PAs And NPs: Are They The Wave Of The Future In Podiatry?

Hiring physician assistants and nurse practitioners can allow DPMs more time for patient treatment, improving the efficiency of care and maximizing the success of the practice. These authors detail the benefits of PAs and NPs, including the ins and outs of the education and the scope of practice governing physician assistants and nurse practitioners.

As we examine healthcare trends and look at the future of medicine and what it means to our individual practices, we often face challenges in finding ways to increase productivity, improve patient satisfaction and maximize reimbursement. With any challenge, there are always obstacles in the way of preventing us from completing our intended goals.

Physicians may find their time taken up with overloaded patient volume, electronic medical record (EMR) charting, endless meetings and travel. Realizing that our time and resources are maximized to the hilt, we come to the conclusion that we must extend ourselves in order to accomplish our goals. We often ask if we should hire more resources or perhaps add another associate to the group dynamics to help lessen the load. However, another growing trend in today’s healthcare is adding physician assistants (PAs) and nurse practitioners (NPs).

Physician assistants are healthcare providers who are nationally certified and state licensed to practice medicine. They are found in every medical and surgical specialty and setting. Physician assistants work under the supervision of a physician in a team approach. In the clinical setting, the functions of a physician assistant mirror those of the supervising physician, including examination, diagnosis, treating new and established patients independently, and performing in-office procedures such as injections, wound care, biopsies and casting. In the operating room, physician assistants function as first assistants and educate patients and family in the pre- and postoperative setting. Over 20 percent of PAs work in primary care and nearly 20 percent work in surgical subspecialties.¹

Nurse practitioners are one of four types of advanced practice registered nurses (APRNs). Nurse anesthetists, nurse midwives and clinical nurse specialists are also included in this group. Nurse practitioners serve as primary or specialty care providers with the majority (nearly 50 percent) working in primary care.² Less than 9 percent work in surgical specialties.² Like PAs, NPs perform in-office job functions similar to physicians. They can be licensed to practice independently and patients with conditions or complications that are beyond a nurse practitioner’s training get referred to a physician.

A Quick History On The Evolution Of PAs And NPs
In the years following World War II, the United States suffered from an acute shortage of physicians. Much of this shortage was evident in rising urban populations and underserved rural communities. The demand for healthcare grew rapidly despite the short supply of medical providers. As one would imagine, this led to rising costs and inaccessibility for care across the country. In the mid-1960s, a physician in North Carolina recruited and educated the first class of physician assistants at Duke University under the physician medical school model. At the same time in Colorado, the nursing organization was starting classes for nurse practitioners. Both models highlighted the training of these individuals to help serve in the primary care setting with the idea of utilizing these providers in underserved urban and rural settings.

Since their inception, the numbers of PAs and NPs continued to grow steadily into the late 1990s. At the turn of the century, the amount of graduating NPs and PAs began to expand exponentially as did the number of nurse practitioner and physician assistant educational programs. To date, there are 350 NP programs and 170 PA programs in the U.S.^3,4 At the end of 2014, there were nearly 90,000 working PAs in all subspecialties and 122,000 NPs with projections of 38 percent and 34 percent growth by 2022 respectively.⁵

Now with the Affordable Care Act (ACA), we will unquestionably have a rise in patients seeking healthcare services who now have insurance coverage. This projection has been estimated as high as 30 million newly covered Americans.6 The ACA specifically mentions in the content of the law that having PAs and NPs is a way to help provide access to this population during an undoubted physician shortage.⁶
 
A Closer Look At The Education Of NPs And PAs
Both PAs and NPs often receive training alongside their future physician peers, sharing in coursework, lab work and clinical rotations. Physician assistants receive training in the medical model and NPs follow the nursing model of education.

The education of physician assistants consists of an average of 26 months of full-time course work.⁷ Most programs require a bachelor’s degree for admission as well as some form of healthcare experience. By 2020, all programs will offer at least a master’s degree upon graduation.⁸ After completion of an accredited program, a PA must pass a national certifying examination before becoming eligible for state licensure. Maintenance of licensure requirements vary from state to state but maintenance of certification requires 100 hours of CME every two years, including self-assessment and performance improvement CME. Every 10 years, PAs must re-certify by passing a national recertification board exam.  

Physician assistants have training as generalists and may choose to specialize after practicing. More recently, PAs have been able to get a Certificate of Added Qualification (CAQ) in seven different clinical specialties. A PA must have a minimum of two years of experience in the specialty, appropriate procedure and patient cases, specialty-specific CME, and pass a specialty exam to earn this designation.

All NPs are initially licensed as registered nurses and then must complete a minimum of a master’s degree from an accredited program to be certified as an NP.¹ Full-time programs last 18 to 24 months for Masters of Science in Nursing (MSN) programs, and two to three years for Doctor of Nursing Practice (DNP) programs. Currently, there is an initiative to transition the entry-level degree for all APRNs to the DNP level.

In contrast to the comprehensive physician assistant education model, NPs focus on a specific population in their education, such as family medicine, adult-gerontology, pediatrics, neonatal, women’s health or psychiatric/mental health. Certification for NPs is required by one of two national certification bodies. If certified through the American Academy of Nurse Practitioners, the NP earns the designation NP-C in the respective focus. If certified through the American Nurses Credentialing Center, the NP receives the title CNP or another designation for the specific focus. Maintenance of certification for both designations (NP-C and CNP) requires a minimum of 1,000 direct patient care hours and 75 CEs in their population’s certification focus every five years. Currently, there is no requirement to recertify through board examination unless an NP does not meet the current CEs and patient contact hours.  

What You Should Know About The State Laws On NPs And PAs
A PA is trained and licensed to work under the supervision of a physician. State laws vary greatly on what constitutes the minimum level of supervision. The required level of supervision by a physician can range from on-site presence to availability by telecommunication. One may determine the scope of practice and chart review process on site or per state regulations.

A state’s Board of Nursing regulates the practice of NPs. Nurse practitioners may or may not be required to work under physician supervision, depending on the jurisdiction. In consideration of the shortage of primary care physicians, states are shifting toward full practice authority for NPs. Twenty states and Washington D.C. currently permit independent practice.⁴ In those states that do not permit full practice autonomy, NPs must have a “collaborative agreement” or more restricted supervision, delegation or team management with a physician. Collaboration may be contractual as per a written agreement or simply more of a referral basis in order to provide comprehensive care.

Physician assistants and nurse practitioners are able to prescribe in all 50 states and can prescribe controlled substances in most states. (Florida prohibits prescriptive authority to PAs and NPs, and Kentucky prohibits only PAs). Physician assistants are delegated prescriptive authority through their supervising physicians and this delegation cannot supersede state regulations. Again, laws vary state to state regarding the schedule of drug, the length of prescription or the specific formulary.

At present, only six states have laws that mention DPMs in regard to PAs. These states are California, Michigan, Ohio, Rhode Island, Virginia and West Virginia. In these states, DPMs currently have recognition to actively participate as a supervisory physician. In California, a PA may assist a podiatrist but the podiatrist may not act as a supervising physician.³ In states where NPs are required to have collaboration with a physician, state law dictates the necessary physician credential to meet this requirement.

Assessing The Impact Of PAs And NPs On Reimbursement
Maximizing reimbursement should always be at the forefront of every discussion before adding physician assistants and nurse practitioners to the practice, and one must consider many factors before moving forward. It is well known that practices that employ NPs and PAs are more productive than those practices that have not yet participated in this model. A recent Medical Group Management Association published resource demonstrates that practices that employ PAs and NPs enjoy higher reimbursement than those practices that do not.⁹

It is important to point out that PAs and NPs indirectly increase physician productivity as well. Not only is there increased reimbursement to the practice as a whole but physicians who utilize PAs and/or NPs are also able to be more productive in seeing more patients and increasing revenue.

Most, if not all, insurance carriers will reimburse PAs and NPs. However, different rules apply concerning each individual carrier and how they are billed through the practice. Some insurance carriers do not directly credential PAs and NPs in their policies. However, reimbursement may still occur by billing under the supervising physician’s National Provider Identifier (NPI) number. Other insurance carriers will credential PAs and NPs, and you may bill their services directly to the carrier at a rate of 85 percent of the supervising physician’s fee for all office-based reimbursement. Surgical first assisting is also billable at 13.5 percent of the surgeon fee for approved cases.³

There are also guidelines in place that will allow nurse practitioners and physician assistants to receive reimbursement at 100 percent of the supervising physician’s fee by way of “incident-to” billing. Incident-to billing allows the PA or NP to bill an office encounter under the supervising physician’s NPI number. According to the current Centers for Medicare and Medicaid Services (CMS) guidelines, incident-to billing is justified in the following circumstances.⁶

1. The PA or NP must be an employee of the physician.
2. The physician must perform the initial visit (for that condition). This does not mean that on each occasion of an incidental service performed by a PA or NP that the patient must also see the physician. It does mean there must have been a direct, personal, professional service furnished by the physician to initiate the course of treatment of which the services being performed by the PA or NP is an incidental part.
3. There must be direct personal supervision by the physician as an integral part of the physician’s personal in-office service. The physician must be physically present in the same office suite and be immediately available to render assistance if that becomes necessary.
4. The physician has an active part in the ongoing care of the patient. Subsequent services by the physician must be of a frequency that reflects his or her continuing active participation in, and management of, the course of the treatment.

Aside from the direct monetary gain, physician assistants and nurse practitioners increase patient satisfaction due to decreased wait time while in the office and decreased wait time to obtain an appointment. Patients also receive more personalized attention by receiving return phone calls regarding test results and having these PAs and NPs answer additional questions they may have after an office consultation. Having a PA or NP as part of the team can contribute to the overall productivity of many office and surgical practices as well as the overall satisfaction of the patient and the ancillary staff.

Are PAs And NPs Right For Your Practice?
Before hiring a physician assistant or nurse practitioner, one must determine the role that he or she will play in each individual practice. There are a number of ways PAs and NPs can help achieve the overall practice goals. Understanding the state statutes surrounding PAs and NPs is paramount to ensure they work within the boundaries of the law. Once there is a solid understanding of the statutes, one can start to formulate a specific plan for how the NPs and PAs will function within the confines of the practice.  

Although there is no uniform model in place as to how one can utilize PAs and NPs, most models cater to what works on an individual basis for the collaborative team of the PA/NP and the supervising physician. However, maximizing the PA’s or NP’s capabilities within the confines of the law is recommended.

All states allow nurse practitioners and physician assistants to see new patients and have prescriptive authority, but as a supervising physician, you may limit this ability should you choose to do so. In some instances, one primarily hires the PA or NP to evaluate postoperative patients and assist in surgery, leaving the new patient encounters and higher complexity patients to the supervising physician. While this is certainly an effective model, recent data suggests allowing a PA or NP full access to the practice and allowing these practitioners to maximize their training is best for them, the supervising physician and for the reimbursement of practice.³

Skeptics of this model have been present throughout the years. Although this trend has been deceasing over the last decade, there are still opponents to physician assistants and nurse practitioners. The primary reasons cited for this are patient acceptance, physician liability and fear of competing with the PAs and NPs within the practice dynamics. In a recently published study, it was mostly physicians who had no familiarity with NPs and PAs who demonstrated these concerns.10 Those who had past experience with PAs and NPs did not have these concerns and the study authors showed that patients often embraced this model as demonstrated by 95 percent satisfaction with PAs and NPs.¹⁰

Given that this model embraces team-based healthcare for patients, competition between the PA/NP and the supervising physician for patient dollars is rarely an issue as reimbursement is reserved for the practice rather than the individual. Utilizing PAs or NPs to the full extent of their education and allowing a team-based approach with parameters and protocols for PAs and NPs and supervising physicians should facilitate maximum reimbursement and patient satisfaction.

In Conclusion
As we examine the role of physician assistants and nurse practitioners in the realm of podiatry, we have assurance that in certain states, PAs and NPs can offer an alternative for expanding podiatric practices. However, many states do not specifically list podiatrist as a supervisory role for physician assistants and nurse practitioners.

We predict that the role of NPs and PAs will be a continuing trend in the future with the emergence of the Affordable Care Act. Many primary and surgical subspecialties will undoubtedly be approaching the world of PAs and NPs to help expand their practice. Indeed, physician assistants and nurse practitioners may help meet the increasing demands of patient satisfaction and insurance reimbursement while maintaining a better quality of life for the supervising physician. However, the podiatry profession needs to do much work to expand the role of podiatry supervision of NPs and PAs at a national level.

Mr. Hunt is a physician assistant at Orthopedic Foot and Ankle Center in Westerville, Ohio.

Ms. Rupert is a physician assistant at Orthopedic Foot and Ankle Center in Westerville, Ohio.

Dr. Hyer is a Fellow of the American College of Foot and Ankle Surgeons, and serves on its Board of Directors. He is the Fellowship Director and an attending physician at the Orthopedic Foot and Ankle Center in Westerville, Ohio.

References

1.     National Commission on Certification of Physician Assistants. 2013 Statistical Profile of Certified Physician Assistants. 2014. Available at www.nccpa.net/Upload/PDFs/2013StatisticalProfileofCertifiedPhysicianAssistants-AnAnnualReportoftheNCCPA.pdf .
2.     U.S. Department of Health and Human Services, Health Resources and Services Administration, National Center for Health Workforce Analysis. Highlights From the 2012 National Sample Survey of Nurse Practitioners. U.S. Department of Health and Human Services, 2014. Available at https://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/nursepractitionersurvey/npsurveyhighlights.pdf .
3.     American Association of Physician Assistants. Available at www.aapa.org/ .
4.     American Association of Nurse Practitioners. Available at www.aanp.org/ .
5.     United States Bureau of Labor Statistics. Available at www.bls.gov/ .
6.     Center for Medicare/Medicaid Services and the Affordable Health Care Act of the United States. Available at https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/se0441.pdf .
7.     Physician Assistant Education Association. Physician Assistant Educational Programs in the United States, Twenty-Eighth Annual Report, 2011-2012. Available at https://www2.paeaonline.org/index.php?ht=d/sp/i/243/pid/243 .
8.     Accreditation Review Commission on Education for the Physician Assistant. Accreditation Standards for Physician Assistant Education, Fourth Edition, 2010. Available at https://arc-pa.org/documents/Standards4theditionwithclarifyignchanges10.2011fnl.pdf .
9.     Medical Group Management Association (2013 Report). Available at www.mgma.com/industry-data/survey-reports/physician-compensation-and-production-survey .
10.     Isberner FR, Lloyd L, Simon B, et al. Utilization of physician assistants: incentives and constraints for rural physicians. Perspective Physician Assistant Education. 2003; 4(2):69-73.