “Why would you waste that resource?”