by Diana West
Providers wanted

About 50 million Americans live in areas without access to basic medical and dental care, according to the National Health Service Corps (NHSC), which Congress established in 1970 to recruit health care professionals to medically underserved areas.

To remedy this disparity, the NHSC provides scholarships and forgives loans to primary care physicians, physician assistants, nurse practitioners, dentists, certified midwives, mental health professionals and dental hygienists in exchange for at least two years of work in those settings. About 4,000 recruits work in the field at any given time, logging 4 million to 5 million patient visits annually. Once their obligation is fulfilled, more than half opt to stay on or serve in similar areas, says Rick Smith, NHSC's head of clinician recruitment.

Patrick Armstrong, 52, is a perfect example. Since graduating at age 35 from the University of Iowa's Carver College of Medicine, he has worked as a physician assistant in rural Montana, beginning at Phillips County Hospital in Malta (pop. 2,120). "We wanted to raise our family in a small town," says Armstrong of he and his wife, Kathy, who have three children.

Intermittently, he was the town's only medical provider, giving him broad experience and long days and weeks on the job. After nine years, Armstrong moved 90 miles west to Chinook (pop. 1,386), where he works with a pediatrician and physician assistant at Sweet Medical Center. Once a month, he travels 150 miles to Glasgow, Mont., to work a long weekend at Frances Mahon Deaconess Hospital.

"The rewards," Armstrong says, "are the gratitude of patients. They tell my children,  'Your father saved my life.'"

High-minded mission
A desire to serve low-income, uninsured and underinsured people drew Margaret Flinter to join the 10-member staff of the Community Health Center in Middletown, Conn. (pop. 43,167), after graduating in 1980 as a nurse practitioner from Yale School of Nursing.

"The center had a real sense of drive and passion for creating a community-oriented primary care center," says Flinter, 56.

That mission has kept Flinter in Middletown through her career as she helped the center grow from a single location to 12 sites in central and southeastern Connecticut.

Nurse practitioners perform many of the same functions as a doctor and are supervised by a physician.

"The challenge is understanding the stress, difficulties and economics that patients face," she says. "The reward is the satisfaction of having made a difference in their life and health."

1 September 2009 | Volume 151 Issue 5 | Pages 321-328
 
 

Background: Retail clinics are an increasingly popular source for medical care. Concerns have been raised about the effect of these clinics on the cost, quality, and delivery of preventive care.

Objective: To compare the care received at retail clinics for 3 acute conditions with that received at other care settings.

Design: Claims data from 2005 and 2006 from the health plan were aggregated into care episodes (units that included initial and follow-up visits, pharmaceuticals, and ancillary tests). After 2100 episodes (700 each) were identified in which otitis media, pharyngitis, and urinary tract infection (UTI) were treated first in retail clinics, these episodes were matched with other episodes in which these illnesses were treated first in physician offices, urgent care centers, or emergency departments.

Setting: Enrollees of a large Minnesota health plan.

Patients: Enrollees who received care for otitis media, pharyngitis, or UTI.

Measurements: Costs per episode, performance on 14 quality indicators, and receipt of 7 preventive care services at the initial appointment or subsequent 3 months.

Results: Overall costs of care for episodes initiated at retail clinics were substantially lower than those of matched episodes initiated at physician offices, urgent care centers, and emergency departments ($110 vs. $166, $156, and $570, respectively; P < 0.001 for each comparison). Prescription costs were similar in retail clinics, physician offices, and urgent care centers ($21, $21, and $22), as were aggregate quality scores (63.6%, 61.0%, and 62.6%) and patient's receipt of preventive care (14.5%, 14.2%, and 13.7%) (P > 0.05 vs. retail clinics). In emergency departments, average prescription costs were higher and aggregate quality scores were significantly lower than in other settings.

Limitations: A limited number of quality measures and preventive care services were studied. Despite matching, patients at differentcare sites might differ in their severity of illness.

Conclusion: Retail clinics provide less costly treatment than physician offices or urgent care centers for 3 common illnesses, with no apparent adverse effect on quality of care or delivery of preventive care.

Primary Funding Source: California HealthCare Foundation.

The already severe shortage of primary care physicians will likely reach critical the within ten years. Depending upon whose estimates are accepted, the doctor shortfall will be between 40,000 and 300,000 physicians.  Because of the time it takes to train a doctor,  the situation will likely persist for more than a generation.

This situation will pose multiple challenges to a U.S. health care system already reeling from criticism about cost and general quality of care.  This shortage will be exacerbated by a lack of medical school and clinical opportunities, an increasing number of retirement age physicians, and an enlarging and aging patient census.  America already has a much lower than average patient/physician ratio.  While the average number of doctors in similar countries is 3.4 per thousand patients, the U.S. has licensed only 2.4 physicians for the same patient load. 

One possible pathway through the shortage may be two relatively new categories of providers Physician Assistants and Nurse Practitioners.   Both the P.A. and N.P. career tracks grew out of the military combat training experiences following the Viet Nam War.

The first P.A. program at Duke University graduated its initial students in 1965 in an effort to expand supply for a perceived shortage of doctors at that time. At about the same time a similar program for N.P.s kicked off at the University of Colorado for the same reason.

While there are training differences between the two groups, many of the job functions overlap. In general, P.A.s and N.P.s are qualified to perform roughly 80 percent of the functions required of a primary care doctor. Physician Assistants were originally allowed licensure with a BA only. Nurse Practitioners have specialized advanced training beyond that required of line Registered Nurses. It is still possible to become an RN without earning a Bachelor’s degree, but this is becoming rarer.

The training philosophies of the two disciplines differ. P.A.s are basically trained from the medical school model. N.P.s are more likely trained inside a School of Nursing. Much of the coursework required for either license is very similar. Nurse Practitioners are allowed to practice independently in some states, but both N.P.s and P.A.s more commonly operate under the direct supervision of a physician.

As each discipline has maturity and training protocols have developed, both are slowly transforming into Master’s Degree level programs or even higher. Both P.A.s and N.P.s are required to have passed local and national licensing tests and each must re-qualify with continuing education and re-testing every six years.

Both P.A.s and N.P.s have prescribing authority, perform physical exams, order and interpret lab results, diagnose illness, and treat patients. A big argument for the expansion of these programs during a time of looming shortages is that P.A.s and N.P.s can be trained in a much shorter time frame than fully certified M.D. or D.O. without any apparent dilution in quality of care. Some studies even show that N.P.s and P.A.s perform some tasks at a higher level than the supervising doctors.

The net effect from the addition of both categories of new professionals is to extend the patient access capabilities for existing physicians. Many P.A.s and N.P.s work in  physician shortage areas. Both groups earn good livings; but normally at about half the salary of what a typical primary care doctor earns.

By 2020, the number of available P.A.s will have expanded from today’s 75,000 to around 140,000. Projections for Nurse Practitioner numbers are harder to come by. There are an estimated 140,000 licensed Nurse Practitioners today. The limiting factor in training additional N.P.s may be the number of doctoral level trainers available and the level of pay that these trainers can expect for their work.

The existence of these two, fairly new, career paths make the looming, primary physician shortage challenge appear more manageable than it  otherwise might have been.

Other shortfalls in nurses and other technical personnel may be harder to solve because of a potential lack of teachers. Pay for experienced professionals in these areas may be in excess of what has traditionally paid to teachers in technical programs.

http://www.examiner.com/x-5968-DC-Public-Policy-Examiner~y2009m8d26-
Doctor-shortage-may-be-mitigated-by-Nurse-Practitioners-and-Physician-Assistants

Assistant Surgeon General 
Encourages Physician Assistant Students To Help Eliminate Health Disparities On Campus 

Mark Stanczak Assistant Surgeon General Rear Admiral Michael R. Milner and Cynthia Lord, clinical assistant professor of physician assistant studies and director of the Physician Assistant Program at Quinnipiac University and chairman of the board and immediate past president of the American Academy of Physician Assistants.

Racial disparities continue to plague America's health care system, but physician assistants can play an important role in creating a more equitable health care system by working in diverse communities, encouraging preventative medicine and improving health care literacy, said Assistant Surgeon General Rear Admiral Michael R. Milner, DHSc, PA-C, regional health administrator, U.S. Public Health Service, New England Region I.

"PAs have got to be in the forefront of prevention," said Milner, the highest-ranking physician assistant in the U.S. Public Health Service, as well as in all the uniformed services. "Programs like Quinnipiac, and also Yale, get the students engaged in the community and they become valuable educators."

Milner delivered a lecture on July 27 at Quinnipiac University to about 150 students, mainly from the Quinnipiac physician assistant program. About a dozen PA students from Yale University also attended the lecture.

As a regional health administrator, Milner works to eliminate the health disparities. His priorities also include improving preparedness for disaster response and increasing prevention of health problems. At least 95 percent of health care is treatment-centered, he explained. "We do very little as a nation to prevent those illnesses in the first place," he said.

Milner's office collaborates with organizations and universities, including Quinnipiac, to improve health literacy.

"It helps people understand where to go to get good health informationinformation they can access, understand and use to help them make appropriate health decisions," Milner said. He praised Quinnipiac physician assistant students, who volunteer in diverse communities.

Kelley Slauson, a Quinnipiac third-year PA student from Stratford is volunteering this summer at clinics that provide health care to migrant farm workers. She said this experience has helped her become more culturally sensitive to patients and acutely aware of differences that can contribute to disparities in health care. "We work hard not to have differences play a role in the care we provide," said Slauson.

Quinnipiac's PA program administrators make an effort to accept students of diverse backgrounds who have different perspectives on health care. "Having these differences enriches the conversations that take place in the program," said William Kohlhepp, associate professor in the program.

"Quinnipiac's PA program integrates this type of education very well, with both classes and hands-on experiences in underserved areas," said Barrett. "Disparities exist in all facets of life, including medicine, and this is a real problem that can have very dire consequences. I think education to future and present health care providers is paramount in the recession of these disparities."

Office of the Press Secretary
____________________________________________________________________
For Immediate Release                                                 July 20, 2009

REMARKS BY THE PRESIDENT ON HEALTH CARE

Children's Hospital
Washington, D.C.

1:25 P.M. EDT

THE PRESIDENT: Well, I just first of all want to thank the Children's Hospital for hosting us today. And I want to thank the participants, Joseph Wright, Brian Jacobs, Yewande Johnson, Michael Knappe, Regina Hartridge, and Kathleen Quigley.

I just had the opportunity to talk to doctors, nurses, physician’s assistants, and administrators at this extraordinary institution. We spoke about some of the strains on our health care system and some of the strains our health care system places on parents with sick children.

We spoke about the amount of time and money wasted on insurance-driven bureaucracy. We spoke about the growing number of Americans who are uninsured and underinsured. We spoke about what's wrong with a system where women can't always afford maternity care and parents can't afford checkups for their kids, and end up seeking treatment in emergency rooms like the ones here at Children's. We spoke about the fact that it's very hard even for families who have health insurance to access primary care physicians and pediatricians. In a city like Washington, D.C., you've got all the doctors in one half of the city, very few doctors in the other half of the city. And part of that has to do with just the manner in which reimbursement is taking place and the disincentives for doctors, nurses, and physicians assistants in caring for those who are most in need.

And we spoke about where we're headed if we once again delay and defer health insurance reform.

These health care professionals are doing heroic work each and every day to save the lives of America's children. But they're being forced to fight through a system that works better for drug companies and insurance companies than for the American people that all these wonderful health professionals entered their profession to serve.

And over the past decade, premiums have doubled in America; out-of-pocket costs have shot up by a third; deductibles have continued to climb. And yet, even as America's families have been battered by spiraling health care costs, health insurance companies and their executives have reaped windfall profits from a broken system.

Now, we've talked this problem to death, year after year. But unless we act -- and act now -- none of this will change. Just a quick statistic I heard about this hospital: Just a few years ago, there were approximately 50,000 people coming into the emergency room. Now they've got 85,000. There's been almost a doubling of emergency room care in a relatively short span of time, which is putting enormous strains on the system as a whole. That's the status quo, and it's only going to get worse.

If we do nothing, then families will spend more and more of their income for less and less care. The number of people who lose their insurance because they've lost or changed jobs will continue to grow. More children will be denied coverage on account of asthma or a heart condition. Jobs will be lost, take-home pay will be lower, businesses will shutter, and we will continue to waste hundreds of billions of dollars on insurance company boondoggles and inefficiencies that add to our financial burdens without making us any healthier.

So the need for reform is urgent and it is indisputable. No one denies that we're on an unsustainable path. We all know there are more efficient ways of doing it. We just -- I spoke to the chief information officer here at the hospital and he talked about some wonderful ways in which we could potentially gather up electronic medical records and information for every child not just that comes to this hospital but in the entire region, and how much money could be saved and how the health of these kids could be improved. But it requires an investment.

Now, there are some in this town who are content to perpetuate the status quo, are in fact fighting reform on behalf of powerful special interests. There are others who recognize the problem, but believe -- or perhaps, hope -- that we can put off the hard work of insurance reform for another day, another year, another decade.

Just the other day, one Republican senator said -- and I'm quoting him now -- "If we're able to stop Obama on this, it will be his Waterloo. It will break him." Think about that. This isn't about me. This isn't about politics. This is about a health care system that is breaking America's families, breaking America's businesses, and breaking America's economy. (for Mike!!) 

And we can't afford the politics of delay and defeat when it comes to health care. Not this time. Not now. There are too many lives and livelihoods at stake. There are too many families who will be crushed if insurance premiums continue to rise three times as fast as wages. There are too many businesses that will be forced to shed workers, scale back benefits, or drop coverage unless we get spiraling health care costs under control.

The reforms we seek would bring greater competition, choice, savings, and inefficiencies [sic] to our health care system, and greater stability and security to America's families and businesses. For the average American, it will mean lower costs, more options, and coverage you can count on. It will save you and your family money, if we have a more efficient health care system. You won't have to worry about being priced out of the market. You won't have to worry about one illness leading your family into financial ruin. You won't have to worry that you won't be able to afford treatment for a child who gets sick.

We can -- and we must -- make all these reforms, and we can do it in a way that does not add to our deficits over the next decade. I've said this before. Let me repeat: The bill I sign must reflect my commitment and the commitment of Congress to slow the growth of health care costs over the long run. That's how we can ensure that health care reform strengthens our national -- our nation's fiscal health at the same time.

Now, we always knew that passing health care reform wouldn't be easy. We always knew that doing what is right would be hard. There's just a tendency towards inertia in this town. I understand that as well as anybody. But we're a country that chooses the harder right over the easier wrong. That's what we have to do this time. We have to do that once more.

So let's fight our way through the politics of the moment. Let's pass reform by the end of this year. Let's commit ourselves to delivering our country a better future -- and that future will be seen in a place like Children's Hospital, when young people are getting the care that they deserve and they need, when they need it, and we don't have an overcrowded emergency room just putting enormous burdens on this excellent institution. I think we can accomplish that, but we're going to have to do some work over the next few weeks and the next few months.

Thank you very much everyone. (Applause.)

END 
1:33 P.M. EDT

PSN  is a monthly video news show for health care professionals. It covers 
significant safety alerts, recalls and new product approvals, and it offers 
 important tips on protecting patients. Read the complete stories and watch 
or  download the video program at _http://www.fda.gov/psn_ 
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educators in  health care facilities and academic institutions. 

This is the second in my series of '4 question interviews', today with
Dr. Jonathan Kotch,MD Professor in the UNC School of Public Health and
an active member of Physicians for a National Health Plan, which
advocates for a single payer health system in the United States. Like
all 4 question interviews, it is published in full.

Question 1. What is the biggest problem facing the U.S. health care
system?

The biggest problem facing the U.S. health care system is that it is
immoral. It violates a national and international consensus that
health care should be a human right. International agreements such as
the U.N. Declaration of Human Rights (1948) and the Alma Ata
Declaration of the W.H.O. (1978) clearly articulate that health care
is a right, and recent polls in both the U.S. and N.C. have documented
that a majority of those polled agree.

One can argue whether We the People intended to include health
promotion when the U.S. Constitution was established in order to
“Promote the general welfare”, but there is no doubt that, in 1789 or
2009, society cannot enjoy a sense of general welfare if its members
are not healthy. The fact of the matter is, compared to other western
developed nations and some middle income nations as well, the general
health of the people of the U.S. is poor. Part of the reason for this
problem is that the indigent, the sick, and minorities are
systematically excluded from early access to the health care that more
privileged members of our society enjoy. Instead of need for care
being the principle criterion for allocation of health care resources,
ability to pay is the criterion. This is immoral.

As a consequence, poor people are trapped in poverty by illness,
minorities are discriminated against in health care institutions, and
many children cannot benefit from the right to a free and appropriate
public education because of illness, pain, disability, or sensory
problems. The majority of such problems, dental caries, speech and
language difficulties, or hearing or vision impairment for example,
are fully preventable or if not, treatable, if one is lucky enough to
be born into a family with money and access to health care.
Increasingly, poor and minority children are not, and as a direct
result of social inequalities exacerbated by our unjust health care
system, health disparities persist.

An unjust and inequitable health care system harms us all. For too
long Americans have been seduced by commercial health care
institutions, private insurance companies and politicians into
believing that U.S. health care is the best in the world. It isn’t.
The W.H.O. ranks the U.S. health care system 37th in the world in
overall quality. It is mainly the cost and access issues that bring
our ratings down, but it is also the case that life expectancy and
infant mortality are worse in the U.S. than in every other developed
country and some not so developed countries.

Yet, the U.S. spends more money on health care, both total and per
capita, than any other country in the world. Where is it all going? In
the first place, up to 30 cents of every health care premium dollar
goes to pay the administrative costs of running a private, for-profit
health insurance system. It has been estimated that, if the
administrative cost of providing health care for all were the same as
that of providing health care for Medicare beneficiaries (about 3%),
there would be enough money saved to provide health care services to
every one of the 46 million uninsured persons in our country. In my
mind, this mis-appropriation of health care resources is immoral.

Other evidence that the U.S. health care system is immoral is over-
spending on unnecessary health care when people are dying (18,000 per
year) because they do not have health insurance. In the U.S., one only
has to have money to have any amount of health care one desires. There
is no limit on how many Botox treatments or tummy tucks one can have
if one can pay for them. More serious is the overuse of medical
technology. Appropriately utilized, advanced medical interventions can
save lives. But in fact, too many patients demand services that they
don’t need (whole body scans being a recent example), and too many
doctors order too many tests and prescribe too many medications. And
those medications, by the way, are more expensive than the identical
medications in those developed countries around the world (and
immediately to our north) where governments purchase them in bulk and
at a great discount, which savings is passed on to consumers.

In a just world, resources for human services would be directed to
where they are most needed. In the U.S., the opposite is true. Health
insurance companies systematically exclude those most in need, reward
their employees for denying claims, drop those with catastrophic
expenses, and continue to return enormous profits to investors. If
that isn’t immoral, then I have a kidney for sale.

Question 2. What do you most want to see preserved about the U.S.
health care system?

What is best about the U.S. health care system is the patient-provider
relationship. I deliberately use the term provider rather than doctor
because of the importance of a patient’s relationship with many
different kinds of health professionals. In fact this privileged
relationship has been undermined by the demands of private, for-profit
insurers and health care institutions. Doctors and other providers are
increasingly practicing medicine in a toxic economic environment,
forcing them to make decisions based on what generates reimbursement
rather than what generates good health.

There is no way to restore trust to the system as long as Wall Street
(and Congress) consider health care to be a commodity. Americans like
their doctors, and the principle that patients should be able to pick
their primary care provider (doctor or mid-level provider such as a
nurse practitioner or physician assistant) is a necessary feature of
any health care reform proposal. The imposition of arbitrary
distinctions between “in-network” and “out-of-network” providers by
profit-driven insurers increasingly violates this principle.

Question 3. What is the most important health policy priority for
North Carolina (or the USA)? [answer which ever you want to answer]

For me, the answer is the same for both the U.S. and N.C., elimination
of health disparities. The unfairness of continuing barriers to health
care, and continuing differences in health status, based on race,
income and ethnicity is appalling. The fact that these disadvantaged
populations suffer disproportionately from illness, injury and
disability is not new. What is increasingly clear is the
discrimination experienced by such patients whose access to care
compared to white patients is compromised, even controlling for the
type and severity of their health problems. Eliminating disparities
should be a first principle of any health care reform proposal.

Question 4. If you could design a health system from scratch, what

would it look like?

In this regard I would refer to Health Care for All NC’s “Guidelines
for Real Health Care Reform” at http://www.healthcareforallnc.org/.
Although crafted as a single payer solution for North Carolina’s
health care crisis, in fact it borrows some ideas from the U.S.
National Health Care Act (HR 676) that is under consideration in the
U.S. House of Representatives.

Among the principles articulated in “Guidelines” (see http://www.healthcareforallnc.org/resources/Brochures/OurPlanmar09.pdf
  for the entire thing) are:

· Access to appropriate health care is a right. It isn’t something you
have to sign up for, and no one would need to be forced to join or
penalized for refusing to join.

· Benefits would include all outpatient and inpatient services deemed
necessary and appropriate by a Public Commission, answerable to
voters, in consideration of available evidence and professional
standards of practice.

· The system would be financed by a progressive system of income and
payroll taxes, with the result that small businesses would pay
proportionately less that large businesses, and low income individuals
would pay proportionately less than the wealthy.

· All current providers, solo and group, private and public, would be
eligible to participate, provided that they are not-for-profit.
Patients would have free choice of their primary health care provider.

· Providers would be compensated based on a fee schedule negotiated
between the Commission and their professional associations.

· The system would reward primary and preventive care and eliminate
incentives for specialty and tertiary care. Access to specialty care
would be by referral only.

· Similarly, outpatient care would be encouraged, and inpatient care
discouraged. Hospitals and other institutional providers would be
given an annual budget within which they would be required to operate.

· Quality would be assured by the appointment of a Quality Board to
monitor the delivery of health care services. The Board would assure
that care is available to all regardless of age, race, ethnicity,
income or geographical location.

Independence Day

"When in the Course of human events, it becomes necessary for one
people to dissolve the political bands which have connected them with
another, and to assume among the powers of the earth, the separate and
equal station to which the Laws of Nature and of Nature’s God entitle
them, a decent respect to the opinions of mankind requires that they
should declare the causes which impel them to the separation".
Thomas Jefferson

“Dependence” is an interesting concept.  While it is widely accepted
that “no man is an island”, there are few examples of laws which bind
one person in dependence to another.  However, one example does exist—
physician assistants are forever dependent to one or more physicians.

In the 1960’s when the concept of non-physician medical providers
developed there were a lot of concerns about how someone not trained
as a physician could do the things that physicians did.  There was no
history, no record of performance, no data to support such an idea.
Necessarily concessions had to be made.

We still live with these concessions.  I am about to take the
recertification examination for the 6th time.  I can only practice
medicine in the office of my supervising physician.

A lot has changed since the 60’s.

I typed the above sentence yesterday, July 4th, at 9:15AM.  Now, a day
later, I return.

At 9:15AM yesterday my house was rocked by a loud boom.  I thought it
was a sonic boom, but the sound and shaking continued for several
seconds.  I thought a branch had fallen from a tree and rolled down
the incline of my roof.  But I knew.  Somehow you know these things.
I called to my wife in the other room.  She knew, too.  We both said,
“The fireworks….”

Like everyone else in the village we went outside and looked toward
the harbor where smoke and flame shot into the air.  Like everyone
else in the village we walked towards the smoke, knowing, not yet
believing, what had happened.

Things like this always happen someplace else.  They are sad stories
carried at the front of the news for a day or two.  They always
involve another place, other people.  This day they were here, right
in front of us, possibly, probably involving people we knew, friends.

We rode our bikes to an area across the harbor, knowing that the
fireworks for the evenings 22 minute pyrotechnics show had exploded on
the ground in 4 or 5 seconds.  We saw flames in the brush around the
harbor and listened to the many sirens just a few hundred yards away.

I went to the health center where I had worked when I was the only PA
on this remote island.  I was prepared to help in what was sure to be
a mass casualty situation.  Many other medical personnel showed up.
Physicians and nurses here on holiday and vacation came to provide
what help they could.  Some went to the scene where the physician and
NP who now staff the clinic had all ready reported.  The island
paramedics rolled all the ambulances and went to the scene.  The
volunteer fire department, the National Park Service, the local
police, and officers of the Marine Fisheries were all on scene.

Two physicians, the health center nurse, and I got out supplies and
prepared to receive casualties.

Fortunately there were only 5 casualties.  Unfortunately their
injuries were serious enough for helicopter evacuation from the
scene.  No casualties came to the health center.

We put our supplies away, turned off the machines we had warmed up and
checked and I went home.

Eventually the details of the story unfolded.  Five members of the
crew employed by the fireworks company were involved in a blast that
involved the 18 wheeler filled with fireworks.  One died on the scene,
4 were transported by helicopter—2 to the regional burn center and 2
to the level one trauma hospital, both on the mainland.

This morning we got the news that 2 more victims died, one at each
hospital.

I am a physician assistant, a dependent practitioner.  My license to
work is tied to the physician and the office where I work off-island.
I have no legal authority to work here on the island where I live.  I
was prepared to violate the letter of the law to help in the tragedy
yesterday.  This is my community and these are my people but my status
as a dependent practitioner ties me to the urgent care 75 miles away
where I still work.

Where was I?  “A lot has changed since the 60’s.”

In the 60’s most medicine was practiced from single physician
offices.  Physicians delivered their pregnant patients, admitted and
cared for their own patients.  Some still did their own
appendectomies.  When one of their patients showed up in the emergency
room, the physician left the office and went to the ER to provide
care.  The idea of an interdependent system of specialists and sub-
specialists and the technology we now take for granted was years away.

Considering the mindset of the 60’s it is easy to understand why a
provider who did not attend medical school was a frightening idea.
How could someone who had not gone to medical school do all the things
that doctors did?

The decision was made to try this “physician’s assistant concept” with
certain stipulations.  The first was that the PA would be tied to the
physician—dependent—and would only perform those tasks that the
physician delegated.  These PAs would not run off and practice
medicine alone.

Oh yes and to assure competence they would take a standardized entry
level exam.  If that’s not enough, we’ll take another exam every six
years to assure continued competency.

It is not the 60’s anymore.  No one practices alone.  Surgeons refer
rashes to dermatologists.  Internists refer diabetics to
endocrinologists.  Family practice refers to everyone, and they all
refer back to the primary-medical-doctor.  No one group or specialty
is independent.  The US health care system has evolved into a complex
network of interdependence.

So who sees the patient when I refer?  Most of the time, the first
contact in the specialist’s office is a PA or NP.

The system has evolved.  My profession has not.  After 31 years of
experience and countless thousands of patient contacts, I am still
defined by the concessions made in the 60’s to birth my profession.

Today I am defined by a vocabulary that is outdated.  PAs are
“dependent”.  NPs “collaborate”.  But in today’s system who does not
collaborate?  Who is not dependent?

All medical providers are trusted with a huge body of evolving
knowledge.  Maybe it was possible in the 60’s for one doctor to
provide all the care that his/her patient’s needed, but it is simply
impossible today.  Each medical provider must know his or her limits
and competencies and stay current with new developments.

So my questions are these:
How many years of clinical experience does it take to know one’s area
of work?
How long will my profession be defined by words and concepts that by
now are quaint pieces of history?
When will the concept of “independent” practice give way to the
reality that we all collaborate, we are all interdependent?

When will my associations realize this is something they have to
tackle for us to become full professionals?

And when can I respond to an emergency and provide my hard earned
expertise and high quality treatment in a crisis when I am not in
contact with my supervising physician’s practice?

 From Medscape:
http://www.medscape.com/viewarticle/705120?src=emailthis

Robert C. Scroggins, JD, CPA, CHBC

Published: 07/09/2009
Introduction

Today it's estimated that less than a third of medical practices use
physician extenders. Some physicians don't want to or don't see the
need. However, as our healthcare climate continues to evolve, there
are more reasons than ever why physicians should consider adding nurse
practitioners (NPs) and physician assistants (PAs).

1) Potential changes in healthcare present an opportunity for
physicians.

If universal healthcare coverage becomes a reality, more than 40
million people will enter the mainstream healthcare system. There's
also talk of patients having a Medical Home, which would drive even
more healthcare delivery and management to the primary care physicians.

To care for the new patients, we would potentially need an additional
10,000 physicians. However, according to the US Department of Health &
Human Services, the increase in the supply of primary care physicians
between 2005 and 2020 is anticipated to be only 18%, on the basis of
anticipated population growth and the aging of our population.

However, PA and NP programs combined are delivering over 10,000
providers into the system annually. Realistically, the only practical
solution will be for physician extenders to help satisfy the demand.

2) Competition may require it.

Physicians have seen an erosion of patients to minute clinics, other
retail clinics, and physician practices that have extended hours:
Saturdays, evenings, lunch hours, and early mornings. Although open
access and other forms of scheduling can increase your hours, there's
nothing like a physician extender to enable your practice to see more
patients sooner.

3) In a time of declining reimbursement, physician extenders can help
boost revenue.

The typical PA brings in revenue of $231,000 with an average salary of
$84,000, according to The MGMA Physician Compensation and Production
Survey: 2008 Report Based on 2007 Data. After covering the cost of his
or her own salary, benefits, and incremental overhead a typical PA can
boost your bottom line by an estimated $30,000 or more.

4) Ancillary services can bring in more revenue, but often you'll need
additional qualified personnel in order to provide some of those
services and still see as many patients. In addition, extenders can
help generate more ancillary revenue because ancillary service volume
is driven by office visit encounters.
Objections

Despite the foregoing advantages, many physicians are still reluctant
to add physician extenders. Physicians who I've spoken with have given
these objections.

PAs and NPs don't fit with the culture of my practice.

This is because you have not incorporated them into your practice, so
of course they are not a part of your current culture. Extender
services need to be thoughtfully added. If you hire on the basis of
intelligence, attitude, and personality, you can maintain your
practice culture without any problem whatsoever.

I don't have the space to add another person.

Space requirements definitely need to be addressed. Relatively
speaking, space is cheap. You should always err on the side of having
a little extra clinical space so that your production is not hampered.
Loss of production costs a lot more than extra square footage. It may
be time to look at relocation. If you are truly short on space, do not
try to add an extender with the assumption that you will make-do.
Enough space is a necessity.

I'm reluctant to invest in the additional overhead; what if I hire
this person and then my volume declines or my income drops?

Taking risks is part of being a business owner, and the flip side of
risk is reward. If you go about it correctly and hire the right
extender(s), it will be worth the investment. Talk to colleagues who
are using extenders successfully to find out how it went for them, and
consider bringing in a practice management consultant to help answer
questions about your specific practice infrastructure and how to plan
for the addition of 1 or more extenders -- and keep in mind that every
practice is different.

I don't know how I'll divide the current workload; this will change my
whole workflow of the office, and it may become chaos.

It may sound obvious, but your NP or PA should handle patient
encounters that do not require the training, knowledge, and experience
of a licensed physician. Remember that you will be there to step in
and/or field questions as needed. You will also want to fill the
extender's schedule before your own. This sounds backward and maybe a
little uncomfortable, but your schedule will fill up. Make sure that
you do not compete with your extender(s) for patients, but instead
ensure that they are as productive as possible.

It is true that not every practice needs physician extenders. There
are situations in which these staff members are less valuable: if
you're a few years away from retirement and are winding down; if
you're content with the way your income has been going and have no
desire for changes; if you don't want the additional management and
supervisory responsibilities.

Like anyone, you need to enjoy your work and not dread going to the
office, so if the addition of extenders would create more stress and
anxiety for you, it wouldn't make sense to add them.

Other physicians who incorporate extenders and learn to delegate the
work that can be done by a nonphysician should experience higher
practice profitability and enjoyment. Put your energy toward figuring
out how to most effectively, efficiently, and profitably position your
practice to sell your product to 40 million new customers.

If you have a question that you'd like this column to address, please
send your questions to BusofMedEditor@medscape.net.

Robert C. Scroggins, JD, CPA, CHBC

Principal, Management Consultant, Clayton L. Scroggins Associate,
Inc., Cincinnati, Ohio

Disclosure: Robert C. Scroggins, JD, CPA, CHBC, has disclosed no
relevant financial relationships.