By Tuyen Tran, M.D.
We have a healthcare crisis in the United States. The relative isolation of consumers to direct cost (government programs, private insurances) has resulted in an unchecked increase in demand. Expenditures are rising faster than overall economic growth. Pricing mechanisms can no longer adequately ration health resources. As such, the only remaining factor which can ration the limited resources is access, or unfortunately, inaccessibility to timely care.
In March of 2015, the Association of American Medical Colleges (AAMC) reported that by 2025, the US will have an estimated shortage of 12,000 – 31,000 primary care physicians and 28,000 – 63,000 non-primary care physicians, most significantly, surgical specialists.1 Of the multiple proposed solutions offered, incorporation of mid-level providers (physician assistants and/or nurse practitioners) into the workforce is most appealing. Interestingly, leaders in healthcare met in 1965 to address a similar pressing national concern – health provider needs. The conference stimulated the discussion, “[Could] physicians train assistants to accept ever-increasing responsibility for appropriate decisions concerning services provided to individual patients?”2
Bradford Schwarz, an active hospitalist Physician Assistant (PA), Associate Professor and PA Program Director at the University of Kentucky, responds, “There is not a greater time than now for physicians and physician assistants to lock arms and unite together as team-based providers with like minds, attitudes, and focus in providing the highest level of patient care possible while maintaining our autonomy and collective bargaining power.” Schwarz elaborates, the practice of medicine has changed. The market place is driving a medical industrial transformation. This is causing dramatic changes in financial considerations, organizational structure, and cultural traditions. The traditional model of a physician-owned practice where the physician assistants were physician employees has rapidly transformed into hospital-owned groups where both physicians and physician assistants are employees, colleagues, and often members of the same team.
It’s important to examine the inception of the physician assistant profession. Although many significant people contributed, Eugene A. Stead, M.D., is credited with the founding of the physician assistant profession. He drew from his experience of developing a program to “fast-track” the training of doctors during World War II. After the war, America experienced a tremendous shortage of physicians. Dr. Stead, the chairman of Duke University’s Department of Medicine, attempted to establish an accredited clinical nursing program in 1950s and again in 1960s. Each time, the National League of Nursing, reluctant to change the traditional nursing role, thwarted his efforts. Dr. Stead was forced to look elsewhere and he immediately identified his ideal candidates for the intense two-year abbreviated medical school – highly skilled medical corpsman returning from Vietnam. And in 1965, Duke University launched the first physician assistant program as a “strategy to help over-extended physicians provide more services…”
The physician assistant’s educational requirements include a bachelor’s degree and a varying amount of clinical experience. A prototypical PA program (Master’s degree) is twenty-seven (27) months divided into a didactic and clinical phase. The didactic phase focuses on the following subject areas: gross anatomy with fresh tissue dissection, graduate level physiology, microbiology, clinical laboratory sciences, pathophysiology, advanced pharmacology (2-3 semesters), physical diagnosis, clinical lecture series, behavioral science, and medical ethics. The clinical phase is a series of 5-8 week clinical clerkships most often mentored by a physician with appropriate expertise to include: Family Medicine, Internal Medicine, Pediatrics, General Surgery, Women’s Health (OB/GYN), Emergency Medicine and Psychiatry (behavioral medicine). Upon graduation from an accredited PA Program, the graduate is eligible to sit for the Physician Assistant National Certifying Examination (PANCE) that is administered by one testing body – the National Commission on Cortication of Physician Assistants (NCCPA). All 50 states and the District of Columbia require for PA licensure and the Physician Assistant – Certified (PA-C) title, successful completion of the following: 1) graduation from an accredited PA school (Accreditation Review Commission on Education for the physician assistant (ARC-PA) is the only accrediting body for PA training programs), 2) NCCPA examination, and 3) maintenance of current certification (100 CME every two years). Specialization requires the achievement of PA-C status, two years of experience, and completion of an additional postgraduate training program followed by certification from the NCCPA. Specialty certification must be renewed every six years. (At the present time there are 200 accredited PA programs in the U.S., graduating approximately 8,000 physician assistants annually with a projected 47 new programs starting in 2018.)
Typically, during the evaluation of the return on investment for hiring a physician assistant, the emphasis is often placed upon productivity and/or enhanced efficiency. The physician assistant often autonomously performs routine services and frees the physician to participate in more complex tasks. This collaboration will often result in enhancement of productivity and efficiency. For example, while the surgeon is performing operations in the OR, the physician assistant can continue to provide healthcare services to patients in the clinic. And when the surgeon’s presence is required in the clinic, the physician assistant can perform routine post-operative evaluations of patients in the hospital. Additionally, chronic conditions, not acute care, are driving both the frequency and cost of healthcare. With the majority of our population living longer, the demand on healthcare will stress our current ability to timely provide this service. As mentioned, physician assistants are capable of working in all fields of medicine – providing acute, chronic, and preventive care for all populations in all settings. Schwarz adds, “A PA’s formative training as a generalist allows [him/her] to move between specialties and practice settings, making them very marketable and valuable.”
As a word of caution, the productivity of the physician assistant is often not transparent as the contribution to productivity may be hidden in the physician’s measure. The commonly accepted currency is RVU (Relative Value Unit). The RVU is a standardized measurement of work which accounts for volume divided by per clinician in aggregate to examine productivity per provider, multiplied by conversion factors to compare work effort across surgical or medical disciplines, including the expenses and liability risk associated with the service. These RVU measures are then coupled to CPT codes. If the physician assistant is completing work which is already captured via a global visit, or if the physician assistant visits are “shared visits,” the workload will not be adequately represented. (However, the comparison of total RVU before and after the physician assistant will often be positive.)
A major “game-changer” is Medicare’s promotion to transition from the traditional fee-for-service to a Value-Based Reimbursement (VRB) model. The focus is to link reimbursement to positive quality outcomes and/or improved patient health. Medical knowledge and access to that knowledge is expanding exponentially. Pharmaceutical innovation, diagnostic tools, and robotic utilization have not only transformed the practice of medicine, these similar technological advances have altered the consumer’s expectations. Patients expect and demand the latest and greatest. More importantly, consumers and/or patients are demanding value. No single provider can master the growing medical knowledge base. A practice-based learning and improvement environment will be critical to closing the gap between the rapid progression of scientific information and patient care. All of these changes signal the team-based care model that is now the standard, not the elective approach. The physician assistant can significantly contribute to the coordination of these important aspects of patient care and treatment, making them invaluable members of the healthcare team.
“The subject of independent practice appears to be a hot button for physicians of recent,” Schwarz explained. “The very title of the Physician Assistant immediately implies that we are teamed with a physician in providing care to our patients. [Physician assistants] and physicians share common goals of providing high-quality, patient-centered care and improving the health status of our patients.” In 2014, the American Academy of Physician Assistants (AAPA) House of Delegates redeveloped the formal definition of the physician assistant to accurately depict the present state of physician-physician assistant team:
“PAs are health professionals licensed or in the case of those employed by the federal government, credentialed to practice medicine in association with designated collaborating physicians. PAs are qualified by graduation from an accredited PA educational program and/or certification by the National Commission on Certification of Physician Assistants … Within the physician-PA relationship, PAs provide patient-centered medical care services as a member of a healthcare team. PAs practice with defined levels of autonomy and exercise independent medical decision making within their scope of practice.”
Although this new definition of the physician assistant’s roles and responsibilities appear independent in nature, physician assistants require a defined supervisory physician to be licensed in any state in the US. And the supervisory physician will delegate responsibilities to the physician assistant which will define that physician assistant’s scope of practice, consistent with the physician assistant’s education, facility policy, and state laws. The renewed definition seeks to underscore the collaborative nature of the physician-physician assistant team. It reflects the current state that physician assistants often work autonomously within that relationship.
The physician-physician assistant relationship is built on trust, respect, and appreciation of the unique role of each team member. As Schwarz summarizes, “Bottom line – physician assistants should be permitted to provide any legal medical service that is delegated to them by the supervising physician when the service is within the PA’s skills and is provided with supervision of a physician.
https://www.aamc.org/newsroom/newsreleases/426166/20150303.html retrieved October 30, 2015.
Hooker, Roderick S. PhD, PA; Cawthon, Elisabeth A. PhD. “The 1965 White House Conference on Health: Inspiring the physician assistant movement.” Journal of the American Academy of Physician Assistants. 28(10):46-51, October 2015.
By Tuyen Tran, M.D.