Transcript Document

PAs: Trends, Opportunities and Challenges
NCF 2015
San Diego
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Speaker Disclosure
Tricia Marriott, PA-C, MPAS, DFAAPA
AAPA Director,
Regulatory & Professional Advisory Services
[email protected]
@TriciaPAC
• I am a full-time employee of the AAPA.
• I am a licensed and certified practicing PA, currently
employed part-time by Yale Medical Group, Department
of Orthopaedics.
• I have no financial/industry disclosures to report.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
STATE UPDATE
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Summary of changes by state: www.aapa.org
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Barriers to PA practice are falling
49 States & DC Made Positive Changes to State Law in 2014
Legislative Goals
•
•
•
•
•
•
Full prescriptive authority
Licensure as the regulatory
term
Scope of practice determined
at the practice level
No ratio restriction
No co-signature requirement in
law
Adaptable supervision
requirements
RI
DE
DC
State made
PA-positive
changes to
law in 2014
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
2014 Highlights
California Medical Board
adopted regulations allowing
PAs to assist in surgery
without personal presence of
physician.
Kentucky decreased chart
co-signature provision from
100% to 10% and abolished
the physician-PA 30 minute
proximity requirement.
Alabama adopted a
regulation authorizing PAs to
prescribe Schedule II
controlled substances.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Ohio made multiple changes
to laws impacting PA
practice, including allowing
PAs to perform admitting
functions in inpatient
settings, DNR orders, and
allowing PAs to supervise
hyperbaric oxygen techs.
States That Enroll PAs In The Medicaid Program
RI
DE
DC
States that enroll PAs
States where PAs have limited
enrollment in Medicaid Program
States that do not enroll PAs
AAPA July 2014
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
AAPA Resources
NEW!
PA State Laws and Regulations-15th Ed.
The most up-to-date and comprehensive collection of state PA laws and regulations,
including the 50 states and the District of Columbia. Learn about general requirements for
PA licensure, or take a deeper dive into state-specific PA laws and regulations. If you
purchase the 15th edition, you will also receive the updated version in July. Your
purchase includes a PDF that contains a link with the option to view the document as an
eBook on your PC, Mac or mobile device.
www.aapa.org/shop
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
FEDERAL UPDATE
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
CMS Progress
Administrative Burden
Reduction/Critical Access Hospitals
removed 100% outpatient chart cosignature requirement for PAs and
NPs, deferring to State law
requirements. If no State law
requirements for co-signature, then
CMS would also not require.
Admission Order and Certification for
Hospital Inpatient Stays-physician
certification requirement eliminated
except for outliers.
Admission orders written by a PA, NP or
resident must be co-signed by a
physician prior to patient’s discharge has
not changed.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Federal Register
May 12, 2014
Effective July 11,
2014
Federal Register
November 10, 2014
Effective January 1,
2015
CMS Challenges
Conditions of Payment
• Hospice
• Home Health
• DME
• Diabetic Shoes
• Medical Nutrition Therapy
• Hospital Admission Order &
Certification (IPPS)
• Supervision of Diagnostic
Tests
• Supervision of Intensive
Cardiac Rehab and Pulmonary
Rehab (S.257 introduced last
week)
Conditions of Participation
Restraints Standard -use of “LIP”.
•
•
Used in Interpretive Guidelines only.
Definition does not align with the Joint
Commission glossary definition which allows
for delegation.
Licensed Independent Practitioner (LIP)
For the purpose of ordering restraint or
seclusion, an LIP is any practitioner permitted by
State law and hospital policy as having the
authority to independently order restraints or
seclusion for patients.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Licensed Independent Practitioner
• Not a term defined in federal statute, but has crept into everyday
lexicon.
• Term continues to create barriers, despite the Joint Commission
glossary disclaimer.
• In areas of the country where facilities have not yet utilized PAs, the
“LIP” terminology leads them to believe PAs cannot provide care
without physician present. The glossary disclaimer has not changed
this.
• “Licensed Practitioner, as allowed by state law and facility policy”
would be an appropriate substitute.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Nomenclature/What’s in a Name?
• Avoid “lumping” language:
– “Mid-level”
– Advanced practice clinician/professional
– Physician extender
– Allied health (PAs and NPs are not allied health by federal
definition.)
– Nonphysician practitioner/provider (NPP)
• Use proper professional titles: Clarity, transparency, truth in
advertising and required by State law in many instances.
– PA, Physician assistant (NOT physician’s assistants)
– Nurse practitioner: NP, APRN, APN, CRNA, CNM
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
EMERGING TRENDS
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PAs in Hospitals and Large Physician Practices
PA/NP Credentialing Committee
PA/NP Centralized Governance
• Created as a subcommittee of
the Med Staff Credentialing
Committee
• Charged with review of PA/NP
applications for appointment
and re-appointment
• Evaluates FPPE/OPPE
reporting.
• Advises on new privileges and
scope.
• Participates in disciplinary
process.
• Parallels the physician
governance structure: Chiefs
at the division level, Director at
the facility level, Executive
Director at the system level.
• Creates infrastructure for
policy development,
consistency across the
enterprise.
• Serves as liaison to
physicians, administration and
clinical operations teams.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
NEW CONSUMER EXPECTATIONS
Patient Satisfaction
The Results Are In: Patients Love PAs
A new AAPA survey conducted by Harris Poll finds:
• 93% agree PAs provide excellent patient service
• 93% agree PAs are going to be part of the solution
• 93% agree PAs add value to healthcare teams
• 92% agree having PAs at a practice makes it easier to get an appointment
• 91% agree PAs improve health outcomes for patients
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
16
Contribution to Quality and Safety
Published Examples
Wilson IB, Landon BE, Hirschhorn LR, et al. Quality of HIV care provided by nurse practitioners,
physician assistants, and physicians. Ann Intern Med. (2005) 143(10):729-736.
Conclusions: For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV
experts and generally better than physician non–HIV experts. Nurse practitioners and PAs can provide high-quality care for
persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and
either participation in teams or other easy access to physicians and other clinicians with HIV expertise.
Moote, M., Englesbe, M., Bahl, V., Hu, H.M., Thompson, M., Kubus, J. & Campbell, D., Jr. (2010). PA-driven VTE risk
assessment improves compliance with recommended prophylaxis. Journal of American Academy of Physician Assistants,
23(6), 27-35.
Conclusion: A physician assistant-driven VTE risk assessment process resulted in a dramatic increase in the number of patients
within the health system who were prescribed appropriate orders for VTE prophylaxis according to published guidelines and
according to individual patient risk.
Brett E. Glotzbecker, MD, Deborah S. Yolin-Raley, PA-C, Daniel J. DeAngelo, MD, PhD, Richard M. Stone, MD, Robert J. Soiffer,
MD, and Edwin P. Alyea III, MD Impact of Physician Assistants on the Outcomes of Patients With Acute Myelogenous
Leukemia Receiving Chemotherapy in an Academic Medical Center Journal of Oncology Practice June 2013
Conclusion: The data demonstrate equivalent mortality and ICU transfers, with a decrease in LOS, readmission rates, and
consults for patients cared for in the PA service. This suggests that the PA service is associated with increased operational
efficiency and decreased health service use without compromising health care outcomes.
Peter L. Althausen, MD, MBA,Steven Shannon, BS,Brianne Owens, MD,Daniel Coll, PA-C, Michael Cvitash, PA-C, Minggen Lu,
PhD,Timothy J. O’Mara, MD, Timothy J. Bray, MD Impact of Hospital-Employed Physician Assistants on a Level II
Community-Based Orthopaedic Trauma System J Orthop Trauma Volume 27, Number 4, April 2013
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
More
Miranda Laurant, Mirjam Harmsen, Hub Wollersheim, Richard Grol, Marjan Faber, Bonnie Sibbald Cost-Effectiveness
of Health Care Services? The Impact of Nonphysician Clinicians : Do They Improve the Quality and CostEffectiveness of Health Care Services? Med Care Res Rev 2009 66: 36S
John P. Nabagiez, MD, Masood A. Shariff, MD, Muhammad A. Khan, MD, William J. Molloy, PA-C, Joseph T. McGinn,
Jr, MD Physician assistant home visit program to reduce hospital readmissions J Thorac Cardiovasc Surg
2013;145:225-33
Conclusions: The 30-day readmission rate was reduced by 25% in patients receiving PAHC visits. The most common
home intervention was medication adjustment, most commonly to diuretic agents, medications for hypoglycemia, and
antibiotics.
Matthew Berger, MD William Southern, MD John Loehner, MD Hospitalist Expansion and Organization
http://www.einstein.yu.edu/departments/medicine/medicine.aspx?id=16850
Results :The infusion of this oversight, which connects young, energetic, dedicated PAs with seasoned specialists who
have devoted their careers to inpatient care has significantly improved the quality and organization of the private
attending service. The hospitalist initiative has improved quality in a number of areas, including shorter length of stay,
lower readmission rates, fewer long-stay cases, maintained continuity of care and better communication with the
Montefiore Medical Group, a network of over twenty ambulatory care sites staffed by faculty and non-faculty physicians
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Prevailing Myths & Misperceptions
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Myths
• PAs/NPs cannot see new patients
• Physician must be in the office when PA/NP sees
patients.
• Physician must see every patient.
• Physician will be sued for PA/NP error
• Reimbursement for services provided by PAs/NPs
“leaves 15% on the table”.
• Patients won’t be happy.
• Commercial payers won’t pay.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
Calls From the Field
• Conscious Sedation
• FPPE/OPPE competency measures
• Privileges for new technology (daVinci)
• Credentialing and Privileging new grads
• PAs taking call; cross coverage and call
• Critical Access hospitals
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
AAPA Resources
• Guidelines for Updating Medical Staff Bylaws: Credentialing and
Privileging Physician Assistants (PDF)
• EMTALA and Physician Assistants (PDF)
– Can a PA take call?
– Conduct a Medical Screening Exam?
– Certify False Labor?
– Sign transfer forms?
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
AAPA Resources
Assessing PA Competencies
Professional competencies for physician assistants include the effective and appropriate
application of medical knowledge, interpersonal and communication skills, patient care,
professionalism, practice-based learning and improvement, and systems-based practice.
• Competencies for the PA Profession 2012 (PDF)
Position paper approved by the four organizations for the PA profession: NCCPA,
ARC-PA, PAEA, and AAPA.
• Physician Assistants: Assessing Clinical Competence (PDF)
This is a useful guide for regulators, hospitals, employers and third-party payers.
• FPPE and OPPE Are More than Just Acronyms (PDF)
This article, published in AAPA's magazine PA Professional, speaks to the Joint
Commission requirements ( and challenges) for Focused Professional Performance
Evaluation and Ongoing Professional Performance Evaluation.
• Sample Competency Assessment Tool (PDF)
This sample, while specific to a PA with privileges in orthopaedics, can serve as a
template for most other specialties, by aligning the specialty-specific page with the
individual delineation of privileges.
© Copyright 2014 AAPA. All rights reserved. These materials may not be duplicated without the express written permission of AAPA.
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