Although physician assistants are relative newcomers to the healthcare field, they have carved out a niche as one of three primary care providers, along with physicians and advance practice nurses.
Ann Davis, PA-C, senior director of State Advocacy for the AAPA said the physician assistant field is about 45 years old. Graduates of the first PA program out of Duke University were medics who had served in Vietnam. Today, there are 159 accredited PA programs in the country. Davis said the vast majority of practicing physician assistants have a four-year undergraduate degree in one of the sciences followed by 27 months in a PA program, which is split between the classroom and clinical rotations. PA education, she added, is based on the medical school model.
Although the field doesn’t have a long history, Davis said the PA role is quite widely accepted. “Everybody is looking at how we can best coordinate care rather than delivering fragmented or fractured care,” said Davis, adding physician assistants are well suited for this role and often serve this function on behalf of their patients and supervising physician.
She also noted PAs play an important part in the workforce dynamic, particularly since there are physician shortages in various geographic regions. In some cases, a PA might be the only provider in an underserved area, communicating with a supervising physician via telecommunication.
Whether or not the Affordable Care Act stands as is or is drastically modified, Davis noted there has been a move in the nation toward preventive, integrated care.
“People want value-based, well-coordinated care. Employers will demand it; patients want it; and certainly if we’re going to contain costs, it’s imperative,” said Davis. “PAs are well known for care coordination. There shouldn’t be an ACO that doesn’t have physician assistants. That would be a big mistake.”
Davis noted a physician-PA team is a great model of collaboration with the physician there to offer decision support. Given a PA’s educational and clinical background, however, collaborating doesn’t mean the physician necessarily has to be at the PA’s elbow, particularly considering the technological advances of telemedicine and distance communication.
In fact, Davis continued, it enhances cost effectiveness and patient satisfaction to have two professionals with some unique and some overlapping skill sets to maximize what each does best. It doesn’t make sense, she said, to have a cardiologist sit down and tell a patient to lower sodium intake and spend 20 minutes on dietary education when another qualified professional is readily available at a more cost efficient reimbursement rate.
“When people choose PA school, they want to be that utility infielder. They want to be that problem solver. They want to look up and down that medical constellation and customize care for the patient,” she said. Maximizing the skills of the PA allows the patient to have the necessary one-on-one time while freeing up the physician to deal with patient problems that require physician-level skills.
“If hospitals and physicians are looking to plan for the future, one of the things they should think of first is how can we maximize PAs in our physician-directed teams,” she said.
The AAPA has identified six key elements of a modern PA practice act that the organization has defined as model legislation. Many of the provisions are to afford flexibility to the physician-PA team since ‘one size fits all’ legislation often doesn’t translate equally across various practice settings and scenarios. The six elements are:
- Licensure (rather than ‘certification’ or ‘registration’) as the regulatory term for physician assistants.
- Scope of practice determined at the practice site.
- Adaptable supervision requirement to maximize care and outcomes for patients.
- Full physician-delegated prescription authority for PAs.
- Chart co-signature requirements should be determined at the practice level.
- Number of PAs supervised by one physician should also be determined at the practice level.
Heading: AAPA Advocacy at the Federal Level
Subheading: Trying to gain momentum in the midst of gridlock
Sometimes errors of omission are the most confounding to correct … particularly in the highly partisan, gridlocked, pre-election environment that exits in Washington, D.C. right now.
That doesn’t mean Sandy Harding, senior director of Federal Advocacy for the American Academy of Physician Assistants, doesn’t keep trying. One example is the physician assistant hospice provision that has no pushback from either side of the aisle … but also no legislative vehicle to move the bill forward.
“The problem right now with the current Congress is there’s not an appetite to create new health policy.”
Unfortunately, physician assistants were omitted from the list of providers when the hospice benefit was written into Medicare … probably because the field, which is only about 45 years old, was still so new at the time. “According to state law, PAs would be allowed to provide hospice care for beneficiaries, but the way federal Medicare law is written, healthcare providers have to be affirmatively mentioned, and (PAs) are not.” She added, “Unfortunately, federal law takes a long time to change.”
While the wait continues, some patients … particularly those in rural areas … are forced to switch providers at a time when they are most vulnerable, at the time they choose to utilize the hospice benefit. Harding said the current situation could actually increase cost to the system if a patient switches to a physician, who is paid at a higher rate. Most importantly, the patient’s care is disrupted.
Workers’ compensation on the federal level is another area the AAPA has targeted. “In the overwhelming majority of states, PAs can diagnose and treat state workers who are injured on the job, but not federal employees,” said Harding. “The Federal Employees Compensation Act is rarely, rarely amended.”
Calling it a ‘bipartisan miracle’ in the House last year, a bill allowing PAs and APRNs to diagnose and treat traumatic injury did pass with unanimous consent. At the time, Harding continued, it was noted the amendment was the most significant change to employee compensation law in 40 years.
“There’s not a companion bill yet in the Senate,” said Harding. “We’re looking for any moving vehicle to attach it to in the Senate right now, but it’s not clear what the vehicle would be.”
The way current law is framed, a U.S. postal worker bitten by a dog couldn’t be treated under the federal workers’ compensation program by a PA unless a physician was on hand to sign the claim form. The PA could provide the care as allowed by state law but with the knowledge there would be no compensation per the federal law. In areas without a nearby physician, the other option would be to send the postal worker to the emergency room where a PA would most likely still administer the care … albeit at about four times the cost of providing services in a clinic setting … but a doctor would be on hand to sign the form.
Although it is unlikely much will happen before the November elections, Harding continues to push for legislation that allows physician assistants to provide quality medical care in accordance with state law and their educational preparation.
“We think there is great promise for continued growth and increased roles for PAs in the U.S. healthcare system,” she concluded.