December 2008 Issue

By the Numbers

THE AMERICAN Association of Physician Assistants, based in Alexandria, VA, reports that about two-thirds of California’s PAs are female, which is just about the same as the national tally of 64 percent female and 36 percent male. And not surprisingly, California’s ethnic mix is delightfully diverse—even more so than the national population of PAs. Here in the Golden State, 13 percent of PAs list themselves as Asian/Pacific Islander, compared to 4 percent of all PAs nationwide. Another 7 percent of California PAs are non-Hispanic black, and about 12 percent are of Hispanic or Latino origin, compared to national figures of about 4 percent for each group. Just under 1 percent of our PAs are American Indian or Alaskan by heritage, which is almost exactly the same as the country as a whole. Our PAs are a pretty experienced bunch, too. The mean age for a PA here is just a notch over 43, and those practitioners have logged almost 11 years since graduation from PA school. The national mean age is closer to 41 than to 43—an important distinction if you happen to be over 40 yourself!—although PAs all over the country have about the same amount of experience under their collective belts. About 80 percent of PAs in California work with a single physician, while closer to 85 percent of PAs nationwide are similarly situated. Almost 20 percent of Golden State PAs work with two or more doctors, and a full percent state they’re “self-employed with multiple contracts.” Nationwide, about 15 percent work with more than one physician and only half a percent or so claim to be selfemployed. Just under 60 percent of our PAs receive a salary, while just over 80 percent of PAs nationwide do. More than 40 percent of California PAs work in solo physician practices or with single- or multi-specialty practice groups, about the same as the national numbers. Another 15 percent or 16 percent work in hospital emergency rooms or hospital operating rooms. Interestingly, 12percent of PAs nationwide work in hospital inpatient units, while just 5 percent of California PAs find themselves in those settings. California PAs’ specialties vary from the national numbers as well. Here, almost one-third of PAs specialize in family or general medicine, compared to about one-quarter of PAs nationwide with that specialty, and just over 19 percent are in surgical subspecialties, compared to just over 22 percent nationwide. And we have fewer PAs in internal medicine, with just under 7 percent of Golden State PAs are, compared to about 11 percent of PAs across the country. Finally, we have more PAs in emergency medicine, with just over 12 percent in that specialty, compared to just over 10 percent nationwide.

PHYSICIAN ASSISTANTS are not MDwannabes who couldn’t cut it in med school. Rather, they are, like you, dedicated healthcare professionals who’ve found the right match for their skills and professional personalities in the industry they love. Indeed, a lot of PAs are like Larry Rosen, PA-C, a practicing PA working in partnership with North Hollywood family practice physician Michael Koshak, MD, and vice president and public relations chair at the California Academy of Physician Assistants. Well, actually, not very many of the nation’s estimated 68,000 PAs are exactly like Rosen. Many, like he did, moved into their PA careers from other lines of work, but it’s doubtful that any of them were successful television writers and producers before making the switch—although in Southern California, you never know. There may be PAs who were successful TV stars before changing careers.

In Rosen’s case, professional transformation followed a personal encounter with the healthcare system. “I worked in television for 35 years,” he says. “I always had a love of medicine, and I started out in college planning to go to medical school, but I had too much fun during my undergraduate career and knew I didn’t have the dedication to study as much as med school students must.” Years later—about a decade and a half ago—he was undergoing knee surgery and, while in rehab, noticed one of his caretakers had “PA-C” on his lab coat after his name. He asked bout the designation and was surprised at what he heard. “I said, ‘After two years of study, you’re practicing medicine?’ and he said, ‘I just did your surgery, man!” That’s all it took. “Here I was in my 50s with an opportunity to realize a lifelong dream of being in the medical profession,” he enthuses now. “I grabbed it. I left my industry and went into medicine. That was 14 years ago and I’ve never looked back.”

Indeed, many PAs are drawn to the field because they really, really want to work in healthcare, but they know they can’t afford medical school or they know they won’t devote 10 years of hardcore studying to it. Looking back now, Rosen probably would have been a doctor, knowing what he knows now about medicine. Perhaps he doesn’t appreciate how wise he was at such a young age. “But medical school takes dedication that I didn’t have in my 20s,” he says. When he went back to school at the University of Southern California to earn his PA-C certification, he was delighted to find he wasn’t the only eager future physician assistant who didn’t pursue that dream right out of high school. The class included an actor and a singer—what class in LA doesn’t?—as well as a truck driver and a few nurses and, as he puts it, “kids from all over the place who had little experience in medicine but a dedication to it and determination to pursue PA certification.”

In California, PAs are licensed by the Sacramento-based Physician Assistant Committee. A PA can apply for licensure after completing a training program approved by the organization, and he or she must also pass the PA National Certifying Exam given by the National Commission on Certification of Physician Assistants. That’s where the “C” for “Certified” after “PA” comes from on lab coats like the one that sparked Rosen’s interest in the profession. To keep it, PAs must be recertified every six years or so by examination through the NCCPA, although California doesn’t require PAs to maintain recertification to be licensed.

In California, PAs are licensed by the Sacramento-based Physician Assistant Committee. A PA can apply for licensure after completing a training program approved by the organization, and he or she must also pass the PA National Certifying Exam given by the National Commission on Certification of Physician Assistants. That’s where the “C” for “Certified” after “PA” comes from on lab coats like the one that sparked Rosen’s interest in the profession. To keep it, PAs must be recertified every six years or so by examination through the NCCPA, although California doesn’t require PAs to maintain recertification to be licensed.

There doesn’t seem to be much a chilling effect so far. Though the notion of a “physician assistant” is barely 30 years old, there are, in addition to the all the practicing PAs, another 12,000 or so in PA academic programs, with about 4,500 graduates in 2007 alone. Indeed, the US Bureau of Labor Statistics says the number of PA jobs will increase by 27 percent by 2016, while the total number of jobs will grow by just 10 percent during the same decade-long period. And the PA profession was ranked the fourth-fastest-growing in the country last year by CNN.com and Forbes.com. Eugene Stead would be proud. Concerned about the shortage and uneven distribution of primary care docs, he’s the one who put together the first class of PA students in 1965, while at the Duke University Medical Center. He chose Navy corpsmen who’d had medical training in the military—and actually based the original PA curriculum in part on the fast-track training World War II doctors had received.

It’s almost like he had Robert T. Miller, PA-C, in mind. A CAPA past president and current treasurer and chair of its Professional Practice Committee—as well as an assistant professor of clinical pediatrics and family medicine at the USC Keck School of Medicine and clinical coordinator of the hemostasis program at Children’s Hospital of Los Angeles, started his PA training in 1972 as a medic returning from Vietnam. He wanted to stay in medicine and was delighted to hear about the nascent specialty. The only real downer, in fact, is how many people inside medicine still are not familiar with it. “It’s frustrating to see the misinformation that exists regarding the extensive training that PAs receive, their scope of practice under state law and the value they can bring to a medical practice,” he says. “Some still think PAs are similar to medical assistants. They’re clearly misinformed.”

Indeed. In California, the regulations that dictate PAs’ scope of practice state that “because PA practice is directed by a supervising physician, and a PA acts as an agent for that physician, the orders given and the tasks performed by a PA shall be considered the same as if they had been given and performed by the supervising physician.” In fact, the regs continue, “unless otherwise specified, those orders may be initiated without the prior patient-specific order of the supervising physician.” But PAs can’t just decide to do what they’ve seen their physician partners do. Rather, they must have written delegation of services agreements in place that outline in detail which services their MDs will allow them to perform.

The state says that, as a general rule, PAs can:

• Take a patient history.
• Perform a physical examination and make an assessment and diagnosis and record and present data in a manner meaningful to the physician.
• Initiate, review and revise treatment and therapy plans.
• Order x-rays, other studies, therapeutic diets, physical therapy, occupational therapy, respiratory therapy and nursing services.
• Order and perform lab, screening and therapeutic procedures.
• Institute treatment procedures essential for the life of the patient.
• Counsel patients about medications, diet, social habits, family planning, normal growth and development and aging and understanding and long-term management of their diseases.
• Initiate arrangements for admissions, complete forms and charts pertinent to the patient’s medical record and provide services to patients requiring continuing care, including patients at home.
• Administer medication to a patient or transmit orally or in writing on a patient’s record a prescription from his or her supervising physician.
• Perform surgical procedures without the personal presence of the supervising physician that are customarily performed under local anesthesia.
• Serve as first or second assistant in surgery.

And once their supervising physicians have officially delegated those services to them, they can in most cases perform them without additional patient-specific permission. It’s key to note that PAs cannot “administer, provide or transmit” a prescription for controlled substances without that specific authority. While they write “drug orders” and not, officially, “prescriptions,” the state regs do note that those drug orders have the legal and prescriptive weight of MD scripts. It’s perhaps even more important to note that, as the regulations say, “the delegation of procedures to a PA shall not relieve the supervising physician of primary continued responsibility for the welfare of the patient.” PAs can, in other words, relieve some of your practice burden, not some of your liability burden. In fact, you have to be at least electronically available whenever a PA is taking care of your patients, and you have to commit to a fair amount of chart review, countersigning and dating for patients treated by the PA, and you have to do it within a defined time frame—especially when pharmaceuticals are involved. And you can’t use more than four PAs at any one time.

Actually, the cost of hiring a PA might do a better job of limiting how many a doctor works with than any rules or regulations. The 2008 AAPA Physician Assistant Census Survey says the median income for an experienced PA who isn’t self-employed is just under $90,000. That’s why a TV producer like Rosen could afford to change careers. Of course, bringing on a PA may allow a practice to also bring on new patients—and PAs do get paid for their services. The major government program payers are surprisingly friendly to such a recently created profession, in fact. Medi-Cal reimburses for physician services provided by PAs at 100 percent of what a physician would receive for the same services, for example, but it only covers certain CPT codes, meaning there are some services PAs can perform but not bill for. Beware those subtle disconnects. CPT codes have been added to the list over time, but there are still a lot of services commonly provided by PAs that don’t yet make the reimbursement cut.

For its part, Medicare Part B indicates that PAs billing under their own identification number will get 85 percent of the program’s physician fee schedule for covered services—paid to the doctor or the group practice or the hospital or the HMO, and not to the PA. Medicare also reimburses for PAs who are first assistants at surgery, paying about 14 percent of the primary surgeon’s fee. Medicare also allows for “incident to” billing for covered services provided by PAs. They’re reimbursed at 100 percent of the physician fee schedule. Further good news: California’s workers’ compensation program reimburses PA services at 100 percent of the physician fee schedule.

Liability insurance covering the PA is generally paid by the employing physician and can be arranged in one of two ways. In the first, the PA is covered by the umbrella policy of the physician. Many carriers do not increase the premium when a PA is employed; some increase it only slightly, while others may increase it significantly. Always consult your carrier about their particular policy when considering hiring a PA. In the second scenario, the PA may take out a separate individual policy.

Still, hiring a PA isn’t simply a matter of math. Of course, you have to start with the numbers, to make sure there’s a return on investment involved. You need to determine if your practice has a sufficient volume of patients to keep a PA occupied, and those patients need to come back again and again and present with a fairly limited range of less-than-highly complex service needs—so the PA’s activities can be planned, more or less, in advance. That’s why Richard Frankenstein, MD, a pulmonary medicine specialist in Garden Grove, doesn’t use PAs. His specialty practice is built on patients who come in one or twice for very specific, very complicated kinds of care. Still, he’s a fan of the PA concept and encourages physicians to consider them as an important physician extender option. But beware the hidden challenge of finding a good PA-physician fit, he warns. Even if your financial model looks good, you have to ask yourself two pretty tough questions: Will I be giving up the things that make my practice fun? And will I actually delegate services to a PA?

PAs can be focused on, say, tracking down lab tests and blood work and performing routine medical care procedures, leaving the more serious issues, those requiring the fruits of all those extra years of training, to become the doctor’s sole province. In a famfamily practice, for example, patients come in with cuts and scrapes or to have stitches removed—exactly the kinds of things that are very easy for a PA to do. “But those might also be exactly the kinds of different, interesting things that make the practice interesting to the doctor,” Frankenstein notes. You’ll almost certainly regret it—as will, likely, your entire office, when you think about it—if you actually give up the parts of your practice that keep you smiling inside and out to add the additional patients a PA could bring.

Of course, there’s a decent chance you know a doctor who has trouble delegating even the tasks he or she detests. There’s just something about the alpha dog personality that makes so many physicians such dynamic, powerful medical team leaders that can sometimes prevent them from functioning as part of a team at all. And that defeats the purpose of PAs. “The advantage of PAs as opposed to other types of physician extenders is the absolute connection to the doctor’s practice and the way the doctor does things,” Frankenstein notes. “Some among us are just too protective of their particular styles of doing things to take a chance on someone else not doing them the right way.”

And without teamwork, there’s no team. And PAs are all about the team approach to care. “We’re utterly dedicated to team practice,” Rosen points out, emphasizing that physician assistants don’t consider themselves physicians. “When Grandma has a stroke, does the family say, ‘Quick, call the PA’? No, they don’t do that. They call the doctor.” In fact, being part of a team is one of the characteristics of PA practice that most appealed to him, and being an effective team member is one of the talents he brought with him from his media career. “When you do a television comedy series, and you’re sitting with a staff of writers and producers trying to come up with a joke or story twist, you’re very aware that it’s a team effort,” he says. “No one person can do a whole show alone.” It may very well be true that no one person can take care of all of the patients in a growing practice alone, either. That’s why so many of your colleagues are, well, holding auditions—to beat the media metaphor completely to death—for physician assistants.