In the last decade, the number of physician assistants (PAs) has dramatically expanded. Since 1997, More than 30 states have experienced greater than 100% growth in the number of PAs practicing there, with a few states (Arizona, Idaho, Illinois and Indiana) logging more than 200% increases in PAs. Overall, more than 65,000 PAs practice in the United States, as stated by the American Academy of Physician Assistants (AAPA).
As for PAs in dermatology, some 2,500 are in practice around the country, according to the Society for Dermatology Physician Assistants.
As PAs expand in their roles, so do the sub-specialties within this group of practitioners. Extenders are no longer limited to internal medicine or family practice. Instead, one can find the PA-C (physician assistant-certified) title monogram stitched on white coats within cardiovascular/cardiothoracic surgery, radiation oncology, orthopedics, dermatology, and plastic surgery, among other areas. As a dermatology PA-C and a cosmetic practice consultant, my area of interest is how PAs can provide maximal benefits to dermatology and cosmetic practices.
What Can a PA Do for Your Practice?
Physician assistants can provide a vast array of traditional and non-traditional services within dermatology practices. According to dermatologists interviewed for this article, practices that utilize PAs have higher patient satisfaction (most likely because they are to focus on high-level patient interactions), decreased waiting time, more efficient interactions with patients, and decreased appointment wait lists.
Miami dermatologist Flor A. Mayoral, M.D., explains how the PAs she employs function in her practice.“Sometimes, patients need to wait a long time to see me. I currently have two PAs working in my office. If someone has a new problem and wants to be seen within a few days, they are scheduled with the PA, who does the initial evaluation, including taking a history, making a decision on treatment, and writing the prescription. He or she then presents to me the patient’s history, physical exam findings, and what he or she is thinking of doing. I then come into the room and the final disposition of the patient is made by me. Most of the time, I do not change the medications that the patient is receiving.”
After proper training, a PA-C can perform biopsies, suture surgical wounds, excise skin cancers, assist with Mohs and perform laser procedures, inject Botox and fillers and perform chemical peels.
In addition to these technical procedures, PAs have many non-tangible benefits.
Dermatologist Kenneth R. Beer states, “The right PA can make a huge difference and free you to perform at the level of most attendings at a training program. In addition, they can make a big difference in freeing up your time to focus on the aspects of patient care that interest you the most.”
But do Most Patients Want to be Treated by a PA?
Recent data from an AAPA survey conducted this past spring indicate that the majority of respondents were willing to be treated by PAs.
In a phone survey of 1,000 adults, more than 80% of respondents said they would be willing to be seen by a PA for a routine health visit if their physician were not available. Of people who had been previously treated by a PA, 90% said they would be willing to see the PA again. Of those who had never been treated by a PA, 76% said they would be willing to see a PA.
PAs in Action: A tale of Two Practices
Physicians who develop a strong PA/MD team can generally delegate routine follow-up appointments, as well as those for rashes, suture removal, psoriasis, acne, or other common disease processes. Such physicians can then be free to concentrate on more difficult cases, add clinical trials to the practice, publish and leave the office before 7 p.m.
In addition to the many hands-on medical roles that PAs provide, they also may function as associate managers of a dermatology practice. For those who take an interest in the business sphere, they can manage/supervise the medical assistants, conduct clinical trials, develop marketing campaigns, and even initiate and manage cosmeceutical products within the practice. Table 1 summarizes some of the roles of a PA-C in a practice. These can be expanded and are dependent upon the needs and desires of the M,D,/PA team.
The following two case reports will give you an idea of how two practices have incorporated PAs.
Case Report 1: Maxed Out
I was recently consulted by a frustrated board-certified dermatologist who, within 30 seconds of beginning our conversation, told me he was “maxed out.” I asked him to explain to me exactly what a day consisted of at his practice, and asked questions such as if he enjoyed going to work, what he viewed as the problems, what were his goals, and what was the makeup of his staff.
After listening to his answers and hearing the discouragement in his voice, I suggested an office site visit during which I would present to the practice posing as a patient. This allows me the opportunity to observe and experience what a patient experiences and to survey the staff without their knowing, enabling me to accurately assess the office. Interestingly enough, often the physician is too busy to notice that I am actually conducting my initial evaluation.
Comments:
This physician had an interesting dilemma. He is a partner in a group of board-certified dermatologist that uses one manager for six offices. While this particular manager was a very talented individual, it was impossible to appropriately manage that many sites without some pitfalls. In this case, the doctor was unsuccessfully striving to run a very efficient practice that could match his needs, desires, and talents. Without an onsite person to take care of the everyday business facets, the physician was unable to focus 100% on his patients, and in turn, all areas of the practice were suffering.
Conclusions:
Several days of survey led me to believe that a PA would benefit this practice. Through the addition of a PA-C who would not only practice as a clinician but also as an onsite manager, numerous predicaments would be solved. The PA-C would oversee, train, and delegate to the medical staff. The extender would also lighten the physician’s patient load by taking on the responsibility of seeing patients for follow-ups, suture removals, acne, psoriasis, and other easily maintained patients.
Six months later, the addition of a PA to this practice was working so well that the dermatologist was considering bringing on a secondary PA-C to assist him in developing a cosmetic element for the practice where none had existed before.
Despite the apparent cost associated with hiring a PA, these healthcare providers pay for themselves. While they are seeing patients, performing laser procedures, or performing simple excisions, they are producing revenue that covers their own salary and several of your staff member’s salaries.
“For follow-up treatment of common problems such as warts, acne, molluscum, stasis dermatitis, etc., the PA does the follow-up visit and the decision on treatment. I come into the room for all body checks for moles/cancers, whether it is a new patient or a follow-up visit,” explains Dr. Mayoral. “For cosmetic procedures such as hair removal, intense pulsed light procedures, or peels, the patient is scheduled to see the PA, and the PA performs these procedures. The financial benefits of this arrangement are obvious, and the logistics of being able to take care of patients on a timely basis are made much easier,” she says.
A Look at Salary Ranges
A Physician Assistant’s salary ranges greatly from sub-specialty to sub-specialty as well as from state to state.
The AAPA reported mean total income (MTI) from primary employers for clinically practicing PAs working at least 32 hours a week in its 2006 census report.
Beyond their salaries, most PA-Cs are given an incentive-based bonus on a bi-weekly basis. This bonus can be based on PA productivity, practice productivity, study income, cosmeceutical income, laser income, or call schedules. The percentage of the bonus is determined by the PA/MD team and can be used as an incentive for the PA to develop a portion of the practice that is underutilized or poorly managed.
Case Report 2: Sticker Shock
One of my first consulting opportunities taught me that sticker shock can be a two-way street. As I wandered around the exhibit hall at the American Academy of Dermatology annual meeting, I was approached by a dermatologist who, by word of mouth, had heard that I was a dermatology physician assistant as well as a practice consultant. Over a cup of coffee, we started to discuss his practice and the extender he had working with him. Although he appreciated the work that his extender performed, he felt that he could teach a “well-qualified” medical assistant or nurse to execute the same duties. For that reason, he felt that the salary that he was paying his extender was excessive. He also complained that the extender did not produce the revenue that he had expected.
My next two questions to him were:
1. “What types of procedures are performed by your extender?”
2. “What is the salary that you pay your extender?”
Not only was I surprised to learn the mundane duties he had assigned his extender, but I also could not believe the minimal salary she was working for. Nor could he believe it when I told him what the average dermatology PA-C earns.
Comments:
Physician extenders have the ability and legal right to perform a majority of the procedures that their supervising physicians execute. The duties that they actually carry out are determined by the MD/PA team. As the physician described how he utilized his extender, I wondered why he had bothered employing a graduate-level staff member and then chosen to utilize that person as a medical assistant/nurse. It was no wonder that she was not producing any revenue and therefore could not increase her salary, receive incentives, or satisfy the physician’s needs.
Conclusions:
It is important to remember that your extender is a clinician/provider. If you want him or her to function in a productive and financially rewarding manner, then he or she needs to be given the opportunity.
After the AAD conference, I spent time within the physician’s office working with him and his entire staff. We established a protocol of patients and procedures that both members of the MD/PA team were comfortable with the extender providing. We also set goals to be accomplished over 6 months that would slowly expand the overall responsibilities of the PA-C. We set up the following plan for the PA:
• give her the autonomy she deserved
• increase her level of satisfaction in the practice
• decrease the physician’s work load
• increase the physician’s level of satisfaction with an extender
• greatly increase the revenue for the MD/PA team.
With this plan in place, the physician was able to gain extra revenue, and he was able to hire a medical assistant, increase the PA-C salary and incentive amount, and increase his own salary.
Where PAs Practice
While physician assistants are now being utilized in every specialty in medicine, they are also employed in a wide variety of facilities. Some of these include: single or multi-specialty physician group practices, hospitals, solo physician offices, urgent care centers, surgical centers, assisted living facilities, HMOs, and correctional systems. Each state has specific guidelines for the scope of practice a PA must follow.
States with the largest numbers of clinically practicing PAs are: New York (8%), California (8%), Texas (6%), Pennsylvania (6%), Florida (5%), North Carolina (5%), and Michigan (5%). Examples of the guidelines for the states of Florida and New York are as follows:
FLORIDA
Qualifications: Graduation from accredited PA program and NCCPA examination.
Application: By PA for license; includes information about supervising physician.
Scope of practice: PA may perform delegated tasks and procedures for which he or she is skilled that are within the supervising physician’s scope of practice. Some duties may be performed only if the physician is on the premises, such as insertion of chest tubes and monitoring cardiac stress tests. Final diagnoses may not be delegated.
Prescribing/dispensing: Negative formulary; PAs may prescribe drugs not listed on the formulary established by Council on PAs and adopted by medical and osteopathic boards. Formulary must include controlled substances. Prior to prescribing, PA must complete a 3-hour course in prescriptive practice, 3 months of clinical experience in the specialty area of the supervising physician, and 10 hours of CME in the specialty area of practice. The Board issues a prescriber number to the PA.
Supervision: Physical presence or easy availability (by telecommunications) of physician is required. During the initial 6 months of supervision, medical records must be reviewed and signed by the physician within 7 days. After the initial 6 months, charts must be co-signed within 30 days. Physicians utilizing PAs in remote offices must follow specific supervision requirements, depending on practice specialty.
Participation in regulation: One PA serves on five-member PA Council.
NEW YORK
Qualifications: Graduation from approved PA program and NCCPA examination.
Application: By PA for state registration.
Scope of practice: Medical acts and duties delegated by the supervising physician, within the physician's scope of practice and appropriate to the PA's education, training, and experience.
Prescribing/dispensing: PA may prescribe Schedules III-V and non-controlled medications. PA prescribers of controlled drugs must register with the DEA.
Supervision: Physician not required to be physically present at time and place where PA performs services.
Participation in regulation: At least two PAs appointed to medical examining board.
Expanding Your Practice in Tune with Your Needs
The benefits to employing PAs in a dermatology practice are limitless. When utilized appropriately, they can easily put your practice on a track of greater efficiency, higher patient satisfaction, and an improved level of job satisfaction for the entire staff.
In Dr. Beer’s opinion, “It enabled me to spend time with patients without spending time with patients — that is, I was able to have someone with a graduate education discuss procedures and diseases with patients in a manner consonant with my practice philosophy.
From a managerial perspective, it was nice to have a provider with the same perspective explain to the staff what needed to happen for the practice to function.” The great advantage in employing an extender is their roles can conform to the MD’s needs as well as the needs of the practice.
In the last decade, the number of physician assistants (PAs) has dramatically expanded. Since 1997, More than 30 states have experienced greater than 100% growth in the number of PAs practicing there, with a few states (Arizona, Idaho, Illinois and Indiana) logging more than 200% increases in PAs. Overall, more than 65,000 PAs practice in the United States, as stated by the American Academy of Physician Assistants (AAPA).
As for PAs in dermatology, some 2,500 are in practice around the country, according to the Society for Dermatology Physician Assistants.
As PAs expand in their roles, so do the sub-specialties within this group of practitioners. Extenders are no longer limited to internal medicine or family practice. Instead, one can find the PA-C (physician assistant-certified) title monogram stitched on white coats within cardiovascular/cardiothoracic surgery, radiation oncology, orthopedics, dermatology, and plastic surgery, among other areas. As a dermatology PA-C and a cosmetic practice consultant, my area of interest is how PAs can provide maximal benefits to dermatology and cosmetic practices.
What Can a PA Do for Your Practice?
Physician assistants can provide a vast array of traditional and non-traditional services within dermatology practices. According to dermatologists interviewed for this article, practices that utilize PAs have higher patient satisfaction (most likely because they are to focus on high-level patient interactions), decreased waiting time, more efficient interactions with patients, and decreased appointment wait lists.
Miami dermatologist Flor A. Mayoral, M.D., explains how the PAs she employs function in her practice.“Sometimes, patients need to wait a long time to see me. I currently have two PAs working in my office. If someone has a new problem and wants to be seen within a few days, they are scheduled with the PA, who does the initial evaluation, including taking a history, making a decision on treatment, and writing the prescription. He or she then presents to me the patient’s history, physical exam findings, and what he or she is thinking of doing. I then come into the room and the final disposition of the patient is made by me. Most of the time, I do not change the medications that the patient is receiving.”
After proper training, a PA-C can perform biopsies, suture surgical wounds, excise skin cancers, assist with Mohs and perform laser procedures, inject Botox and fillers and perform chemical peels.
In addition to these technical procedures, PAs have many non-tangible benefits.
Dermatologist Kenneth R. Beer states, “The right PA can make a huge difference and free you to perform at the level of most attendings at a training program. In addition, they can make a big difference in freeing up your time to focus on the aspects of patient care that interest you the most.”
But do Most Patients Want to be Treated by a PA?
Recent data from an AAPA survey conducted this past spring indicate that the majority of respondents were willing to be treated by PAs.
In a phone survey of 1,000 adults, more than 80% of respondents said they would be willing to be seen by a PA for a routine health visit if their physician were not available. Of people who had been previously treated by a PA, 90% said they would be willing to see the PA again. Of those who had never been treated by a PA, 76% said they would be willing to see a PA.
PAs in Action: A tale of Two Practices
Physicians who develop a strong PA/MD team can generally delegate routine follow-up appointments, as well as those for rashes, suture removal, psoriasis, acne, or other common disease processes. Such physicians can then be free to concentrate on more difficult cases, add clinical trials to the practice, publish and leave the office before 7 p.m.
In addition to the many hands-on medical roles that PAs provide, they also may function as associate managers of a dermatology practice. For those who take an interest in the business sphere, they can manage/supervise the medical assistants, conduct clinical trials, develop marketing campaigns, and even initiate and manage cosmeceutical products within the practice. Table 1 summarizes some of the roles of a PA-C in a practice. These can be expanded and are dependent upon the needs and desires of the M,D,/PA team.
The following two case reports will give you an idea of how two practices have incorporated PAs.
Case Report 1: Maxed Out
I was recently consulted by a frustrated board-certified dermatologist who, within 30 seconds of beginning our conversation, told me he was “maxed out.” I asked him to explain to me exactly what a day consisted of at his practice, and asked questions such as if he enjoyed going to work, what he viewed as the problems, what were his goals, and what was the makeup of his staff.
After listening to his answers and hearing the discouragement in his voice, I suggested an office site visit during which I would present to the practice posing as a patient. This allows me the opportunity to observe and experience what a patient experiences and to survey the staff without their knowing, enabling me to accurately assess the office. Interestingly enough, often the physician is too busy to notice that I am actually conducting my initial evaluation.
Comments:
This physician had an interesting dilemma. He is a partner in a group of board-certified dermatologist that uses one manager for six offices. While this particular manager was a very talented individual, it was impossible to appropriately manage that many sites without some pitfalls. In this case, the doctor was unsuccessfully striving to run a very efficient practice that could match his needs, desires, and talents. Without an onsite person to take care of the everyday business facets, the physician was unable to focus 100% on his patients, and in turn, all areas of the practice were suffering.
Conclusions:
Several days of survey led me to believe that a PA would benefit this practice. Through the addition of a PA-C who would not only practice as a clinician but also as an onsite manager, numerous predicaments would be solved. The PA-C would oversee, train, and delegate to the medical staff. The extender would also lighten the physician’s patient load by taking on the responsibility of seeing patients for follow-ups, suture removals, acne, psoriasis, and other easily maintained patients.
Six months later, the addition of a PA to this practice was working so well that the dermatologist was considering bringing on a secondary PA-C to assist him in developing a cosmetic element for the practice where none had existed before.
Despite the apparent cost associated with hiring a PA, these healthcare providers pay for themselves. While they are seeing patients, performing laser procedures, or performing simple excisions, they are producing revenue that covers their own salary and several of your staff member’s salaries.
“For follow-up treatment of common problems such as warts, acne, molluscum, stasis dermatitis, etc., the PA does the follow-up visit and the decision on treatment. I come into the room for all body checks for moles/cancers, whether it is a new patient or a follow-up visit,” explains Dr. Mayoral. “For cosmetic procedures such as hair removal, intense pulsed light procedures, or peels, the patient is scheduled to see the PA, and the PA performs these procedures. The financial benefits of this arrangement are obvious, and the logistics of being able to take care of patients on a timely basis are made much easier,” she says.
A Look at Salary Ranges
A Physician Assistant’s salary ranges greatly from sub-specialty to sub-specialty as well as from state to state.
The AAPA reported mean total income (MTI) from primary employers for clinically practicing PAs working at least 32 hours a week in its 2006 census report.
Beyond their salaries, most PA-Cs are given an incentive-based bonus on a bi-weekly basis. This bonus can be based on PA productivity, practice productivity, study income, cosmeceutical income, laser income, or call schedules. The percentage of the bonus is determined by the PA/MD team and can be used as an incentive for the PA to develop a portion of the practice that is underutilized or poorly managed.
Case Report 2: Sticker Shock
One of my first consulting opportunities taught me that sticker shock can be a two-way street. As I wandered around the exhibit hall at the American Academy of Dermatology annual meeting, I was approached by a dermatologist who, by word of mouth, had heard that I was a dermatology physician assistant as well as a practice consultant. Over a cup of coffee, we started to discuss his practice and the extender he had working with him. Although he appreciated the work that his extender performed, he felt that he could teach a “well-qualified” medical assistant or nurse to execute the same duties. For that reason, he felt that the salary that he was paying his extender was excessive. He also complained that the extender did not produce the revenue that he had expected.
My next two questions to him were:
1. “What types of procedures are performed by your extender?”
2. “What is the salary that you pay your extender?”
Not only was I surprised to learn the mundane duties he had assigned his extender, but I also could not believe the minimal salary she was working for. Nor could he believe it when I told him what the average dermatology PA-C earns.
Comments:
Physician extenders have the ability and legal right to perform a majority of the procedures that their supervising physicians execute. The duties that they actually carry out are determined by the MD/PA team. As the physician described how he utilized his extender, I wondered why he had bothered employing a graduate-level staff member and then chosen to utilize that person as a medical assistant/nurse. It was no wonder that she was not producing any revenue and therefore could not increase her salary, receive incentives, or satisfy the physician’s needs.
Conclusions:
It is important to remember that your extender is a clinician/provider. If you want him or her to function in a productive and financially rewarding manner, then he or she needs to be given the opportunity.
After the AAD conference, I spent time within the physician’s office working with him and his entire staff. We established a protocol of patients and procedures that both members of the MD/PA team were comfortable with the extender providing. We also set goals to be accomplished over 6 months that would slowly expand the overall responsibilities of the PA-C. We set up the following plan for the PA:
• give her the autonomy she deserved
• increase her level of satisfaction in the practice
• decrease the physician’s work load
• increase the physician’s level of satisfaction with an extender
• greatly increase the revenue for the MD/PA team.
With this plan in place, the physician was able to gain extra revenue, and he was able to hire a medical assistant, increase the PA-C salary and incentive amount, and increase his own salary.
Where PAs Practice
While physician assistants are now being utilized in every specialty in medicine, they are also employed in a wide variety of facilities. Some of these include: single or multi-specialty physician group practices, hospitals, solo physician offices, urgent care centers, surgical centers, assisted living facilities, HMOs, and correctional systems. Each state has specific guidelines for the scope of practice a PA must follow.
States with the largest numbers of clinically practicing PAs are: New York (8%), California (8%), Texas (6%), Pennsylvania (6%), Florida (5%), North Carolina (5%), and Michigan (5%). Examples of the guidelines for the states of Florida and New York are as follows:
FLORIDA
Qualifications: Graduation from accredited PA program and NCCPA examination.
Application: By PA for license; includes information about supervising physician.
Scope of practice: PA may perform delegated tasks and procedures for which he or she is skilled that are within the supervising physician’s scope of practice. Some duties may be performed only if the physician is on the premises, such as insertion of chest tubes and monitoring cardiac stress tests. Final diagnoses may not be delegated.
Prescribing/dispensing: Negative formulary; PAs may prescribe drugs not listed on the formulary established by Council on PAs and adopted by medical and osteopathic boards. Formulary must include controlled substances. Prior to prescribing, PA must complete a 3-hour course in prescriptive practice, 3 months of clinical experience in the specialty area of the supervising physician, and 10 hours of CME in the specialty area of practice. The Board issues a prescriber number to the PA.
Supervision: Physical presence or easy availability (by telecommunications) of physician is required. During the initial 6 months of supervision, medical records must be reviewed and signed by the physician within 7 days. After the initial 6 months, charts must be co-signed within 30 days. Physicians utilizing PAs in remote offices must follow specific supervision requirements, depending on practice specialty.
Participation in regulation: One PA serves on five-member PA Council.
NEW YORK
Qualifications: Graduation from approved PA program and NCCPA examination.
Application: By PA for state registration.
Scope of practice: Medical acts and duties delegated by the supervising physician, within the physician's scope of practice and appropriate to the PA's education, training, and experience.
Prescribing/dispensing: PA may prescribe Schedules III-V and non-controlled medications. PA prescribers of controlled drugs must register with the DEA.
Supervision: Physician not required to be physically present at time and place where PA performs services.
Participation in regulation: At least two PAs appointed to medical examining board.
Expanding Your Practice in Tune with Your Needs
The benefits to employing PAs in a dermatology practice are limitless. When utilized appropriately, they can easily put your practice on a track of greater efficiency, higher patient satisfaction, and an improved level of job satisfaction for the entire staff.
In Dr. Beer’s opinion, “It enabled me to spend time with patients without spending time with patients — that is, I was able to have someone with a graduate education discuss procedures and diseases with patients in a manner consonant with my practice philosophy.
From a managerial perspective, it was nice to have a provider with the same perspective explain to the staff what needed to happen for the practice to function.” The great advantage in employing an extender is their roles can conform to the MD’s needs as well as the needs of the practice.
In the last decade, the number of physician assistants (PAs) has dramatically expanded. Since 1997, More than 30 states have experienced greater than 100% growth in the number of PAs practicing there, with a few states (Arizona, Idaho, Illinois and Indiana) logging more than 200% increases in PAs. Overall, more than 65,000 PAs practice in the United States, as stated by the American Academy of Physician Assistants (AAPA).
As for PAs in dermatology, some 2,500 are in practice around the country, according to the Society for Dermatology Physician Assistants.
As PAs expand in their roles, so do the sub-specialties within this group of practitioners. Extenders are no longer limited to internal medicine or family practice. Instead, one can find the PA-C (physician assistant-certified) title monogram stitched on white coats within cardiovascular/cardiothoracic surgery, radiation oncology, orthopedics, dermatology, and plastic surgery, among other areas. As a dermatology PA-C and a cosmetic practice consultant, my area of interest is how PAs can provide maximal benefits to dermatology and cosmetic practices.
What Can a PA Do for Your Practice?
Physician assistants can provide a vast array of traditional and non-traditional services within dermatology practices. According to dermatologists interviewed for this article, practices that utilize PAs have higher patient satisfaction (most likely because they are to focus on high-level patient interactions), decreased waiting time, more efficient interactions with patients, and decreased appointment wait lists.
Miami dermatologist Flor A. Mayoral, M.D., explains how the PAs she employs function in her practice.“Sometimes, patients need to wait a long time to see me. I currently have two PAs working in my office. If someone has a new problem and wants to be seen within a few days, they are scheduled with the PA, who does the initial evaluation, including taking a history, making a decision on treatment, and writing the prescription. He or she then presents to me the patient’s history, physical exam findings, and what he or she is thinking of doing. I then come into the room and the final disposition of the patient is made by me. Most of the time, I do not change the medications that the patient is receiving.”
After proper training, a PA-C can perform biopsies, suture surgical wounds, excise skin cancers, assist with Mohs and perform laser procedures, inject Botox and fillers and perform chemical peels.
In addition to these technical procedures, PAs have many non-tangible benefits.
Dermatologist Kenneth R. Beer states, “The right PA can make a huge difference and free you to perform at the level of most attendings at a training program. In addition, they can make a big difference in freeing up your time to focus on the aspects of patient care that interest you the most.”
But do Most Patients Want to be Treated by a PA?
Recent data from an AAPA survey conducted this past spring indicate that the majority of respondents were willing to be treated by PAs.
In a phone survey of 1,000 adults, more than 80% of respondents said they would be willing to be seen by a PA for a routine health visit if their physician were not available. Of people who had been previously treated by a PA, 90% said they would be willing to see the PA again. Of those who had never been treated by a PA, 76% said they would be willing to see a PA.
PAs in Action: A tale of Two Practices
Physicians who develop a strong PA/MD team can generally delegate routine follow-up appointments, as well as those for rashes, suture removal, psoriasis, acne, or other common disease processes. Such physicians can then be free to concentrate on more difficult cases, add clinical trials to the practice, publish and leave the office before 7 p.m.
In addition to the many hands-on medical roles that PAs provide, they also may function as associate managers of a dermatology practice. For those who take an interest in the business sphere, they can manage/supervise the medical assistants, conduct clinical trials, develop marketing campaigns, and even initiate and manage cosmeceutical products within the practice. Table 1 summarizes some of the roles of a PA-C in a practice. These can be expanded and are dependent upon the needs and desires of the M,D,/PA team.
The following two case reports will give you an idea of how two practices have incorporated PAs.
Case Report 1: Maxed Out
I was recently consulted by a frustrated board-certified dermatologist who, within 30 seconds of beginning our conversation, told me he was “maxed out.” I asked him to explain to me exactly what a day consisted of at his practice, and asked questions such as if he enjoyed going to work, what he viewed as the problems, what were his goals, and what was the makeup of his staff.
After listening to his answers and hearing the discouragement in his voice, I suggested an office site visit during which I would present to the practice posing as a patient. This allows me the opportunity to observe and experience what a patient experiences and to survey the staff without their knowing, enabling me to accurately assess the office. Interestingly enough, often the physician is too busy to notice that I am actually conducting my initial evaluation.
Comments:
This physician had an interesting dilemma. He is a partner in a group of board-certified dermatologist that uses one manager for six offices. While this particular manager was a very talented individual, it was impossible to appropriately manage that many sites without some pitfalls. In this case, the doctor was unsuccessfully striving to run a very efficient practice that could match his needs, desires, and talents. Without an onsite person to take care of the everyday business facets, the physician was unable to focus 100% on his patients, and in turn, all areas of the practice were suffering.
Conclusions:
Several days of survey led me to believe that a PA would benefit this practice. Through the addition of a PA-C who would not only practice as a clinician but also as an onsite manager, numerous predicaments would be solved. The PA-C would oversee, train, and delegate to the medical staff. The extender would also lighten the physician’s patient load by taking on the responsibility of seeing patients for follow-ups, suture removals, acne, psoriasis, and other easily maintained patients.
Six months later, the addition of a PA to this practice was working so well that the dermatologist was considering bringing on a secondary PA-C to assist him in developing a cosmetic element for the practice where none had existed before.
Despite the apparent cost associated with hiring a PA, these healthcare providers pay for themselves. While they are seeing patients, performing laser procedures, or performing simple excisions, they are producing revenue that covers their own salary and several of your staff member’s salaries.
“For follow-up treatment of common problems such as warts, acne, molluscum, stasis dermatitis, etc., the PA does the follow-up visit and the decision on treatment. I come into the room for all body checks for moles/cancers, whether it is a new patient or a follow-up visit,” explains Dr. Mayoral. “For cosmetic procedures such as hair removal, intense pulsed light procedures, or peels, the patient is scheduled to see the PA, and the PA performs these procedures. The financial benefits of this arrangement are obvious, and the logistics of being able to take care of patients on a timely basis are made much easier,” she says.
A Look at Salary Ranges
A Physician Assistant’s salary ranges greatly from sub-specialty to sub-specialty as well as from state to state.
The AAPA reported mean total income (MTI) from primary employers for clinically practicing PAs working at least 32 hours a week in its 2006 census report.
Beyond their salaries, most PA-Cs are given an incentive-based bonus on a bi-weekly basis. This bonus can be based on PA productivity, practice productivity, study income, cosmeceutical income, laser income, or call schedules. The percentage of the bonus is determined by the PA/MD team and can be used as an incentive for the PA to develop a portion of the practice that is underutilized or poorly managed.
Case Report 2: Sticker Shock
One of my first consulting opportunities taught me that sticker shock can be a two-way street. As I wandered around the exhibit hall at the American Academy of Dermatology annual meeting, I was approached by a dermatologist who, by word of mouth, had heard that I was a dermatology physician assistant as well as a practice consultant. Over a cup of coffee, we started to discuss his practice and the extender he had working with him. Although he appreciated the work that his extender performed, he felt that he could teach a “well-qualified” medical assistant or nurse to execute the same duties. For that reason, he felt that the salary that he was paying his extender was excessive. He also complained that the extender did not produce the revenue that he had expected.
My next two questions to him were:
1. “What types of procedures are performed by your extender?”
2. “What is the salary that you pay your extender?”
Not only was I surprised to learn the mundane duties he had assigned his extender, but I also could not believe the minimal salary she was working for. Nor could he believe it when I told him what the average dermatology PA-C earns.
Comments:
Physician extenders have the ability and legal right to perform a majority of the procedures that their supervising physicians execute. The duties that they actually carry out are determined by the MD/PA team. As the physician described how he utilized his extender, I wondered why he had bothered employing a graduate-level staff member and then chosen to utilize that person as a medical assistant/nurse. It was no wonder that she was not producing any revenue and therefore could not increase her salary, receive incentives, or satisfy the physician’s needs.
Conclusions:
It is important to remember that your extender is a clinician/provider. If you want him or her to function in a productive and financially rewarding manner, then he or she needs to be given the opportunity.
After the AAD conference, I spent time within the physician’s office working with him and his entire staff. We established a protocol of patients and procedures that both members of the MD/PA team were comfortable with the extender providing. We also set goals to be accomplished over 6 months that would slowly expand the overall responsibilities of the PA-C. We set up the following plan for the PA:
• give her the autonomy she deserved
• increase her level of satisfaction in the practice
• decrease the physician’s work load
• increase the physician’s level of satisfaction with an extender
• greatly increase the revenue for the MD/PA team.
With this plan in place, the physician was able to gain extra revenue, and he was able to hire a medical assistant, increase the PA-C salary and incentive amount, and increase his own salary.
Where PAs Practice
While physician assistants are now being utilized in every specialty in medicine, they are also employed in a wide variety of facilities. Some of these include: single or multi-specialty physician group practices, hospitals, solo physician offices, urgent care centers, surgical centers, assisted living facilities, HMOs, and correctional systems. Each state has specific guidelines for the scope of practice a PA must follow.
States with the largest numbers of clinically practicing PAs are: New York (8%), California (8%), Texas (6%), Pennsylvania (6%), Florida (5%), North Carolina (5%), and Michigan (5%). Examples of the guidelines for the states of Florida and New York are as follows:
FLORIDA
Qualifications: Graduation from accredited PA program and NCCPA examination.
Application: By PA for license; includes information about supervising physician.
Scope of practice: PA may perform delegated tasks and procedures for which he or she is skilled that are within the supervising physician’s scope of practice. Some duties may be performed only if the physician is on the premises, such as insertion of chest tubes and monitoring cardiac stress tests. Final diagnoses may not be delegated.
Prescribing/dispensing: Negative formulary; PAs may prescribe drugs not listed on the formulary established by Council on PAs and adopted by medical and osteopathic boards. Formulary must include controlled substances. Prior to prescribing, PA must complete a 3-hour course in prescriptive practice, 3 months of clinical experience in the specialty area of the supervising physician, and 10 hours of CME in the specialty area of practice. The Board issues a prescriber number to the PA.
Supervision: Physical presence or easy availability (by telecommunications) of physician is required. During the initial 6 months of supervision, medical records must be reviewed and signed by the physician within 7 days. After the initial 6 months, charts must be co-signed within 30 days. Physicians utilizing PAs in remote offices must follow specific supervision requirements, depending on practice specialty.
Participation in regulation: One PA serves on five-member PA Council.
NEW YORK
Qualifications: Graduation from approved PA program and NCCPA examination.
Application: By PA for state registration.
Scope of practice: Medical acts and duties delegated by the supervising physician, within the physician's scope of practice and appropriate to the PA's education, training, and experience.
Prescribing/dispensing: PA may prescribe Schedules III-V and non-controlled medications. PA prescribers of controlled drugs must register with the DEA.
Supervision: Physician not required to be physically present at time and place where PA performs services.
Participation in regulation: At least two PAs appointed to medical examining board.
Expanding Your Practice in Tune with Your Needs
The benefits to employing PAs in a dermatology practice are limitless. When utilized appropriately, they can easily put your practice on a track of greater efficiency, higher patient satisfaction, and an improved level of job satisfaction for the entire staff.
In Dr. Beer’s opinion, “It enabled me to spend time with patients without spending time with patients — that is, I was able to have someone with a graduate education discuss procedures and diseases with patients in a manner consonant with my practice philosophy.
From a managerial perspective, it was nice to have a provider with the same perspective explain to the staff what needed to happen for the practice to function.” The great advantage in employing an extender is their roles can conform to the MD’s needs as well as the needs of the practice.
