States, the VA Embracing the Vital Roles of PAs
By Lawrence Herman, MPA, PA-C, DFAAPA
Chair of the Department of Physician Assistant Studies
New York Institute of Technology
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Original Publish Date: February 10, 2014
The U.S. Department of Veterans Affairs’ Veterans Health Administration (VHA), one of the largest healthcare systems in the country, released an updated directive designed to enhance utilization of PAs while continuing to embrace a patient-centered and team-based approach to practicing medicine.
The directive establishes new policy by authorizing PAs to practice medicine within defined levels of autonomy and to exercise autonomous medical decision-making. PAs practice medicine similarly to physicians including conducting physical exams, diagnosing and treating illnesses, writing prescriptions and providing follow-up care among many other services. More than 95,000 PAs practice in every medical and surgical setting and specialty.
This is a welcome and encouraging development from the VHA and demonstrates not only how versatile and dynamic PAs can be when it comes to practicing medicine, but the VHA's confidence in the quality of care PAs can render autonomously. As President of the American Academy of Physician Assistants, we applaud the VHA for empowering PAs to fully deliver high-quality medicine to our veterans.
Denni Woodmansee, PA-C, director of PA services at the U.S. Department of Veterans Affairs (VA), played a critical role in updating the PA practice language by working with all stakeholders at the VHA to clarify the roles and appropriate utilization of PAs in VA medical facilities.
The VA employs approximately 2,200 PAs, making it one of the leading employers of the profession, and provides clinical rotation sites for more than 30 accredited PA educational programs. PAs in the VA practice across the continuum of care in medical and surgical specialties, as well as emergency medicine, geriatrics, mental health, occupational health, primary care, and rehabilitation medicine. PAs practice in virtually all of the VA’s medical systems including medical centers, ambulatory and community-based outpatient clinics, nursing homes, and other medical facilities.
It is estimated that by 2020 there will be a shortage of 90,000 physicians in the United States, and the VA is not alone in embracing the value of PAs.
For example, the U.S. Army has for many years utilized PAs as flight surgeons, and the U.S. Air Force, Army, Coast Guard and Navy categorize PAs as medical officers in defining PAs’ duties and medical roles. The Indian Health Service’s utilization guidelines for PAs acknowledge that PAs are often required to practice in isolated settings where physician consultation is not always readily available.
By acknowledging the critical role of PAs in the healthcare workforce, the Patient Protection and Affordable Care Act (ACA) set the stage for reducing barriers to PA practice in state laws and regulations. PAs were included in the law’s definition of primary care provider, and the ACA contains provisions for loan repayment, Medicare incentive payments and integration of PAs into newly established models of care.
Health and Human Services Secretary Kathleen Sebelius, in a keynote address to the AAPA in 2011, called the work of PAs, “critical to our nation’s health,” adding, “Physician assistants play a critical role in our healthcare system. And that role is only going to get more prominent as we look at the future of care delivery in this country.” HHS has created grant incentives for PA education programs to engage in veteran recruitment, retention, and training and has partnered with the U.S. Department of Defense to promote the hiring of veterans in advanced medical occupations, including PA positions.
“That work is important not only because it enhances opportunities for our service members, but because it also strengthens the PA profession as a whole. And we’re going to need our PA workforce to be as strong as it can be—because as quickly as your profession is growing in terms of numbers, it’s growing in importance even faster,” Sebelius said.
At the state level, 42 states and the District of Columbia amended and enacted laws and regulations to lower barriers to full PA practice in 2013.
And it is not surprising that support for PAs has also come from other groups of medical providers.
Since 2010, three major physician organizations – the American College of Physicians (ACP), American Academy of Family Physicians (AAFP) and American Osteopathic Association (AOA) – have each issued joint statements with AAPA publically recognizing the value of the team-based model of medical care. ACP and AAFP both declared that, “physicians and PAs working together in a team-oriented practice, such as the patient-centered medical home, is a proven model for delivering high-quality, cost-effective patient care.” The AOA noted that, “Physician-PA teams, working together with other team members, are ideally suited to the comprehensive, patient-centered, coordinated, accessible, and ongoing delivery of patient care found in team-based models, such as the patient-centered medical home.”
All three joint statements call for flexibility in federal and state regulation so that each practice determines clinical roles within the medical team, enabling each clinician to work to the fullest extent of his or her education, license, and expertise and allowing each team to decide how to best meet the needs of their particular patients.
That is because the most effective physician-PA team practices provide optimal patient care by designing practice models where the skills and abilities of each team member are used most efficiently. The military commonly refer to this strategy as a force-multiplier.
Such models require a shared commitment to achieving positive patient outcomes, a mutual understanding of each team member’s roles, and joint communication and decision-making to meet the health care needs of patients. A growing body of research continues to prove the value of team based care and that effective physician-PA teams improve patient access and satisfaction, increase revenues, and reduce physician workload.i,ii
Practices find that PAs are cost-effective. A California HealthCare Foundation (CHCF) look at specialty practices across the United States found that the practices reported being financially stable in large part because of the integration of PAs and nurse practitioners (NPs). The study also found that in many practices, the increased patient volume was divided: PAs and NPs saw routine follow-up patients, and physicians saw more acute, complex cases that tended to be paid at higher rates.iii The Medical Group Management Association reports for every dollar of collected professional charges that a PA generated for a primary care practice in 2009, the employer paid on average 36 cents compensation to the PA.iv
Studies identify high-quality care with physician-PA teams. The CHCF team also found “maintenance or improvement in quality of care” where PAs or NPs were employed. Four studies found that effective utilization of physician-PA teams reduced hospitalizations among nursing home residents.v,vi,vii,viii A study of HIV care provided by PAs and NP HIV experts found the quality was similar to that of physician HIV experts and generally better than that of physicians who were not HIV experts.
The physician-PA team is effective because of the similarities in physician and PA education, the PA profession’s commitment to collaborative practice, and the efficiencies created by utilizing the strengths of each professional in the clinical practice setting. The Pew Health Commission, as far back as 1998, recognized the value of the physician-PA team approach: “The traditional relationship between PAs and physicians, the hallmarks of which are frequent consultation, referral and review of PA practice by a physician, is one of the strengths of the PA profession. The characteristics of this relationship are also considered to be the elements of professional relationships in any well-designed health system.”ix
Lawrence Herman, MPA, PA-C, DFAAPA, is Chair of the Department of Physician Assistant Studies at the New York Institute of Technology and is a tenured associate professor. He has received multiple awards for teaching, scholarship and service. His career in medicine spans more than nearly two decades and he currently serves as president of the American Academy of Physician Assistants. Herman earned his bachelor’s degree as a PA at the State University of New York at Stony Brook and a master’s degree in public administration in Health Care Finance and Hospital Administration at Long Island University.
iRoblin DW, et al. Patient satisfaction with primary care: does type of practitioner matter? Med Care. 2004;42(6): 579-590.
iiRoblin DW, et al. Use of midlevel practitioners to achieve labor cost savings in the primary care practice of an MCO. Health Serv Res. 2004 June;39(3):607-626.
iiiDower C, Christian S. Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work. San Francisco, CA: Center for the Health Professions, University of California, San Francisco; June 2009.
ivMedical Group Management Association. Physician Compensation and Production Survey: 2010 Report Based on 2009 Data. July 2010.
vAckerman RJ, Kemle KA. The effect of a physician assistant on the hospitalization of nursing home residents. J Am Geriatr Soc. 1998 May;46(5):610-614.
viIntrator O, Zinn J, Mor V. Nursing home characteristics and potentially preventable hospitalizations of long-stay residents. J Am Geriatr Soc. 2004 Oct;52(10):1730-1736.
viiOuslander, JG, et al. Potentially avoidable hospitalizations of nursing home residents: frequency, causes, and costs. J Am Geriatr Soc. 2010;58(4):627-635.
viiiPhillips VL, et al. Health care utilization by old-old long-term care facility residents: how do Medicare fee-for-service and capitation rates compare? J Am Geriatr Soc. 2000;48(10):1330-1336.
ixPew Health Professions Commission.Charting a Course for the Twenty-First Century – Physician Assistants and Managed Care. San Francisco, CA: Center for the Health Professions, University of California, San Francisco; 1998.