A Way to Reduce Healthcare Costs

Insurers and all healthcare stakeholders can benefit from broadening use of certified physician assistants.

As policymakers inside the beltway negotiate the future of the American Health Care Act (AHCA), the focus appears to be on who will pay for healthcare, how it will be subsidized and whether the state insurance exchanges will remain viable. The assumption is being made that access to care is the same as access to high quality care, and the driving force for change to the AHCA are these cost issues. In this changing marketplace, it is imperative that insurers consider the quality of care being provided, in addition to the finances, because medical errors and poor care cost us all in the long run. There is good news for insurers in this battle of ideologies. Certified Physician Assistants (PA-Cs) deliver on both fronts, providing high-quality care in a cost-effective manner. A 2016 article in the Journal of Clinical Outcomes Management showed no significant difference over 18 months in patient mortality, hospital readmissions, lengths of stay and consults with specialists when care was led by PAs compared with doctors. Additionally, PA-Cs can help meet the new and still confusing performance metrics designated by the Centers for Medicare and Medicaid services, such as the new Medicare Access and CHIP Reauthorization Act (MACRA). For these reasons, it is important that insurers and all healthcare stakeholders understand the role and qualifications of Certified PAs in healthcare today, including: education and commitment to lifelong learning; rigorous certification; how PAs are compensated and reimbursed; and the demographics and distribution of PAs around the U.S. These insights will help insurers understand how PA-Cs can contribute to improved cost management and patient satisfaction metrics while meeting patient needs and regulatory demands. First, consider the credentials of Certified PAs. Certified PAs are prepared and proven to meet the needs of patients today through a combination of a graduate level education and a rigorous certification and certification maintenance process. PA-Cs are educated in the medical model. Like physicians, they maintain certification at the highest level in healthcare. They must earn substantial continuing medical education (CME) credits every two years and sit for a proctored exam that covers general medical knowledge every 10 years to remain certified. Certification is a hotly debated topic in healthcare today. There is an anti-maintenance of certification (MOC) movement — a belief that initial assessment by exam after graduating from school is sufficient and maintenance of certification should be through CME only. See also: What Physicians Say on Workers’ Comp   Periodic assessment helps to ensure that PAs maintain and objectively demonstrate a baseline fund of knowledge that is essential for practice across the health care spectrum. The combination of substantive, relevant CME and periodic assessments ensure that PA-Cs maintain relevant knowledge throughout their careers. The National Commission on Certification of Physician Assistants (NCCPA) believes this combined approach reinforces the public trust and assures employers and payers that PA-Cs provide the safe, quality care patients should expect and demand. Who we are; where we practice NCCPA has the most comprehensive source of workforce data for the PA profession, with input from 94% of the nation’s PA-Cs. From that, we publish four reports annually detailing statistics on: all Certified PAs; those in 22 specialties; PA demographics by state; and on those PAs who were newly certified in the previous year. Here are some key findings:
  • More than 70% of Certified PAs now practice in specialties outside primary care. There are 103 Certified PAs for every 1,000 physicians in the U.S., with notably higher ratios in surgical subspecialties, emergency medicine and dermatology.
  • The median age of Certified PAs is only 38, so they are not nearing retirement age like many physicians. Only 0.6% planned to retire in 2016.
  • The states with the largest number of PAs are New York, California, Texas, Pennsylvania and Florida. However, three of the top five states with the largest number of PAs per capita are Alaska, South Dakota and Montana, indicating that Certified PAs often fill the void for healthcare in rural areas.
  • Certified PAs make an average salary of more than $104,000, which is less than half of a physician, making them an affordable provider who can still meet the clear majority of patient needs.
PA-Cs are everywhere, in every specialty, clinical setting and state, with services running the gamut from providing core medical services to performing surgical procedures, to assisting in complex surgical procedures.
  • Almost 19% practice in surgical specialties like cardiovascular and thoracic surgery and orthopedic surgery, handling pre-ops and post-ops but also performing procedures like vein harvesting, central IV-line placement, lumbar punctures and fracture reduction.
  • More than 14% are employed in emergency medicine, working in every area from fast track to admitting patients to the hospital or referring for follow up to a community physician.
  • Almost 1.5% practice in psychiatry, managing patients with the gamut of mental health issues from anxiety to schizophrenia, providing continuity of care for patients on long-term medications and helping to detoxify substance abuse patients and referring for counseling.
  • They manage complex patients with multiple co-morbidities and conditions such as diabetes, HIV and hypertension.
  • Certified PAs are also improving efficiency in work places across the country, working on task forces to develop telemedicine programs, observation units to reduce hospital admissions and processes to increase patient satisfaction.
How PAs are paid and reimbursed Most PAs are employed and salaried providers. In some states, Certified PAs can own their own business, with a physician as medical director. Medicare pays PAs at 85% of the physician fee to perform the same services. Medicare increases that to 100% if the service is “incident to” the physician’s care. To be considered as “incident to,” the physician must perform the full first visit, services must be rendered in the office/clinic and a physician must be onsite when PAs treat the patient. Hospitals that employ PAs bill for their clinical services under Medicare Part B. Most often, private insurers follow Medicare guidelines. Thus, Certified PAs represent immediate cost-savings for insurers. See also: Medicare Implements Value-Based Purchasing   Q. What do MACRA, HCHAPS, PCMH, ACO, ACA have in common? A. Value-based care! Whether the ACA is changed or repealed, the demand for quality and cost-effective care will not lessen. Every healthcare model is seeking data to back up its promises. As patients, we all want to see metrics that can be replicated so that we know we are getting the best value care for our money. Solutions need to be refined in everything from clinical setting to workflows. However, as in any business, staff is one of the most significant factors in success—what they do and how much it costs for them to do it. As Congress debates how we pay for this coverage, and wrangles about the details of exchanges and subsidies, insurers are being asked to reduce the cost of healthcare insurance, while at the same time being true to stakeholders, be they public or private, by remaining profitable. The simple answer is to reduce the cost of medical care. Employing Certified PAs is one way employers can do that. Knowing they maintain certification at the highest standards in healthcare provides a level of assurance that PAs are a quality solution, not just a lower-cost solution. That should boost confidence in reimbursing Certified PAs who, at the end of the day, are a bargain for payers.

Dawn Morton-Rias

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Dawn Morton-Rias

Dawn Morton-Rias is president and CEO of the National Commission on Certification of Physician Assistants. She has served the PA profession for over 30 years, including as Dean of the College of Health Related Professions and Professor at SUNY Downstate Medical Center and President of the Physician Assistant Education Association. She is nationally recognized for her leadership in PA education and commitment to cultural competence in education and clinical practice.

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