- Email: [email protected]
Incorporating Physician Assistants and Physician Extenders in the Contemporary Interventional Oncology Practice
Incorporating Physician Assistants and Physician Extenders in the Contemporary Interventional Oncology Practice Kelvin Hong, MD, Christos S. Georgiades, MD, PhD, Jillyn Hebert, PA-C, Tamara Wahlin, PA-C, Sally E. Mitchell, MD, and Jean-Francois H. Geschwind, MD Interventional radiology (IR) has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. With increasing oncologic procedures and patient volume, the balance between quality clinical care, and the time constraints on the busy interventionalist pull in opposing forces. The need for greater clinical support staff in the IR practice is unquestionable. Physician Assistants (and other Physician Extenders) have been in the medical field since the 1960s with intensive clinical training, capabilities of providing patient care and ability to generate revenue income more than justifies their place in the IR. The contemporary model of a clinical orientated service within IR for cancer patients undergoing interventional oncology procedures should include Physician Extenders as a vital part of the team allowing delivery of high-quality patient care. Tech Vasc Interventional Rad 9:96-100 © 2006 Elsevier Inc. All rights reserved. KEYWORDS physician assistants, physician extenders, interventional oncology, clinical practice
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harles T. Dotter, the father of Interventional Radiology (IR) reported in 1968, “if my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities, they will face forfeiture of territorial rights based solely on imaging equipment others can obtain and skills others can learn.”1 The modern interventionalist face an ever increasing need to embrace clinical responsibilities and changing skill set, that for a generation of radiologists, was not a key element their education nor training. The emphasis for stronger clinical service are at times beyond the time constraints, interest, and training for an Interventional Radiologist, including clinic consultation, insurance coding, and preapproval, preprocedure workup and investigation, and inpatient rounding and long term follow-up. It is a priority of interventional radiologists, recognized by the Society of Interventional Radiology (SIR) to advance the agenda of Interventional Oncology (IO) under the aegis of SIR, to confront and address these clinical challenges.2 IR has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. The reasons for this gradual change are numerous and include: 1. Development of new oncologic interventions: birth of a new subspecialty From the Johns Hopkins Medical Institutions, Baltimore, MD. Address reprint requests to JF Geschwind, MD, Johns Hopkins Hospital University School of Medicine, 600 North Wolfe Street, Blalock 545, Baltimore, MD 21287.E-mail: [email protected].
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2. Transformation from procedure technician to becoming the primary care team for patients 3. Acquiring hospital admission privileges by IR staff 4. Developing specialty IR clinical service teams 5. Holding patient clinic, inpatient rounds, follow-up clinic 6. Attendance at multi-disciplinary tumor board meetings 7. Increasing communication demands (patient-physician, physician-physician) As the clinical responsibilities of IR groups mature and duties multiply, they require input and assistance from dedicated support personnel. This role has begun to be filled by Physician Assistants (PA), Nurse Practitioners (NP), and Radiology Practitioner Assistants (RPA) collectively termed Physician Extenders (PE), or alternatively called mid-level providers or nonphysician practitioners.3-5 PEs have long played a significant role in clinically oriented specialties, particularly primary health. At the authors’ institution, recognizing the importance of direct participation in patient care and clinical management, admission privileges for interventional radiologist has long been long established since the early 1980s, described by White and co-workers.6,7 Since 1982 our academic clinical IR practice has embraced the incorporation of Physician Extenders (PE), in PAs into the IR practice as a vital part of the growth and foundation of a busy group practice that today encompasses 8 clinical faculty members, 2 research faculty, 4 Physician Assistants, and 7 IR training fellows.
PAs and PEs in the contemporary interventional oncology practice This article serves to outline the roles of PE; in particular PAs and briefly reviews their training, compliance, and credentialing requirements, financial justification, and possible duties.
Background PAs are a young profession with it roots in the 1960s8 where physician educators recognized a shortage and uneven distribution of primary care health providers. Eugene Stead Jr, Medicine chair at Duke University first initiated a plan to train assistants to physicians in 1965, with the first graduating class of 3 PAs in 1967.9 He based the curriculum of the PA program in part on his knowledge of the fast-track training of doctors during World War II. This was the birth of a profession that has become one of the fastest growing professions assessed by the United States Department of Labor because of anticipated expansion of the health care industry and an emphasis on cost containment, resulting in increasing utilization of PAs by physicians and health care institutions through to 2014.10 By 2006, over 70,612 persons were eligible to practice as a PA.10 PAs are nonphysician clinicians licensed to practice medicine with a physician’s supervision. PAs are formally trained to perform medical histories and examinations, order treatments, diagnose acute and chronic illnesses, prescribe medication, interpret diagnostic tests, perform invasive and noninvasive procedures, refer patients to specialists when appropriate, and first assist in major procedures. The education of a PA is a generalist approach, modeled after the medical school curriculum. PAs may practice in general medicine or any medical or surgical specialty. Because of their broad based medical education, PAs can change specialties and have the ability to work throughout their career in different medical/surgical specialties. According to the AAPA, PAs must always work under the supervision of a physician. In 48 States and the District of Columbia, PAs may prescribe medications11 and the Drug Enforcement Agency (DEA) has a special registration category specifically for PA and other “midlevel practitioners” authorized by state law or regulation to prescribe controlled substances.12 The PAs function within the scope of practice is established and defined by the supervising physician(s), but must lie within the scope of practice of that physician. PAs strengths lie in clinical patient care, which reflects their training and curriculum. In an IR practice, the role of a PA extends not only to seeing and managing clinical aspects of the patient, but can perform minor IR procedures and assist the physician in more major interventions and re-imbursement is paid at 85% of physician rates. By 2006, of all registered PAs, the vast majority were in clinical practice (91%) with over 60% performing some minor surgical type procedure and 40% taking after hours call responsibilities.10 The American Medical Association (AMA) Guidelines for Physician/ Physician Assistant Practice by adopted the following principles13: 1. Health care services delivered by physicians and PAs must be within the scope of each practitioners authorized practice as defined by state law. 2. The physician is ultimately responsible for coordinat-
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3. 4.
5.
6.
7. 8.
9.
ing and managing the care of patients and, with the appropriate input of the PA, ensuring the quality of health care provided to patients. The physician is responsible for the supervision of the PA in all settings. The role of the PA(s) in the delivery of care should be defined through mutually agreed on guidelines that are developed by the physician and the PA and based on the physician’s delegatory style. The physician must be available for consultation with the PA at all times either in person or through telecommunication systems or other means. The extent of the involvement by the PA in the assessment and implementation of treatment will depend on the complexity and acuity of the patient’s condition and the training and experience and preparation of the PA as adjudged by the physician. Patients should be made clearly aware at all times whether they are being cared for by a physician or a PA. The physician and PA together should review all delegated patient services on a regular basis, as well as the mutually agreed on guidelines for practice. The physician is responsible for clarifying and familiarizing the PA with his supervising methods and style of delegating patient care.
Training The curriculum used to instruct PAs is based on the medical school model, designed to complement physician training and many accredited PA training programs have clinical teaching affiliations with traditional medical schools. All States require that PAs complete an accredited, formal education program, usually 2 years (median 26 months) and pass a national examination to obtain a licensure. In 2006, more than 135 education programs for PAs were accredited or provisionally accredited by the American Academy of Physician Assistants (AAPA). Most applicants to PA educational programs already have a Bachelor’s degree and programs are offered at both bachelor and Masters degree level (Bachelor’s degree 44%, Masters 35%).10Admission requirements vary, but many programs require 2 years of college and some work experience in the health care field. Applicants to PA school often have prior medical experience as registered nurses, military medics, and allied health occupations such as respiratory and physical therapists, and emergency medical paramedics. PAs substantial education includes basic sciences in biochemistry, pathology, human anatomy, physiology, microbiology, clinical pharmacology, clinical medicine, geriatric and home health care, disease prevention, and medical ethics. Students obtain supervised clinical training in several areas, including family medicine, internal medicine, surgery, prenatal care and gynecology, geriatrics, emergency medicine, psychiatry, and pediatrics, all totaling over 2000 hours in supervised clinical practice, producing well balanced generalists, with an emphasis on a team based approach. Federal data and analysis has shown that within their scope of practice, quality of care by PAs can be comparable to physicians.14 All States have legislation governing the qualifications or practice of PA. All jurisdictions require PAs to pass the Phy-
K. Hong et al.
98 sician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants (NCCPA) to graduates of accredited PA education programs only. Only those successfully completing the examination may use the credential “Physician Assistant-Certified” (PA-C). To remain certified, PAs must complete 100 hours of continuing medical education every 2 years. Every 6 years, they must pass a recertification examination.
Credentialing National credentialing occurs through the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which governs the accreditation of the 134 programs.15 On the state and local level, the credentialing process for PAs is different for the various states. In general, the licensing and credentialing at both state and local (hospital level) are performed by the same bodies that regulate physicians, with similar scrutiny and rigor. Usually, the most extensive set of rules are at the State level, covering Certification, educational requirements, scope of practice, collaborative agreements, supervisory requirements, radiation policy, and prescription authority. In the authors’ state of Maryland, the PA credentialing process is regulated by the Maryland Board of Physicians. To check on the process for individual state, the AAPAs Webpage details each state’s Laws and Regulations.16 The applicant PA will be required to fills out educational and clinical work experience and in combination with the intended supervising physician, the application needs to lists the specific types of responsibilities they will hold in their role as a PA in that particular setting; this is called the Delegation Agreement. These roles have to be within the scope of practice of the supervising physician(s). For example, the PA cannot be given the responsibility of a task that could not be done by the supervising physician, if needed. This Delegation Agreement is signed by the physician(s) and PA and outlines the duties and additional privileges (such as prescriptive rights) that are needed for the position. This Delegation Agreement must be approved by the Maryland Board of Physicians. In Maryland, the Board meets monthly to determine if the PA can be credentialed to perform the duties requested. For credentialing to perform specific minor procedures independently (eg, Mediport placement), the state Board will usually required documentation of how many were performed under the guidance of a physician, validation demonstrating knowledge of side effects and complications and other related documentation (eg sedation training course was completed). The credentialing institution requirements are different from state to state as well as within each individual hospital, so discussion with a PA representative at that particular institution may save time and effort during the credentialing process. At the local hospital level, PA credentialing is mostly managed by the hospital medical staff board, and comparable in complexity and rigor compared with physician requests for clinical privileges.
Compliance The Center for Medicare and Medicaid Services (CMS) www.cms.hhs.gov, which governs compliance and reimburse-
ment payment for patients under the Federal medical programs, give PAs and their supervising physicians increased latitude in billing for evaluation and management (E/M) services provided in the hospital setting. The policy allows PAs and physicians to share visits made to patients with the combined work of both covered at 100% of the fee schedule (“Incident to” billing). That is, if the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician’s name and Physician Identification number (PIN). The practitioner who substantially performs the procedure is the one under whose name and number the procedure should be billed. To combine the professional work done by a PA and a physician, the following guidelines must be followed: ● ● ●
The PA and the physician must work for the same entity. The regulation applies only to E/M services and not to procedures. The physician must provide some face-to-face portion of the E/M services
However, “Incident to” billing has never applied to the hospital setting.17 If the physician is not present for any of the face-to-face portion of the E/M encounter, the service is appropriately billed under the PAs name and PIN, with reimbursement at the 75 to 85% rate. When billing for hospital services provided by PAs under the PAs name and PIN, Medicare does not require the on-site presence of the supervising physician; access to telephonic communication is sufficient. Most of the private insurers have the same reimbursement policy, but there is varying compensation from company to company, and from states to state. Always check with your state law and hospital policies, which may be more restrictive than Medicare’s policies.
Other PE: NP and RPA NPs are licensed independent practitioners who provider primary and specialty nursing and medical care in ambulatory, acute, and long-term care settings. They are RNs with specialized advanced education and clinical competency to provide health and medical care for diverse populations in a variety of primary care, acute and long-term care settings. NPs have qualifications of at least Master’s and some even doctoral degrees. They do not require the supervision of a physician, and can be reimbursed for their services directly from insurance company and federal health services. This is in contra-distinction from PA who bill and reimbursed to the supervising physician(s). NPs are registered and licensed by State nursing boards.18 In the clinically setting, functionally, there is little otherwise to differentiate between NPs and PAs, who can perform similar duties and services within a subspecialty like IR with little to differentiate them apart. Both group can manage patients including histories and physicals, ordering and interpreting diagnostic tests and prescribe medication and treatments. However, there appears to be a greater number of PAs within surgical services compared with NPs and appear more procedure orientated who have a greater focus on health promotion and disease prevention.19
PAs and PEs in the contemporary interventional oncology practice RPAs emerge from the need to increase the scope of function of the Radiology Technologist (RT) in the 1970s, typically a registered RT with extensive experience, then completes more specialized training of at least 21 months, and passed the national certification examination by the Certification Board of Radiology Practitioner Assistants.20 Originally intended to supplement the function of RTs to perform diagnostic radiology procedures under the supervision of a physician radiologist (similar to PAs), as well as provide patient care and assist in patient management. However, there are several important differences between PAs/NPs compared with RPAs. PAs and NPs have broad general medical training, whereas RPAs training is rooted in Radiology, and do not have education of licensing to practice medicine and cannot order diagnostic tests, procedures, or prescribe medications and are not recognized providers for medical insurance reimbursement.4,20
PAs in Your Practice: Recruitment and Benefits The justifications in employing a PE to your interventional oncology practice are several fold. With the advent of increasing oncologic interventions, the role of the interventional radiologist in the treatment of the cancer patient is dramatically increasing, from central venous access for chemotherapy, percutaneous gastrostomy tubes for supportive care, through to primary treatment liver cancers with chemoembolizations, tumor ablation, radioembolization, and newer musculoskeletal therapies. With that, emerging new clinical responsibilities that require greater commitment in both time and effort for the procedure based IR physician. Cancer patient are unique and challenging with greater psychosocial needs regarding treatment options and procedure counseling. In the periprocedural period, one is faced with clinical challenges of palliating complex pain, peri-procedural complications, and follow up commitments that require newer strategies for maintaining clinical excellence. With fluctuating supply of fellowship trained interventionalists and increase in minor procedure types and numbers, PE with their clinical training and background serve as the ideal addition to the Interventional oncologic team to effectively increase the clinical service. Other intangible benefits including the downstream imaging revenues that are generated from the interventions that are usually cross-sectional studies, multiple sequential follow up. Below outlines the possible scope of duties and responsibilities that may be delegated to PAs including5: 1. Performing minor procedures and increasing income revenue (central and peripheral venous access, implantable ports) and drainage tubes 2. Removal of tunneled catheters and catheter maintenance/ troubleshooting 3. Outpatient clinic: new patient consultation (including history and physicals, collecting relevant diagnostic imaging, brief explanation of procedure options, and information) 4. Follow-up clinic: wound checks, suture removal, gastropexy removal, catheter troubleshooting
99 5. Database tracking for research, clinical outcomes, and quality assurance 6. Evaluation of billing and liaison between insurance companies and practice for preprocedural authorizations 7. Admission service—in patient: daily patient rounds, morning rounds, communication with other services 8. In patient consultations 9. Tumor Board coordinator: to stimulate multidisciplinary meeting and referrals 10. Patient and referring physician telephone follow up Recruitment of a PE should commence with the salary available and compared it to the average PA salary in that particular state or region. If the projected salary is below that of the average, consider advertising for a new graduate by contacting your local PA programs. The downside of hiring new graduates is that you may have to wait until they pass the certifying examination provided by the NCCPA and well as place more training emphasis initially. Typically, PAs with experience have higher income expectations, but if your practice requires the filling of immediate clinical input with someone with experience, it may be advisable to advertise with professional organizations such as the Society of Interventional Radiology or the American Society of Clinical Oncology. In most practices, the revenue generated by the new services and procedures provided by PAs outstrips the costs of recruitment and their employment, as well as being a vital part of the clinical service. A reasonable strategy to recruiting a PA is to consider several key steps, outlined in AAPA Website (http://www.aapa.org/gandp/paempguide.pdf )21: ● ● ● ●
Create a Job Description, Assignment of responsibilities Read Your State PA Practice Act Develop an Employment Package Understand PA Credentialing and Privileging (www. ama-assn.org/amaprofiles)
Conclusion IR has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. With increasing oncologic procedures and patient volume, the balance between quality clinical care, and the time constraints on the busy interventionalist pull in opposing forces. The need for greater clinical support staff in the IR practice is unquestionable. PA have been in the medical field since the 1960s with intensive clinical training, capabilities of providing patient care and ability to generate revenue income more than justifies their place in the IR. It is the combination of novel image guided interventional therapies, and the delivery of quality patient care to our cancer patients that will finally gain acceptance of our subspecialty, IO as the fourth pillar of the cancer treatment, along with medical and surgical oncologists and Radiation Therapists. The contemporary model of a clinical orientated service within IR for cancer patients undergoing IO procedures should include PE as a vital part of the team allowing delivery of high-quality patient care.
References 1. Dorfman GS: The 2002 Dr. Charles T. Dotter lecture: Revolution, evolution, or extinction—a report of an imaginary conversation among
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2.
3. 4. 5. 6.
7. 8. 9. 10.
11.
12.
Dotter, Darwin, and a few selected revolutionaries. J Vasc Interv Radiol 13(Pt 1):869-878, 2002 Goldberg SN, Bonn J, Dodd G, et al: Society of Interventional Radiology Interventional Oncology Task Force: Interventional oncology research vision statement and critical assessment of the state of research affairs. J Vasc Interv Radiol 16:1287-1294, 2005 McCowan TC, Goertzen TC, Lieberman RP, et al: Physician’s assistants in vascular and interventional radiology. Radiology 184:582, 1992 Van Valkenburg J, Ralph B, Lopatofsky L, et al: The role of the physician extender in radiology. D Radiol Technol 72:45-50, 2000 Stecker MS, Armenoff D, Johnson MS: Physician assistants in interventional radiology practice. J Vasc Interv Radiol 15:221-227, 2004 White RI Jr, Rizer DM, Shuman KR, et al: Streamlining operation of an admitting service for interventional radiology. Radiology 168:127-130, 1988 White RI Jr, Denny DF Jr, Osterman FA, et al: Logistics of a university interventional radiology practice. Radiology 170(Pt 2):951-954, 1989 Hudson CL: Expansion of medical professional services with nonprofessional personnel. JAMA 176:839-841, 1961 Stead EA Jr: PA profession in review: A founder’s perspective. Physician Assist 10:12, 19, 22, 1986 Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2006-07, Physician Assistants, http://www.bls.gov/ oco/ocos081.htm (visited February 9, 2007) American Academy of Physician Assistants (AAPA), Prescribing Authority, http://www.aapa.org/gandp/rxchart.html (visited February 9, 2007) American Academy of Physician Assistants (AAPA), DEA Brief, http:// www.aapa.org/gandp/issuebrief/DEA.htm (visited February 9, 2007)
13. American Medical Association. Guidelines for Physician/Physician Assistant Practice. 2001 Policy Compendium.Chicago, IL. H-160.947 14. US Congress, Office of Technology Assessment. Nurse Practitioners, Physicians Assistants, and Certified Nurse-Midwives. A Policy Analysis (Case Study 37) OTA-HCS-37, Washington DC: US Gov Printing Office, 1986 15. Accreditation Review Commission on the Education for the Physician Assistant. History of the ARC-PA. http://www.arc-pa.org/general/ history.html 16. American Academy of Physician Assistants (AAPA), Regulatory Authorities, www.aapa.org/gandp/statelawsand regulations.htm (visited February 9, 2007) 17. American Academy of Physician Assistants (AAPA), Reimbursement Hospital Billing, http://www.aapa.org/gandp/sharedbilling.html 18. American Academy of Nurse Practitioners. Scope of Practice for Nurse Practitioners. http://www.aanp.org/Practice⫹Policy⫹and⫹Legislation/ Practice/Position⫹Statements⫹and⫹Papers/Position⫹Statements⫹and⫹ Papers.asp 19. American Academy of Nurse Practitioners. Nurse Practitioners as an Advanced Practice Nurse: Role Position Statement. http://www. aanp.org/Practice⫹Policy⫹and⫹Legislation/Practice/Position⫹Statements ⫹and⫹Papers/Position⫹Statements⫹and⫹Papers.asp 20. American Academy of Physician Assistants. Physician Assistants and Radiology Practitioner Assistants. The Distinction. http://www.aapa.org/ gandp/rpas 21. American Academy of physician Assistants. Physician Assistants and Radiology Practitioner Assistants. Guide to New Hires. http://www. aapa.org/gandp/paempguide.pdf
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harles T. Dotter, the father of Interventional Radiology (IR) reported in 1968, “if my fellow angiographers prove unwilling or unable to accept or secure for their patients the clinical responsibilities, they will face forfeiture of territorial rights based solely on imaging equipment others can obtain and skills others can learn.”1 The modern interventionalist face an ever increasing need to embrace clinical responsibilities and changing skill set, that for a generation of radiologists, was not a key element their education nor training. The emphasis for stronger clinical service are at times beyond the time constraints, interest, and training for an Interventional Radiologist, including clinic consultation, insurance coding, and preapproval, preprocedure workup and investigation, and inpatient rounding and long term follow-up. It is a priority of interventional radiologists, recognized by the Society of Interventional Radiology (SIR) to advance the agenda of Interventional Oncology (IO) under the aegis of SIR, to confront and address these clinical challenges.2 IR has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. The reasons for this gradual change are numerous and include: 1. Development of new oncologic interventions: birth of a new subspecialty From the Johns Hopkins Medical Institutions, Baltimore, MD. Address reprint requests to JF Geschwind, MD, Johns Hopkins Hospital University School of Medicine, 600 North Wolfe Street, Blalock 545, Baltimore, MD 21287.E-mail: [email protected].
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1089-2516/06/$-see front matter © 2006 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2007.02.005
2. Transformation from procedure technician to becoming the primary care team for patients 3. Acquiring hospital admission privileges by IR staff 4. Developing specialty IR clinical service teams 5. Holding patient clinic, inpatient rounds, follow-up clinic 6. Attendance at multi-disciplinary tumor board meetings 7. Increasing communication demands (patient-physician, physician-physician) As the clinical responsibilities of IR groups mature and duties multiply, they require input and assistance from dedicated support personnel. This role has begun to be filled by Physician Assistants (PA), Nurse Practitioners (NP), and Radiology Practitioner Assistants (RPA) collectively termed Physician Extenders (PE), or alternatively called mid-level providers or nonphysician practitioners.3-5 PEs have long played a significant role in clinically oriented specialties, particularly primary health. At the authors’ institution, recognizing the importance of direct participation in patient care and clinical management, admission privileges for interventional radiologist has long been long established since the early 1980s, described by White and co-workers.6,7 Since 1982 our academic clinical IR practice has embraced the incorporation of Physician Extenders (PE), in PAs into the IR practice as a vital part of the growth and foundation of a busy group practice that today encompasses 8 clinical faculty members, 2 research faculty, 4 Physician Assistants, and 7 IR training fellows.
PAs and PEs in the contemporary interventional oncology practice This article serves to outline the roles of PE; in particular PAs and briefly reviews their training, compliance, and credentialing requirements, financial justification, and possible duties.
Background PAs are a young profession with it roots in the 1960s8 where physician educators recognized a shortage and uneven distribution of primary care health providers. Eugene Stead Jr, Medicine chair at Duke University first initiated a plan to train assistants to physicians in 1965, with the first graduating class of 3 PAs in 1967.9 He based the curriculum of the PA program in part on his knowledge of the fast-track training of doctors during World War II. This was the birth of a profession that has become one of the fastest growing professions assessed by the United States Department of Labor because of anticipated expansion of the health care industry and an emphasis on cost containment, resulting in increasing utilization of PAs by physicians and health care institutions through to 2014.10 By 2006, over 70,612 persons were eligible to practice as a PA.10 PAs are nonphysician clinicians licensed to practice medicine with a physician’s supervision. PAs are formally trained to perform medical histories and examinations, order treatments, diagnose acute and chronic illnesses, prescribe medication, interpret diagnostic tests, perform invasive and noninvasive procedures, refer patients to specialists when appropriate, and first assist in major procedures. The education of a PA is a generalist approach, modeled after the medical school curriculum. PAs may practice in general medicine or any medical or surgical specialty. Because of their broad based medical education, PAs can change specialties and have the ability to work throughout their career in different medical/surgical specialties. According to the AAPA, PAs must always work under the supervision of a physician. In 48 States and the District of Columbia, PAs may prescribe medications11 and the Drug Enforcement Agency (DEA) has a special registration category specifically for PA and other “midlevel practitioners” authorized by state law or regulation to prescribe controlled substances.12 The PAs function within the scope of practice is established and defined by the supervising physician(s), but must lie within the scope of practice of that physician. PAs strengths lie in clinical patient care, which reflects their training and curriculum. In an IR practice, the role of a PA extends not only to seeing and managing clinical aspects of the patient, but can perform minor IR procedures and assist the physician in more major interventions and re-imbursement is paid at 85% of physician rates. By 2006, of all registered PAs, the vast majority were in clinical practice (91%) with over 60% performing some minor surgical type procedure and 40% taking after hours call responsibilities.10 The American Medical Association (AMA) Guidelines for Physician/ Physician Assistant Practice by adopted the following principles13: 1. Health care services delivered by physicians and PAs must be within the scope of each practitioners authorized practice as defined by state law. 2. The physician is ultimately responsible for coordinat-
97
3. 4.
5.
6.
7. 8.
9.
ing and managing the care of patients and, with the appropriate input of the PA, ensuring the quality of health care provided to patients. The physician is responsible for the supervision of the PA in all settings. The role of the PA(s) in the delivery of care should be defined through mutually agreed on guidelines that are developed by the physician and the PA and based on the physician’s delegatory style. The physician must be available for consultation with the PA at all times either in person or through telecommunication systems or other means. The extent of the involvement by the PA in the assessment and implementation of treatment will depend on the complexity and acuity of the patient’s condition and the training and experience and preparation of the PA as adjudged by the physician. Patients should be made clearly aware at all times whether they are being cared for by a physician or a PA. The physician and PA together should review all delegated patient services on a regular basis, as well as the mutually agreed on guidelines for practice. The physician is responsible for clarifying and familiarizing the PA with his supervising methods and style of delegating patient care.
Training The curriculum used to instruct PAs is based on the medical school model, designed to complement physician training and many accredited PA training programs have clinical teaching affiliations with traditional medical schools. All States require that PAs complete an accredited, formal education program, usually 2 years (median 26 months) and pass a national examination to obtain a licensure. In 2006, more than 135 education programs for PAs were accredited or provisionally accredited by the American Academy of Physician Assistants (AAPA). Most applicants to PA educational programs already have a Bachelor’s degree and programs are offered at both bachelor and Masters degree level (Bachelor’s degree 44%, Masters 35%).10Admission requirements vary, but many programs require 2 years of college and some work experience in the health care field. Applicants to PA school often have prior medical experience as registered nurses, military medics, and allied health occupations such as respiratory and physical therapists, and emergency medical paramedics. PAs substantial education includes basic sciences in biochemistry, pathology, human anatomy, physiology, microbiology, clinical pharmacology, clinical medicine, geriatric and home health care, disease prevention, and medical ethics. Students obtain supervised clinical training in several areas, including family medicine, internal medicine, surgery, prenatal care and gynecology, geriatrics, emergency medicine, psychiatry, and pediatrics, all totaling over 2000 hours in supervised clinical practice, producing well balanced generalists, with an emphasis on a team based approach. Federal data and analysis has shown that within their scope of practice, quality of care by PAs can be comparable to physicians.14 All States have legislation governing the qualifications or practice of PA. All jurisdictions require PAs to pass the Phy-
K. Hong et al.
98 sician Assistant National Certifying Examination, administered by the National Commission on Certification of Physician Assistants (NCCPA) to graduates of accredited PA education programs only. Only those successfully completing the examination may use the credential “Physician Assistant-Certified” (PA-C). To remain certified, PAs must complete 100 hours of continuing medical education every 2 years. Every 6 years, they must pass a recertification examination.
Credentialing National credentialing occurs through the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA), which governs the accreditation of the 134 programs.15 On the state and local level, the credentialing process for PAs is different for the various states. In general, the licensing and credentialing at both state and local (hospital level) are performed by the same bodies that regulate physicians, with similar scrutiny and rigor. Usually, the most extensive set of rules are at the State level, covering Certification, educational requirements, scope of practice, collaborative agreements, supervisory requirements, radiation policy, and prescription authority. In the authors’ state of Maryland, the PA credentialing process is regulated by the Maryland Board of Physicians. To check on the process for individual state, the AAPAs Webpage details each state’s Laws and Regulations.16 The applicant PA will be required to fills out educational and clinical work experience and in combination with the intended supervising physician, the application needs to lists the specific types of responsibilities they will hold in their role as a PA in that particular setting; this is called the Delegation Agreement. These roles have to be within the scope of practice of the supervising physician(s). For example, the PA cannot be given the responsibility of a task that could not be done by the supervising physician, if needed. This Delegation Agreement is signed by the physician(s) and PA and outlines the duties and additional privileges (such as prescriptive rights) that are needed for the position. This Delegation Agreement must be approved by the Maryland Board of Physicians. In Maryland, the Board meets monthly to determine if the PA can be credentialed to perform the duties requested. For credentialing to perform specific minor procedures independently (eg, Mediport placement), the state Board will usually required documentation of how many were performed under the guidance of a physician, validation demonstrating knowledge of side effects and complications and other related documentation (eg sedation training course was completed). The credentialing institution requirements are different from state to state as well as within each individual hospital, so discussion with a PA representative at that particular institution may save time and effort during the credentialing process. At the local hospital level, PA credentialing is mostly managed by the hospital medical staff board, and comparable in complexity and rigor compared with physician requests for clinical privileges.
Compliance The Center for Medicare and Medicaid Services (CMS) www.cms.hhs.gov, which governs compliance and reimburse-
ment payment for patients under the Federal medical programs, give PAs and their supervising physicians increased latitude in billing for evaluation and management (E/M) services provided in the hospital setting. The policy allows PAs and physicians to share visits made to patients with the combined work of both covered at 100% of the fee schedule (“Incident to” billing). That is, if the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician’s name and Physician Identification number (PIN). The practitioner who substantially performs the procedure is the one under whose name and number the procedure should be billed. To combine the professional work done by a PA and a physician, the following guidelines must be followed: ● ● ●
The PA and the physician must work for the same entity. The regulation applies only to E/M services and not to procedures. The physician must provide some face-to-face portion of the E/M services
However, “Incident to” billing has never applied to the hospital setting.17 If the physician is not present for any of the face-to-face portion of the E/M encounter, the service is appropriately billed under the PAs name and PIN, with reimbursement at the 75 to 85% rate. When billing for hospital services provided by PAs under the PAs name and PIN, Medicare does not require the on-site presence of the supervising physician; access to telephonic communication is sufficient. Most of the private insurers have the same reimbursement policy, but there is varying compensation from company to company, and from states to state. Always check with your state law and hospital policies, which may be more restrictive than Medicare’s policies.
Other PE: NP and RPA NPs are licensed independent practitioners who provider primary and specialty nursing and medical care in ambulatory, acute, and long-term care settings. They are RNs with specialized advanced education and clinical competency to provide health and medical care for diverse populations in a variety of primary care, acute and long-term care settings. NPs have qualifications of at least Master’s and some even doctoral degrees. They do not require the supervision of a physician, and can be reimbursed for their services directly from insurance company and federal health services. This is in contra-distinction from PA who bill and reimbursed to the supervising physician(s). NPs are registered and licensed by State nursing boards.18 In the clinically setting, functionally, there is little otherwise to differentiate between NPs and PAs, who can perform similar duties and services within a subspecialty like IR with little to differentiate them apart. Both group can manage patients including histories and physicals, ordering and interpreting diagnostic tests and prescribe medication and treatments. However, there appears to be a greater number of PAs within surgical services compared with NPs and appear more procedure orientated who have a greater focus on health promotion and disease prevention.19
PAs and PEs in the contemporary interventional oncology practice RPAs emerge from the need to increase the scope of function of the Radiology Technologist (RT) in the 1970s, typically a registered RT with extensive experience, then completes more specialized training of at least 21 months, and passed the national certification examination by the Certification Board of Radiology Practitioner Assistants.20 Originally intended to supplement the function of RTs to perform diagnostic radiology procedures under the supervision of a physician radiologist (similar to PAs), as well as provide patient care and assist in patient management. However, there are several important differences between PAs/NPs compared with RPAs. PAs and NPs have broad general medical training, whereas RPAs training is rooted in Radiology, and do not have education of licensing to practice medicine and cannot order diagnostic tests, procedures, or prescribe medications and are not recognized providers for medical insurance reimbursement.4,20
PAs in Your Practice: Recruitment and Benefits The justifications in employing a PE to your interventional oncology practice are several fold. With the advent of increasing oncologic interventions, the role of the interventional radiologist in the treatment of the cancer patient is dramatically increasing, from central venous access for chemotherapy, percutaneous gastrostomy tubes for supportive care, through to primary treatment liver cancers with chemoembolizations, tumor ablation, radioembolization, and newer musculoskeletal therapies. With that, emerging new clinical responsibilities that require greater commitment in both time and effort for the procedure based IR physician. Cancer patient are unique and challenging with greater psychosocial needs regarding treatment options and procedure counseling. In the periprocedural period, one is faced with clinical challenges of palliating complex pain, peri-procedural complications, and follow up commitments that require newer strategies for maintaining clinical excellence. With fluctuating supply of fellowship trained interventionalists and increase in minor procedure types and numbers, PE with their clinical training and background serve as the ideal addition to the Interventional oncologic team to effectively increase the clinical service. Other intangible benefits including the downstream imaging revenues that are generated from the interventions that are usually cross-sectional studies, multiple sequential follow up. Below outlines the possible scope of duties and responsibilities that may be delegated to PAs including5: 1. Performing minor procedures and increasing income revenue (central and peripheral venous access, implantable ports) and drainage tubes 2. Removal of tunneled catheters and catheter maintenance/ troubleshooting 3. Outpatient clinic: new patient consultation (including history and physicals, collecting relevant diagnostic imaging, brief explanation of procedure options, and information) 4. Follow-up clinic: wound checks, suture removal, gastropexy removal, catheter troubleshooting
99 5. Database tracking for research, clinical outcomes, and quality assurance 6. Evaluation of billing and liaison between insurance companies and practice for preprocedural authorizations 7. Admission service—in patient: daily patient rounds, morning rounds, communication with other services 8. In patient consultations 9. Tumor Board coordinator: to stimulate multidisciplinary meeting and referrals 10. Patient and referring physician telephone follow up Recruitment of a PE should commence with the salary available and compared it to the average PA salary in that particular state or region. If the projected salary is below that of the average, consider advertising for a new graduate by contacting your local PA programs. The downside of hiring new graduates is that you may have to wait until they pass the certifying examination provided by the NCCPA and well as place more training emphasis initially. Typically, PAs with experience have higher income expectations, but if your practice requires the filling of immediate clinical input with someone with experience, it may be advisable to advertise with professional organizations such as the Society of Interventional Radiology or the American Society of Clinical Oncology. In most practices, the revenue generated by the new services and procedures provided by PAs outstrips the costs of recruitment and their employment, as well as being a vital part of the clinical service. A reasonable strategy to recruiting a PA is to consider several key steps, outlined in AAPA Website (http://www.aapa.org/gandp/paempguide.pdf )21: ● ● ● ●
Create a Job Description, Assignment of responsibilities Read Your State PA Practice Act Develop an Employment Package Understand PA Credentialing and Privileging (www. ama-assn.org/amaprofiles)
Conclusion IR has been for the last few years undergoing a transformation from a service oriented to a clinically oriented specialty. With increasing oncologic procedures and patient volume, the balance between quality clinical care, and the time constraints on the busy interventionalist pull in opposing forces. The need for greater clinical support staff in the IR practice is unquestionable. PA have been in the medical field since the 1960s with intensive clinical training, capabilities of providing patient care and ability to generate revenue income more than justifies their place in the IR. It is the combination of novel image guided interventional therapies, and the delivery of quality patient care to our cancer patients that will finally gain acceptance of our subspecialty, IO as the fourth pillar of the cancer treatment, along with medical and surgical oncologists and Radiation Therapists. The contemporary model of a clinical orientated service within IR for cancer patients undergoing IO procedures should include PE as a vital part of the team allowing delivery of high-quality patient care.
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