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Physician assistants can enhance experience in a practice
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In our practice at Minnesota Eye Consultants, we are committed to what I call an “integrated eye care delivery model.” We have 13 ophthalmologists and 13 optometrists. To support these doctors and the six offices and four ASCs we staff, Minnesota Eye Consultants employs about 55 certified ophthalmic technologists/technicians/assistants and optometric assistants, 26 RNs/LPNs, seven certified operating room technicians, six opticians and, starting 5 years ago, a physician assistant, up to three PAs today.
In our practice, the PAs practice independently within our state of Minnesota’s scope of practice laws, much like our doctors of optometry, but we have assigned our PAs distinctly different duties and responsibilities from our optometrists. With 12 surgeons performing more than 16,000 surgical procedures a year, there are many history and physical examinations (H&P) to be performed within 30 days of surgery. We have our YAG lasers in our ASCs, as our surgeons do YAG laser procedures between cataract surgery cases, and each YAG laser patient also requires an H&P. In addition, we have a total of 290 employees, and we “self-insure” with catastrophic third-party insurance coverage using a high deductible for our employee and our own health care. Our PAs therefore also provide significant primary and preventive medical care to our team members. This is a valued service for our employees and also reduces their and our health care costs significantly.
We have found in our model that optometrists and “ophthalmic techs” are more valuable in the clinic, as the typical PA and nurse practitioner training is as a primary care provider. Both my cardiologist and orthopedic surgeon also employ PAs, and as a patient, I am on a first-name basis with both. They are delegated significant responsibility, and the fellowship-trained orthopedic surgeon I favor has one PA in the OR with him opening and closing, one in the hospital making rounds on postoperative patients, and one in the clinic seeing patients every day. My orthopedic surgeon has a large surgical practice, including many VIP patients, and we have all come to accept and appreciate the quality of care provided by these surgeon extenders. Surveys confirm that 92% of patients are comfortable having a PA or NP share in their care.
Now, a little more about PAs and NPs. There is an American Academy of Physician Assistants and an American Association of Nurse Practitioners. Much can be learned on their websites. The Accountable Care Act of 2010 was the first law to adopt the “provider” descriptor rather than the “physician” descriptor. We MDs, DOs as physicians, NPs and PAs were all defined in the ACA equally as “providers.” The importance of being an official “provider” as defined by our federal and state governments is significant because providers can practice independently within their individual state-defined scope-of-practice laws and, of more importance, get reimbursed by patients directly and by both private and governmental third-party insurance programs, including Medicare and Medicaid. As most of you know, we ophthalmologists and our optometric colleagues are also classified equally as “eye care providers,” and both of us can practice independently and bill patients or insurance.
The training of a PA or NP is rigorous and focused on general medicine. PA training is similar to going to medical school, but for only 3 years. PAs must complete 2,000 hours (50 weeks, much like an internship) of supervised clinical training with rotations in family medicine, internal medicine, obstetrics, pediatrics, general surgery, emergency room and psychiatry. They must pass a National Certifying Examination to be certified and must then apply for and obtain a state license, very similar to MDs. They must recertify every 10 years and complete 100 hours of CME each 2 years to retain their certification and licensure.
NP training varies somewhat depending on the school of nursing where the training is provided and can result in an MS or PhD degree in addition to the required RN. NPs, officially titled advanced practice registered nurses, are licensed through the state boards of nursing, but the practice privileges and responsibilities are similar to those of a PA. According to the national societies, there are 108,000 certified PAs in the United States and slightly more NPs, especially if nurse anesthetists, nurse psychiatrists and those teaching in nursing schools are included.
Many studies suggest that we will have an 80,000 MD-shortage based on projected demand by 2025, and PAs and NPs are one set of well-trained providers positioned to fill the gap. The American Academy of Physician Assistants website suggests that 300,000 PAs will be needed in a decade and that the position represents a great opportunity for young people in the health care field. The current median salary for a PA or NP is approximately $100,000, and 84% are happy and would choose the same profession again (of interest, that is higher than any primary care MD). Two-thirds of PAs and even a larger proportion of NPs are women. Because it is a new profession, the median age is 38 years. Most work in primary care, but 19.5% work with surgical specialist MDs, and while many work in hospitals or emergency rooms, 54% are employed by private physicians. PAs on average see about 60 patients a week.
We have found our PAs generate enough revenue to pay for their salaries and benefits, but we do not consider them a meaningful current or potential future profit center. They are employed as a service to our patients and employees with the goal of enhancing both groups’ experience in our practice. In this regard, they have been a great success and a very positive addition to our practice.