Over the course of posting interview with various health figures, many commenters have asked about the
American Academy of Physician Assistants
role of non-physician providers, both in terms of scope and cost. When writing up the nomination of
Dr. Regina Benjamin for Surgeon General, I learned that she, like myself, works with a health team that includes physician assistants. And given that the PA that I work with was recently elected to the position of president-elect of the American Academy of Physician Assistants, this seemed like an opportune time to explore another dimension of health care.
Patrick E. Killeen MS, PA-C currently serves as the president elect of the American Academy of Physician Assistants (AAPA). He has held an active role within AAPA for more 22 years as a board member and participant of the House of Delegates, Medical Congress and strategic relations workgroup. He also has served as a peer reviewer and liaison coordinator for AAPA. Killeen earned a BS in human development and family studies with a concentration in early childhood education from Colorado State University. He is certified as a child life specialist from John Hopkins University and earned his MS as a child health associate and certified PA from the University of Colorado Health Science Center. I've known Patrick for a decade and a half, and am delighted to have him as an interviewee.
Daily Kos: Patrick, thanks for taking some time for this interview. One of the key components of health reform involves cost control, and one way to control costs is to more expansively use non-physician providers such as Physician Assistants and Advance Practice Nurses. Does the AAPA have a position about health reform, and in particular the role PAs can play?
Physician assistants (PAs) are an integral part of health care reform. PAs are primary care providers and work in all medical and surgical specialties and settings as part of physician-PA teams. PAs practice medicine in a team-based model of care with physician supervision.
PAs control health care cost by:
• Participating in the provision of preventive care, management of long term and chronic conditions and in patient education. The most cost effective treatment of any disease is prevention.
• Helping to assure that patients are seen at the right time, in the right setting by the right provider. Every time a patient who could be seen in a primary care setting is seen in an emergency department it is an unnecessary cost for the system, and unnecessary stress for the patient.
• PAs can help decrease waiting time and efficiency in practices, making the physician’s time and talents used more cost effectively. This also helps patients get appointments more readily – something that can help assure that conditions are treated in their early stages, before more traumatic and costly treatments are required.
• The profession’s affordable salaries (averaging about $89,000 per year across all specialties) make PAs an attractive choice for increasing the volume of providers within the medical system at a fraction of the cost. Because of their generalist medical training, PAs often deliver or supplement primary and preventative care even if they work in specialties. It is not uncommon for PAs in oncology to see survivors for years after their cancer has been treated and the routine, diligent monitoring of the patients’ health often uncovers other issues such as diabetes or heart disease.
• We’re continuing to learn more about how PAs deliver care and whether or not they skew toward quality of care or quantity of care. Recently, Perri Morgan, PhD, PA-C, director of Physician Assistant Research at the Duke University Medical Center, examined PA cost-efficiency by asking whether they increase the availability of the services offered by physicians or instead provide additional care that actually increases the number of visits that a patient uses. Morgan and her colleagues concluded that, on average, PAs are replacing care that would be provided by physicians rather than offering additional or redundant services to patients. The research showed that when PAs provided 30 percent or more of a patient's office visits in a year, there was no increase in the total number of office visits per year.
Daily Kos: Numbers! Let's have some numbers about the profession. is there growth ahead for PAs?
• The American Academy of Physician Assistants (AAPA) estimates there were 85,345 people eligible to practice as PAs and 73,893 people in clinical practice as PAs at the beginning of 2009
• Approximately 257 million patient visits were made to physician assistants in 2008.
• Approximately 332 million medications were prescribed or recommended by PAs in 2008.
• All 50 states, the District of Columbia, and Guam authorize PAs to prescribe.
• The United States Bureau of Labor Statistics (BLS) projects that the number of PA jobs will increase by 27 percent between 2006 and 2016. The BLS predicts the total number of jobs in the country will grow by 10 percent over this 10-year period. The PA profession was ranked the fourth fastest growing profession in the country by CNN.com and Forbes.com in 2007.
Daily Kos: As it happens, you and I have worked as a team for many years, and I recently became aware that the new Surgeon General nominee, Dr. Regina Benjamin, works as a team with PAs in her clinic in Alabama. Can you tell me anything about that partnership from the PAs perspective?
Dr. Benjamin is an advocate for care to the underserved, primary care, elimination of health disparities and of using creative options to provide care to difficult to serve populations. These values are shared by the PA profession. Dr. Benjamin has seen the value of the physician-PA team personally in her clinic, the La Batre Rural Health Clinic. Currently, she employs and works closely with a PA who is an AAPA member.
Dr. Benjamin is also a friend to the PA profession and the AAPA. Most recently, Benjamin was featured as a keynote speaker at a February 2009 AAPA conference for constituent organization leaders during her tenure as Chair of the Federation of State Medical Boards in 2008-2009. She spoke about the physician-PA team, the important roles of professional organizations working together, the initiatives of the Federation that were important to PAs and PA practice, and the work to be done by all health professionals to assure access to care and the elimination of disparities of all kinds.
We think she will be a true leader as the nation’s surgeon general.
Daily Kos: Does the AAPA have a position on the public option currently being discussed in Congress as part of health reform?
AAPA policy does not speak specifically to the public plan option that is currently being considered by Congress. AAPA policy does, however, address the need to provide access to quality, affordable, cost-effective health care to all Americans. AAPA will certainly evaluate the various health care reform proposals by their ability to fulfill that policy.
Daily Kos: Did the AAPA taken a position on CHIP (children's health insurance program) or tobacco taxes and FDA regulation of tobacco?
AAPA strongly supported the reauthorization and expansion of the Children’s Health Insurance Program. Additionally, AAPA has strong policy encouraging PAs to strive to eliminate tobacco products from their personal lives and the lives of their patients and colleagues.
More specifically, on tobacco, the American Academy of Physician Assistants (AAPA) applauded the 111th Congress for enacting, and President Obama for signing into law, the "Family Smoking Prevention and Tobacco Control Act."
The Act protects public health by granting the Food and Drug Administration (FDA) certain authority to regulate tobacco products. The regulation of tobacco products by the FDA is essential to AAPA’s goal to educate consumers and eliminate the use of tobacco products. AAPA encourages all PAs to be actively involved in community outreach that educates people of all ages about the dangers of smoking with the goal of eliminating tobacco use.
On CHIP, AAPA applauded the Congressional approval of the expansion of the Children's Health Insurance Program (CHIP) on February 4. This move provides coverage for an additional four million children of working parents. Congressional action on the CHIP reauthorization is an important step forward, but more remains to be done. As evidenced in the recent Institute of Medicine (IOM) report, "America's Uninsured Crisis: Consequences for Health and Health Care," massive health care reform is imperative to improving the health care of those Americans who are uninsured and underinsured.
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Daily Kos: What health care issues does the public need to be aware of in regard to PAs that does not get discussed enough?
Two federal issues that the public needs to be more aware of are the inability of PAs to diagnose and treat federal workers who are injured on the job and the inability of PAs to determine social security disability. Both are the result of outdated laws and regulations and need to be changed to provide greater access to quality medical care.
Overall, in a new health care system, it is imperative that physician assistants (PAs) are fully integrated into new models of care, such as the primary care medical home and chronic care coordination. The PA profession is the very embodiment of the medical home definition: patient-centered care delivered by a physician-led team. The opportunities for PA involvement in a reformed health care system are many – without a team-based approach that allows all members of the health care team at all levels to practice, the ripple effect of adding millions to the ranks of the insured will impact every American.
We already know physicians cannot possibly shoulder the demand for health care in this country alone. We know, too, that PAs are educated in about two and half years, roughly one-third the time it takes to educate physicians. In the next five years, the PA workforce is expected to be 100 thousand strong; PAs will play an important role in offsetting shortages of care. Thus, throughout any health care reform effort, special attention must be devoted to ensuring that PAs are fully integrated into the medical home and chronic care coordination models of care so that new measures created to regulate health care reform do not create new, unintended barriers to care provided by PAs.
With PAs’ orientation to team practice, their broad medical education and their orientation toward primary care, they are the perfect addition to the care plan for patients in a primary care medical home, offering continuity, comprehensiveness and coordination of care. By design, the PA profession extends the reach of medicine and the promise of health care to the most remote and in-need communities of our nation. In many rural communities a PA is the only health professional available and is the primary care medical home. Likewise, PAs provide medical care to elderly populations and manage chronic medical conditions. The use of PAs in increasingly overwhelmed medical practices across the country has been shown to PAs expand patient access to care, decrease wait times and reduce costs.
Widespread acceptance of team-based models of care will require the elimination of barriers to medical care provided by PAs that exist in Medicare, Medicaid, and the Federal Employees Compensation Act (FECA). For example, PAs are still not allowed to order home health, hospice, skilled nursing facility care, or provide the hospice benefit for Medicare beneficiaries. At best, this robs patients, physicians and PAs of the time it takes to secure a physician signature for an order or form. At worst, it causes delayed access to care and inappropriate more costly utilization of care, such as longer stays in hospitals and, for patients at the end of their lives, it creates an unconscionable disruption of care.
With Medicaid, although most states recognize services provided by PAs in their programs, it is not required by law. And the federal workers’ compensation program does not recognize the ability of PAs to diagnose and treat federal employees who are injured on the job, requiring the patients to go to emergency rooms for worker’ compensation-related care rather than to a practice where the PA is the only available health care provider.
PAs are key to any health care reform effort. However, to be fully utilized, current barriers need to be addressed and the language of new laws must be consciously inclusive of PAs on the medical team.
Daily Kos: Has the AAPA done any work on pandemic preparedness? if so, what recommendations are there for the PA workforce and for the public?
AAPA has been involved with several federal agencies and other national organizations working on pandemic preparedness as well as disaster preparedness.
Physician assistants, like other health professionals, are anxious and willing to provide medical care in an emergency or disaster situation. Currently 40 states authorize PAs to provide disaster relief or emergency care. But many state laws do not contain the language that would allow this to happen. In these states, PAs may violate state laws on licensing or supervision if they assist in emergency or disaster relief efforts outside of their licensing jurisdictions or without their customary supervision arrangements. While several states have adopted language similar to AAPA’s model law on disasters and emergencies to address these concerns, many have not.
To allow for the most effective response to such situations, every state should authorize its PAs to respond to disasters and emergencies.
The laws governing PA practice reflect two key principles: supervision by licensed physicians and physician delegation. The profession endorses these concepts. However, state law exemptions to these requirements are necessary to allow PAs to respond to exceptional circumstances created by disasters or emergencies.
More information can be found at www.AAPA.org Physician Assistants and Medical Response to Disasters and Emergencies: Amending State Laws www.aapa.org/advocacy-and-practice-resources/issue-briefs/511-physician-assistants-and-medical-respo
nse-to-disasters-and-emergencies-amending-state-laws
With regard to pandemic planning AAPA staff participates in meetings of the Advisory Committee on Immunization Practices and the National Vaccine Advisory Committee. Working with these two federal advisory committees allows AAPA to keep its finger on the pulse of national immunization preparedness activities. Just last month AAPA staff attended and gave a presentation at the National Influenza Vaccine Summit sponsored by AMA and CDC. We are also members of the Childhood Influenza Immunization Coalition and supports of National Influenza Vaccine Week.
AAPA’s policies are extremely supportive of immunizations. We recognize the critical preventive health role played by immunizations and our policies support immunization of adults, children, physician assistants and PA students. A special area of emphasis is influenza vaccination for PAs as health care workers. In 2008 67% of PAs reported receiving an annual influenza vaccine, well above the national average for health care workers. In the face of a potential Novel H1N1 (swine flu) pandemic in the Fall, vaccination against seasonal flu will be particularly important.
In addition, 22% of PAs report they have been trained to respond to an influenza pandemic. AAPA policies on preparedness recommends that all PAs be knowledgeable about disease surveillance and control activities, be alert to unexplained illness in the community, understand public health interventions, and know how to communicate risk messages to patients and the media.
Daily Kos: Thank you, Patrick, for your time.