Clinical and Health Affairs
Physician Assistant Practice in Minnesota
Providing Care as Part of a Physician-Directed Team
By Beverly A. Kimball, B.S.N., PA-C, and Walter S. Rothwell, B.S., PA-C
Abstract
Physician assistants (PAs) practice medicine with physician supervision, which allows physicians to see more patients and concentrate their efforts on the needs of those with complex medical conditions. Physician assistants have been practicing in Minnesota since 1970. They work in a variety of settings and specialties, although most are in primary care practices. This article profiles the PA profession and describes the type of work PAs do, the training and credentialing required to become a PA, and the relationship between physicians and PAs.
The physician assistant (PA) profession has its roots in the Vietnam War. In 1961, Charles Hudson, M.D., recognizing that military corpsmen returning from service had skills with no corollary in the civilian sector, gave an address to the American Medical Association (AMA) calling for the development of a “midlevel” medical provider who would work under the supervision of a physician.1 Four years later, Eugene Stead, M.D., of Duke University, which had been using former corpsmen to staff specialty units, created a 2-year curriculum. This became the first formal PA education program in the United States. On October 6, 1967, the first class of 3 PAs graduated from Duke.
The idea behind these founding physicians’ efforts was to extend their ability to provide care, particularly in underserved areas. During the 1970s, PA educational programs were subsequently standardized and accredited by the AMA. Today, more than 68,000 PAs practice in the United States, and 1,100 are actively credentialed in Minnesota.2,3
Credentialed PAs practice medicine with the supervision of a physician. Educated in the medical model, PAs complete a nationally standardized core curriculum that is widely applicable across medical specialties. They can perform a variety of medical and surgical services, as delegated to them by their supervising physician, including the prescribing of medications and therapies. The literature indicates that, practicing as members of physician-directed teams, PAs can provide 75% to 90% of primary care services.4
Most PAs practice in primary care fields (Table). They also work in a variety of subspecialty practices and can provide services in any patient care setting. Clinics, hospitals, nursing homes, correctional facilities, military bases, and even the White House have all been sites of PA practice.
In Minnesota, 67% of PAs are female, with a mean age of 40 years. The average PA in the state has been in clinical practice for more than 8 years. In Minnesota, 53% of PAs practice in urban areas with populations greater than 1 million, 41% in communities of 50,000 or less, and 16% in communities with fewer than 5,000 residents.5
A number of researchers have examined the quality of health care provided by PAs. Studies conducted in the 1970s indicated that more than 90% of patients surveyed about care they received from PAs reported acceptable to high levels of satisfaction.6 Studies that have been conducted since then show similar results. The U.S. Department of Health and Human Services’ Physician Assistants in the Health Workforce Report of 1994, for instance, cited a high level of patient acceptance and satisfaction with the care they received from PAs.7 Sox reviewed data from more than a dozen studies on the clinical performance of PAs and concluded that PAs provide high-quality care.8 And Jones and Cawley found that indirect indicators of quality such as physician acceptance and patient satisfaction also reflected favorably on care provided by PAs.9
An AMA report on PAs employed by solo physicians that looked at their effect on physician productivity and other practice characteristics states the following: “The incentives for employing nonphysician practitioners include increases in net income and physician productivity—office visits per hour and visits in all settings, both on a weekly and yearly basis. By employing nonphysician practitioners, solo physicians were able to expand the scale of their practices and provide greater access to care.”10 Medical Group Management Association studies have also demonstrated that PAs are cost-effective members of group practices.11
Education
Physician assistant education is modeled on physician education and is standardized through an independent accrediting body, the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA).12 The commission includes representatives from the AMA, the American College of Surgeons, and other national medical organizations.
The average PA educational program is more than 26 months long. The majority of PA students enter their training with a bachelor’s degree and prior health care experience.13 Applicants come from a broad range of backgrounds, including nursing and subspecialty technical fields. In the first year of PA training, the curriculum is broad and the teaching approach didactic, covering topics such as anatomy, physiology, biochemistry, pharmacology, behavioral sciences, physical diagnosis, microbiology, clinical laboratory sciences, and medical ethics. In the second year, students receive hands-on training through a series of clinical rotations in both inpatient and outpatient settings. Required rotations include family medicine, internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. On average, PA students complete more than 2,000 hours of supervised clinical practice prior to graduation.14
Physician assistant education is competency-based, meaning that students must demonstrate proficiency of their knowledge in various areas of medicine and meet behavioral and clinical learning objectives. Although all 141 ARC-PA-accredited programs in the United States must meet the same educational standards, each can choose whether to offer a bachelor’s or master’s degree. More than three-fourths of the programs currently offer a master’s degree.14
St. Cloud State University started the first PA program in Minnesota. Two classes graduated—one in 1975 and the other in 1976. But the program did not become accredited and was discontinued. Augsburg College in Minneapolis accepted its first class of PA students in 1995 and continues to host the only Minnesota-based program. The University of Wisconsin-La Crosse has had a PA program since 1995 in partnership with Mayo Clinic and Gundersen Lutheran Medical Foundation. Some of the teaching is done in Minnesota.
After graduation from an accredited program, a PA must pass a national certifying examination developed jointly by the National Board of Medical Examiners and the National Commission on Certification of Physician Assistants (NCCPA), which includes commissioners from 10 physician and health care organizations as well as other stakeholders. Passing this examination allows one to use the title “certified physician assistant” (PA-C). In order to maintain certification, PAs must complete a minimum of 100 hours of continuing medical education every 2 years and pass a written generalist examination every 6 years.
Clinical postgraduate specialty training for PAs is available in a variety of fields including dermatology, rheumatology, psychiatry, sleep medicine, emergency medicine, occupational medicine, hospital medicine, critical care, general surgery, neurosurgery, orthopedic surgery, and urology. None of these programs are currently offered in Minnesota. Accreditation standards recently were established for these optional training programs, and voluntary accreditation is available through ARC-PA.14 Advanced training or extended experience does not change the fact that a PA works under a supervising physician and that the clinical tasks delegated to the PA still must fall within the physician’s scope of practice.
Regulation of the Profession
The first graduate of a PA program began practicing in Minnesota in 1970. The Minnesota Academy of Physician Assistants (MAPA) was incorporated in 1977. The following year, MAPA officers approached the Minnesota Legislature to seek regulation of the profession. Rules defining PA scope of practice were adopted in 1984. In 1990, with the support of physicians, delegation of prescribing became possible. The profession is currently regulated under Minnesota statute 147A. However, some Minnesota PAs, including those in the military, employed by the Federal Bureau of Prisons, and serving on Disaster Medical Assistance Teams, provide care under federal rather than state jurisdiction.
Minnesota is one of only 6 states that does not use “licensed” as the regulatory term for PA practice. Instead, PAs are “registered” in Minnesota. The registration process is equivalent to the licensing process that exists in most states.15
Physician assistants who graduate from an accredited program and are NCCPA-certified may register with the Board of Medical Practice. For ongoing registration, the PA and primary supervising physician must submit a practice setting description defining the PA’s delegated scope of practice and prescribing abilities. In addition, a more detailed supervisory agreement must be maintained at the practice site.
Each physician may supervise up to 2 PAs at any given time. Each PA must have a primary supervising physician and may also have any number of alternate supervising physicians. In accordance with AMA Guidelines and Minnesota law, the PA may only be delegated care that is within their training and experience, within the scope of the supervising physicians’ practice, and in compliance with any institutional provisions.
The only specific restriction on PA practice in Minnesota relates to certain anesthesia services. Language was placed in statute in 1995 excluding the prescribing, administering, and dispensing of “anesthetics, other than local anesthetics, injected in connection with an operating room procedure, inhaled anesthesia and spinal anesthesia.”16
Because PAs and physicians practice as a team, many hospitals choose to credential and privilege them as members of the medical staff, ensuring their participation in quality assurance and peer-review activities.17 The Joint Commission requires a credentialing process for PAs practicing in accredited health care settings, either as members of the medical staff or through an equivalent process. However, some hospitals and accredited facilities credential PAs as allied health practitioners.
The Physician-Physician Assistant Relationship
Each PA works in partnership with a primary supervising physician and takes seriously the concept that they serve to extend the physician’s practice and approach to patient care. The role of the PA is highly individualized, depending on the physician’s needs and preferences, the type of practice, the setting, and the PA’s training and experience. Both MAPA and the American Academy of Physician Assistants remain committed to physician-led team practice.
Physician assistants provide direct patient care but also serve as a link between the physician and the patient, family, and other members of the health care team. They can increase the number of patients seen in a physician practice, improve efficiency, ensure better patient compliance and outcomes, and enhance patient satisfaction.
In some practices, the PA’s role will closely resemble that of the physician’s. For example, PAs will often serve as the primary care provider for some of the patients in a panel. In a primary care setting, these will be patients who need routine health maintenance or well-child care, as well those with acute complaints. The PA also may help patients manage chronic health conditions such as hypertension, diabetes, dyslipidemia, asthma, obesity, and depression. Having PAs care for patients with these conditions allows the physician to devote more time and attention to patients who have more complex conditions.
In other settings, the PA may function at the periphery of the physician’s work, implementing medical decisions, performing procedures, and instructing and educating patients and caregivers; on the other hand, those with extensive training or experience may provide high-level consultations. In an inpatient, emergency room, or procedural practice, the PA and physician may practice side-by-side and confer on an ongoing basis throughout the day.
Regardless of the structure of their practice, if a PA feels that a patient’s condition warrants expertise beyond their ability, he or she will expedite referral to the supervising physician or another specialist.
Supervising physicians assume all responsibility for the care given by the PA. Although the physician does not have to be present when the PA provides care, he or she (or an alternate physician) must be available by phone or electronically. In most cases, the PA and physicians work closely and have regular opportunities to discuss cases and practice standards.
Employing PAs can generate revenue for medical practices, as clinics can schedule more patients and bill for the services provided by the PA. Since 1997, Medicare has reimbursed for medical and surgical services provided by PAs and advanced practice nurses at 85% of the physician rate in all practice settings. Since 2002, CMS rules for “shared visits” give PAs and their supervising physicians increased latitude in hospital and office billing for evaluation and management services. Medicare Transmittal 1776 allows PAs and physicians who work for the same employer or entity to share many types of visits made to patients the same day by billing their combined work under the physician’s NPI number for reimbursement at 100 percent of the physician fee schedule, even if the PA did the majority of the work. Medicaid, TRICARE, and private payers cover medical and surgical physician services provided by PAs in almost all instances.
Conclusion
Physician assistants practicing with the supervision of a physician provide high-quality, cost-effective health care. They are members of physician-directed teams yet are capable of exercising a degree of autonomy in medical decision making, allowing physicians to better use their time and talents to serve patients with complex conditions. MM
Beverly Kimball is a physician assistant who practices in the Ingalls Family Medicine Clinic in Webster, Wisconsin, and at Now Express Care in the Twin Cities. Walter Rothwell is a physician assistant in the department of orthopedic surgery at Mayo Clinic in Rochester. Both are members and past presidents of the Minnesota Academy of Physician Assistants.
References
1. Hudson CL. Expansion of medical professional services with nonprofessional personnel. JAMA. 1961;176:839-41.
2. American Academy of Physician Assistants. Information Update: Projected Number of People in Clinical Practice as PAs as of January 1, 2008. Alexandria, VA: American Academy of Physician Assistants.
3. Minnesota Board of Medical Practice, April 2008.
4. Osterweis M, Garfinkel S. The roles of physician assistants and nurse practitioners in primary care: an overview of the issues. In: Clawson DK, Osterweis M, eds. The Roles of Physician Assistants and Nurse Practitioners in Primary Care. Washington, D.C.: Association of Academic Health Centers. 1993:1-9.
5. 2007 Physician Assistants Census Report. Alexandria, VA: American Academy of Physician Assistants.
6. Nelson E, Jacobs A, Johnson K. Patient acceptance of physician assistants. JAMA. 1974;228:63-7.
7. Health Resources and Services Administration Bureau of Health Professions. Physician Assistants in the Health Workforce 1994. Washington, D.C.: U.S. Department of Health and Human Services. 1994:46-7.
8. Health Resources and Services Administration, Bureau of Health Professions. Physician assistants in the health workforce 1994. Washington, D.C.: U.S. Department of Health and Human Services. 1994:38-55.
9. Jones PE, Cawley JF. Physician assistants and health system reform. JAMA.1995;271:1266-72.
10. Wonzniak G. Physician utilization of non-physician practitioners. In: Gonzalez M., ed. Socioeconomic characteristics of medical practice 1995. American Medical Society, Center for Health Policy Research. 1995:15-21.
11. Medical Group Management Association. Physician compensation and production survey: 2007 report based on 2006 data.
12. Cooper RA. New directions for nurse practitioners and physician assistants in the era of physician shortages. Acad Med. 2007;82(9):827-8.
13. Physician Assistant Education Association. 23rd Annual Report on physician assistant educational programs in the United States, 2006-2007. Alexandria, VA: Physician Assistant Education Association, January 2008.
14. Jones JP. Physician assistant education in the United States. Acad Med. 2007; 82(9):882-7.
15. Summary of Regulatory Terms for Authorization to Practice as a Physician Assistant and State Supervision Requirements, revised April 2008. Alexandria, VA: American Academy of Physician Assistants.
16. Minnesota Statute 147A.09 Sub. 1
17. Physician Assistants and Hospital Practice. Alexandria, VA: American Academy of Physician Assistants.