A Spot at the Table
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A Spot at the Table            | Derrick O’Connell, Lisa Shock, American Medical Association, American Academy of Physician Assistants, Patient Centered Medical Home, NCQA, American College of Family Physicians, Eugene Stead Jr., Utilization Review Accreditation Commission, American College of Physicians...

Derrick O’Connell,
PAs and NPs prepare for growing role in era of post healthcare reform

After sitting on the sidelines for decades, physician assistants (PAs) are moving to the table with primary care providers (PCPs) in the post healthcare reform era.

“Many aspects of patient care may be handled by PAs,” said Derrick O’Connell, RN, MBA, CQO for Esse Health in St. Louis, a nationally recognized Patient-Centered Medical Home (PCMH) expert. “The medical home system, if followed by the letter of the law as described by the NCQA, sets up team-based care already.”

PAs review data so doctors aren’t burdened with healthcare tasks that are below the scope of their licensures, he explained.

“That’s where the medical home supports the use of healthcare professionals like PAs,” he said. “As of last year, the NCQA began accepting applications for PAs – if they had their own panel of patients as a medical home. It was an evolution for them.”

Lisa Shock, MHS, PA-C, CEO of Utilization Solutions in Healthcare in Hillsborough, NC, a nationally recognized expert on policy matters, said that as healthcare delivery continues to transform, the implementation of the PCMH as a vehicle for patient care is rapidly expanding.

“PAs are becoming increasingly recognized as important players on the patient care team,” she said, noting that recent studies from the American College of Physicians (ACP) and the American College of Family Physicians (ACFP) show that PAs should be recognized as primary care providers in the PCMH model, and that accrediting bodies such as NCQA and the Utilization Review Accreditation Commission (URAC) support the PCMH as a proven model for delivering high quality, cost-effective patient care and encourage the inclusion of PAs.

Eugene Stead Jr., MD, of Duke University Medical Center, founded the PA profession in 1965 to improve and expand healthcare delivery after physicians and educators recognized the trending shortage of PCPs.

Even though some PCMH experts may consider nurses-turned-PAs better suited for the greater role, Stead selected Navy corpsmen who had received considerable medical training during their military service for the first class body of PAs.

The level of education for entry-level PAs continues to be debated. At the PA Clinical Doctorate Summit in March 2009, the Physician Assistant Education Association (PAEA) produced a consensus statement based on the following set of preliminary recommendations after delegates – practicing PAs, PA educators and students, physicians from allopathic and osteopathic medicine, workforce experts, and physical therapists, and nurses – addressed the question: Is the clinical doctorate appropriate to the profession as an entry-level degree, as a post-graduate degree, or not at all?

Summit participants agreed on the following set of primary recommendations:

  • The PA profession endorses the master's degree as the single, entry-level, and terminal degree for the profession.
  • The PA profession opposes the entry-level, PA-specific clinical doctorate.
  • The PA profession supports advanced professional development and education, including the option of non-profession-specific postgraduate doctorates.
  • The PA profession should explore with physician education groups the development of a model for advanced standing for PAs who desire to become physicians, sometimes called a “bridge program.”

“Redesigning healthcare delivery systems will require use of PAs at the top of their licenses to address the primary care shortage,” said Shock.

A significant amount of money in the 2010 Affordable Care Act (ACA) funded programs to train not only doctors, but also PAs.

“Health policy advocates believe the well-known shortage in primary care will be alleviated, not just by having more doctors, but also by having doctors work in teams with other less highly trained specialists who can deliver quality primary care,” said Shock. “Many studies show that good, quality primary care can be delivered by PAs and NPs on a physician-led team.”

Ann Davis, senior director of state advocacy and outreach at the American Academy of Physician Assistants (AAPA), said in a recent National Public Radio (NPR) interview that when “you … think about a scarce resource, there's sort of three ways to think about that. You can increase supply … of physicians. You can use the scarce resource more wisely, or you can actually reduce demand. And I think the second two are where physician assistants are particularly critical.”

Complicating matters, a great disparity in scope of practice laws for PAs exists state to state.

“That needs to be rectified on a national level, and standardized to fit the needs of our populations across the country,” said O’Connell, who maintains his nursing license in Michigan to maintain a higher level of training. (Missouri doesn’t require continuing education for nurses.) “Variance is a barrier, without a doubt.”

For example, PA prescribing authority by state in Medical News markets are:

  • Alabama, Arkansas, Louisiana: Schedule III-V of controlled substances.
  • Florida: Formulary of prohibited drugs.
  • Kentucky: none.
  • Mississippi and Tennessee: Schedule II-V of controlled substances.
  • Missouri: Schedule III-V of controlled substances, with schedule III limited to a 5-day supply with no refill.
  • North Carolina: Schedule II-V of controlled substances, with Schedule II-III limited to a 30-day supply.

According to an October 11 AAPA issue brief, the first state laws for PAs, passed in the 1970s, allowed broad delegatory authority for supervising physicians. Many laws were simple amendments to the medical practice act that allowed physicians to delegate patient care tasks within the doctor’s scope of practice to PAs with their physician supervision.

“In some states, though, the initial delegatory language was replaced by a more regulatory approach. Many state legislatures or licensing boards created lists of items that could be included in a PA’s scope of practice. However, states soon determined that this approach was both impractical and unnecessary,” according to the brief.

In early 1996, the North Dakota Board of Medical Examiners changed the rules governing PAs to nix a procedure checklist and instead employ a physician-delegated scope of practice.

“Although there’s still some variation, most state laws have abandoned the concept that a medical board or other regulatory agency should micromanage physician-PA teams. Wyoming, for example, articulates in its regulations that having the Board delineate the scope of practice for PAs isn’t only inefficient, but is also counterproductive to patient-centered care.

In 1995, the American Medical Association (AMA) House of Delegates adopted guidelines for physician-PA practice. Even though PAs continue to work in primary care settings, many PAs work in specialties ranging from the neonatal intensive care unit to long-term care facilities.

“PAs extend the reach of physicians by that team practice that we really look toward,” said Shock. “And then, if the PAs are available to do some health promotion, some exquisite coordination of care so that you decrease readmissions, that helps address the physician shortage also.”

Editor’s note: Watch next month when Medical News focuses on the role of nurse practitioners (NPs) in the new paradigm of healthcare.  





American Academy of Physician Assistants, American College of Family Physicians, American College of Physicians..., American Medical Association, Derrick O’Connell, Eugene Stead Jr., Lisa Shock, NCQA, Patient Centered Medical Home, Utilization Review Accreditation Commission

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