Physician Associates:

An International

Perspective

Mary Ellen Gray, PA-C,

Professor David Martin, MD, FRCP

Lahey Hospital and Medical Center,

Burlington, Massachusetts

I have no disclosures…Just my

handsome dog

How it all began:

In the 1950s medicine became divided

into specialties as medical acumen grew

too large for the General Practitioner and

the General Surgeon

In 1957 Dr Eugene Stead tried to launch a

program at Duke University to train nurses

to deliver primary care…It was denied

accreditation

Dr Stead: We owe it all to him

Dr Stead turns to military

corpsmen

He observed the skills of military corpsmen and the

lack of primary care for rural populations. He

pitched the idea to Duke to train corpsmen as

primary care providers. Duke agreed. The first class

had 4 students. This was 1965.

1965: Medicare and Medicaid

are established

Lyndon Johnson was President. Now more Americans than ever before had health care coverage. The need for primary care providers became ever more pressing.

In the late 1960s, the AMA formally endorsed Physician Assistants.

A Precedent was established

1966: “People vs Whittier”:

An ex-Navy corpsman is sued for

practicing medicine without a license by

acting as assistant to a neurosurgeon. Dr.

Stead enrolled him at Duke. This case

highlighted the need for a licensure

pathway for non-physicians.

1967: Here we go!

Duke graduates its first class of PAs:

Victor Germino, Kenneth F. Fennell,

Richard J. Scheele

University of Alabama launches the first

Surgical Assistant Program

October 6 (Dr Stead’s birthday,

coincidentally) chosen as National PA Day

The AAPA was established in 1968

In 1970 Kaiser Permanente becomes the first HMO to employ PAs

More than 100 PA programs exist in the US but without standardization. Ultimately, a 2 year training model is adopted as the norm

Governor Ronald Reagan of California signs law formalizing PAs as licensed health care providers for the state

1970s: Growth

Individual states enact legislation governing

PA practice

AAPA opens an office and NCCPA is established

First certificates issued to PAs passing the

NCCPA exam

2 year certification cycle/6 year exam cycle

enacted

State PA chapters work toward persuading

legislation to sanction and grow PA practice.

Federal Government gets

involved:

1978: PAs appointed as commissioned

officers in the Air Force

Federal Government offers grants to PA

programs to train students

By 1980, 42 PA programs are accredited

by the NCCPA. 9431 certified PAs exist

1980’s: Firmly established

49 out of 50 states adopt PA practice

Prescriptive privileges the norm

Medicare allows for reimbursement of PA services

1983: PANCE exam formally adopted

1984: Canadian National Forces begin training and using PAs

1985: PANCE exam offered to informally trained PAs for the last time (“Grandfathered”)

1990s: Further growth.

By 1990, 45 accredited PA programs in the

US

21,194 nationally certified PAs (PA-C)

2000: Finally!

Mississippi becomes the final state to pass

legislation allowing PAs to practice in the

state

There are now 114 PA programs

There are 45,847 certified PAs in the US

Internationally: 2000 and beyond

2001: PAs introduced into the Netherlands

2002: PAs introduced into Canada, UK

2005: first PA program in the UK:

University of Wolverhampton. First class

of PAs graduate from the Netherlands.

First German PA program starts: Steinbeis

University, Berlin

2006: Scotland enrolls 12 PAs into a pilot

program developed by the NHS.

Back in the USA: Further development

2007:, the first doctorate degree (DScPA)

awarded at Baylor University for 18 month

ER residency

Indiana become the last state to allow PAs

to prescribe

2010: Obamacare!

The Affordable Care Act adds 30 million

Americans to the ranks of the insured. All are

needing health care!

148 PA programs

92,049 certified PAs

NCCPA adds exams for “Added Qualification”

(CAQ) for CT surgery, Nephrology,

Orthopaedics, Psychiatry.

Today:

PAs in Australia, Ireland, India, New

Zealand, South Africa, Bulgaria

220 US PA programs. Vast majority are

Masters Degrees

108,500 certified US PAs

PAs own their own practices and

employ MDs to supervise them

Challenges: We are recognized

but are we reimbursed/paid?

US has ”third party payers” – private insurance companies for people under age 65, working, not disabled. Insurance usually provided through employer. Some insurance companies do not reimburse for PA services

Services delivered by a PA must be billed under a supervising MD’s name

Under Medicare regulations, PA services are paid at 85% of the fee for MD services. Private insurers differ in approach (no coverage, 85%, or 100%)

Nurse Practitioners in the US have their own independent medical license making them easier to employ for billing purposes. Lots of jobs going to NPs for that reason alone

Unbillable services in the US

context:

How does the PA get credit for managing

patient care on the inpatient unit? For returning patient phone calls and managing care via telephone? For reviewing and refilling (or denying) prescription refills?

Much of what PAs do that keep the wheels of medical care delivery in smooth operation cannot be accounted for using “billable fee for service” model. Insurers, including Medicare, want documentation of all services for reimbursement

The challenges of success…be

careful what you wish for!

PA salaries are growing due to high demand. We have proven our value: high quality care comparable to care delivered by physicians. But will our swelling numbers eventually decrease demand and cause salaries to diminish?

If PAs and NPs take over the bulk of primary care, will primary care be even further devalued?

Salary caps: Hospitals are unaccustomed to paying PAs salaries commensurate with MDs regardless of the value the PAs bring to the institution

Glass ceiling: Not just for salaries, but also professional growth

Specialization: losing the ability to move between specialties in medicine and surgery if “special qualifications” become mandatory

About Lahey Hospital and

Medical Center

Lahey is an integrated group practice of approximately 600 MDs

Operating a 325 bed tertiary care hospital in greater Boston, and a 10 bed hospital/ambulatory clinic on the North Shore of Boston

21,000 discharges annually

1.2 million patient clinic visits annually

20,000 surgeries annually

70,000 emergency visits annually

A founding member of Lahey Health, an integrated healthcare delivery system including 2 additional community hospitals, community-based primary care behavioral health, home care and rehabilitation/nursing facilities

Affiliated with Tufts Medical School

Total number of APs at Lahey: 220

Total number of PAs at Lahey: 100

Total number of PA students completing clinical rotations at Lahey in 2015: 49

PA schools routinely sending students to Lahey for clinical rotations:

Northeastern University

Mass. College of Pharmacy

Tufts University

Boston University

Springfield College

University of New England

Lahey Departments with PAs on staff:

Cardiology

Cardiothoracic

Surgery

Colon-rectal Surgery

Emergency Medicine

General Internal

Medicine

General Surgery

Hospital Medicine

Neurology

Neurosurgery

Orthopedic Surgery

Pulmonary and

Critical Care

Radiology

Vascular Surgery

Progress at Lahey:

PAs will have their photos and bios included on Lahey

website for patients to view

PAs included in Medical Staff meetings, formerly

exclusively for physicians

PAs listed as primary care providers now that

Medicare recognition is formalized

PAs starting to be included on high level committees

formerly only open to physicians and administrators:

a voice for Advanced Practitioners institution-wide

Many thanks for your attention

Samira Al-Ayed,

computer enabler

Joanne Wozniak, PA-C

Danielle Callahan, PA-C

Stephanie Schifano, PA-C

Beth Doll, PA-C

Susan Stempek, PA-C

Carolyn Hamilton, PA-C

Rebecca Natale, PA-C

Giuseppe Sarno, PA-C

Ran Ku, PA-C

Robin Childress, PA-C

Tom McLaughlin, PA-C

Steven Noiseux, PA-C

And thanks to: