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PAs in the orthopedics practice: Use this resource to extend your capabilities
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As I have traveled around the United States throughout my career visiting colleagues in their different clinic and surgery settings, I have observed many varied and productive relationships between physicians and skilled, conscientious physician assistants (PAs) who work together in a symbiotic way.
I have learned that it is important for the orthopedic surgeon to give a good deal of thought to the scope of the PA’s position and responsibilities within a practice. If done correctly, incorporating a PA into a practice can result in a very productive relationship in which both individuals continue to grow and expand in scope and practice.
There are many reasons relating to efficiency and quality-of care for bringing a PA into your practice environment, as well as individual financial considerations. We all have had experience in adding or becoming a partner, but adding a PA is somewhat different.
I turned to the president of the American Academy of Physician Assistants to moderate this discussion with members of his organization to help all of us understand these relationships as a starting point for those wishing to add or expand the role of a PA.
Douglas W. Jackson, MD
Chief Medical Editor
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Gregor F. Bennett, MA, PA-C
Radford J. Hayden, PA-C
Tricia Marriott, PA-C, MPAS
Dennis Rivenburgh, MS, ATC, PA-CGregor F. Bennett, MA, PA-C: How did you and your supervising physician establish your scope of practice?
Tricia Marriott, PA-C, MPAS: Fortunately, my supervising physicians trained in hospitals that utilize PAs in orthopedics. The PAs and physicians in our practice have worked together to determine how the PAs are utilized and the scope of our practice. There is a symbiosis and synergy that arises out of such an approach. Communication between the supervising physician(s) and the PA(s) is the key to a successful physician/PA team. No matter how much experience someone has, a PA must know that, when faced with an unusual case presentation, X-ray finding or management dilemma, the physician is willing and available for consultation. Conversely, the physician needs to be sure that the PA will seek guidance when appropriate. The new PA is a true apprentice, learning “your” way of doing things. An experienced PA often has insight and judgment skills that can be valuable to your practice. Regardless of experience, every PA has been educated in the medical model of diagnosis and treatment. A PA performs “physician services” that otherwise would have to be performed by the physician. The PA is an extension of your practice.
Radford J. Hayden, PA-C: The first decision that the surgeon needs to make is how much time they are willing to invest in training and orienting the PA to their practice. The second most important decision is to determine what you want the PA to do and to clearly define the role to the prospective candidate. A candid discussion between the surgeon and PA about scope of practice issues and position responsibilities avoids future frustration. Finally, everyone needs to be aware of any legislative and institutional limitations on a practice.
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| PAs are educated in a broad spectrum of surgery and medicine and provide services that are delegated by the supervising physician. Images: American Academy of Physician Assistants |
In my case, with the years of experience in my specialty and with the number of residents available to scrub, I’m most valuable in clinic seeing a variety of patients and shortening wait times for appointments.
Bennett: What is the biggest reimbursement hurdle faced by your employer when it comes to being paid for the services provided by a PA? How do you address the issue?
Dennis Rivenburgh, MS, ATC, PA-C: Our biggest reimbursement hurdle was with a number of the private insurers. We worked with our provider representative to make sure that we were billing correctly and did what we needed to do to appropriately maximize reimbursement.
Hayden: Although reimbursement for services provided by PAs has increased over the years, surgeons and hospital administrators should appreciate that the PA profession was never created to be an income generator; rather, we are extenders of physician services. To help defray the costs of PA salaries and benefits it is not unusual to have the PA performing nonrevenue generating tasks, such as postop visits under the global fee model, while the surgeon is freed up to engage in activities that produce additional income for the practice. I would also recommend a review of the practice’s billing system. Proper use of coding and billing modifiers often allow for increased reimbursement.
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| In all 50 states, PAs are licensed to practice medicine with physician supervision, conferring with physicians as required by law and when necessary for unusual or complicated cases. |
Marriott: The biggest reimbursement challenge facing surgical practices in general is the tremendous amount of work that is included in the global fee payment. PAs can contribute significantly by performing many of the time-consuming tasks associated with the primary procedure, such as hospital rounds, medication management, dressing changes, suture removal, hospital paperwork, etc. The physician is then able to use his or her time seeing new patients, performing more procedures, and other revenue- generating functions.
From a practical standpoint, the payers have varying rules regarding reimbursement for services provided by PAs. It is paramount for the practice manager to obtain, in writing, specific instructions regarding how the insurance company wishes to be billed for those services. Additionally, Explanations of Benefits (EOBs) must be monitored for payment and challenged when denied.
Bennett: What are the significant differences in PA use in private practice vs. a university environment?
Hayden: There are several. The first is decreased operating room exposure. I have practiced in both the private and university milieus, and I have less exposure to the OR in the teaching hospital than in private practice. The purpose of the teaching hospital is to train young surgeons, and they need as much exposure as possible.
A second difference is in education. If a PA is interested in teaching and research, there is plenty of time and resources to focus on these activities in the university setting. In private practice, the primary focus is on patient care and maintaining the financial health of the practice. Finally, in the university setting, salaries are generally less but the hours are not as demanding, and there is less call time and weekend activity.
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| Source: American Academy of Physician Assistants, www.aapa.org/research/06census-content.html |
Rivenburgh: The biggest area is in billing for services provided by PAs. For example, the presence of a resident in surgery may limit reimbursement for first-assist services provided by a PA. However, PAs need to develop an effective relationship with the new orthopedic surgeons coming up. We need to continue to establish ourselves with them and provide the assistance that they need to become the orthopedists of the future.
Marriott: Faced with fewer residents, higher patient acuity and larger caseloads, hospitals have turned to PAs for staffing relief. In the world of shrinking resident hours, PAs have become the “glue” in teaching hospitals. Having a PA on the service provides continuity for the physicians and hospital staff, as the residents rotate through and move on.
PAs can perform any function delegated by the physician within the PA’s scope of practice and the medical staff delineation of privileges. Assisting at surgery, fracture reduction, wound closure, evaluating and treating patients in the emergency department or the clinic, and ordering tests or medications, are some of the functions a PA can perform. Each practice setting should evaluate its needs and use the PA accordingly. However, it must be mentioned that, like our physician colleagues, PAs enjoy a healthy balance between clinic and procedures.
Bennett: What’s the difference between a PA and an OPA?
Rivenburgh: There are several major differences between PAs certified by National Commission for the Certification of Physician Assistants (NCCPA) and the certified orthopedic physician assistant (OPA-C).
The first difference is in education. To become a PA, individuals must graduate from one of the more than 130 nationally accredited PA educational programs. PA education is in the physician model with didactic and clinical training in all aspects of medicine. There was physician support of the OPA educational programs in the beginning; however, the programs were never accredited as physician assistant programs, and all have closed.
The second difference is certification. The professional society for OPAs established its own certification board and developed an examination administered by the Professional Testing Corporation. To be eligible to take the exam, candidates must be graduates of an OPA, PA or nurse practitioner program, or show proof of 5 years of experience (on-the-job training) in orthopedics that is documented by a sponsoring orthopedic surgeon. Graduates of OPA programs have never been allowed to sit for the NCCPA certification examination. Passage of the NCCPA exam is a requirement for PA licensure in all 50 states.
The third difference is Medicare covers services provided by PAs who are legally recognized by the state. It does not reimburse for services provided by OPAs.
A fourth difference is state licensure and scope of practice. Only Tennessee has an OPA-C practice act. California and Minnesota recognized a limited number of OPAs back in the 1970s. All 50 states authorize physicians to delegate prescribing authority to PAs. No state allows OPAs to prescribe.
For more information:
- Gregor F. Bennett, MA, PA-C, can be reached at Spectrum Health Urgent Care, 2332 Alpine Ave., NW, Grand Rapids, MI 49544; 616-391-6269; e-mail: gregorben@comcast.net.
- Radford J. Hayden, PA-C, can be reached at University of Michigan, Department of Orthopedics, 2098 S. Main St., Ann Arbor, MI 48103-5827; 734-998-6541; e-mail: rhayden@med.umich.edu.
- Tricia Marriott, PA-C, MPAS, can be reached at Orthopaedic Surgery, PC, 1579 Straits Turnpike, Middlebury, CT 06762-1835; 203-598-0700; e-mail: MarriottTBonz@sbcglobal.net.
- Dennis Rivenburgh, MS, ATC, PA-C, can be reached at 11890 88th Terrace, Seminole, FL 33772-3535; 727-480-5548; e-mail: dennisriv@mindspring.com.