Sometimes it seems like two steps forward, and one step backward for team practice in the U.S. healthcare system.
This past week, I got an urgent communication from my professional organization, the American Academy of Physician Assistants (AAPA). They asked me to write my congressional representatives to ask them to help delay or modify implementation of new hospital admissions requirements that mandate new requirements that limit the ability of physician assistants and nurse practitioners to admit patients.
The new admissions requirements contained in section 412.3(b) will create major problems for PAs and other nonphysician healthcare professionals who currently admit patients to hospitals under delegated authority, physicians who delegate roles in the admissions process, hospitals, and most importantly, patients. Additionally, the new admissions requirements run contrary to HHS Secretary Kathleen Sebelius’ role in removing unnecessary regulatory barriers to the provision of healthcare in rural and other medically underserved communities.
I really hope that implementation of the new admissions requirements can be delayed until a workable alternative can be developed by CMS and stakeholders.
I currently work in a busy, hospital-based practice in plastics and reconstructive surgery in Bakersfield, Calif. My physician partner and I have worked as a team for years. Many times, he is at another nearby hospital seeing patients and performing surgery when an emergency, burn, or other significant injury is presented to our emergency department for care. Currently, consistent with state law and our facility's medical staff bylaws, I am able to admit a patient under the authority of my surgeon to begin needed — and sometimes critical — care for injured patients. Waiting for the surgeon to physically admit the patient could delay needed and critical care for our patients for hours in some situations. Our facility employs many PAs and nonphysician providers who have the ability today to initiate admission orders and needed care for patients who present to the hospital requiring hospitalization. This rule will have a dramatic and negative impact on access to care, morbidity, mortality, and disability, and makes no sense whatsoever in the current environment of health care reform.
AAPA data confirms that approximately 40 percent of the more than 92,000 PAs in practice are employed in hospitals; many of whom are involved in the admissions process. PAs play a critical role in the admissions process in our hospital and all hospitals that include directly evaluating and admitting patients. Physicians need to continue to delegate their admitting authority in order to provide the best and most appropriate medical care for patients. This has been essential in rural areas where PAs may be the only medical practitioner staffing a critical access hospital or during overnight or low-volume shifts when a PA may be the only medical practitioner staffing a hospital emergency room. Requiring a physician to be physically on-site in order to admit a patient will create a significant barrier to patient care.
The final rule promises to disrupt the current role of PAs and others in the hospital admissions process by mandating new requirements that:
• PAs and other qualified nonphysician practitioners must have admitting privileges at the hospital (Most PAs and others admit through the delegation of a physician; this is precisely how it works in my practice).
• PAs and other qualified practitioners must be permitted by state law to admit patients to hospitals (State laws do not specifically address admitting privileges of PAs or other qualified practitioners. The regulations should be revised to permit qualified practitioners, working within their scope of practice as defined by state law, to admit patients to hospitals).
• Prohibit physicians from delegating admissions (PA practice is predicated on the ability of physicians to delegate to PAs. To discontinue this practice would create a significant disruption to the medical system. The prohibition on delegation is antiquated thinking that is not supported by current collaborative practice models and does nothing to reduce inappropriate admissions).
All together, I believe these provisions will create monumental problems in the hospital admissions process, without furthering CMS’ goal of reducing inappropriate admissions. PAs are highly trained medical providers that work on teams with physicians to make appropriate medical judgments related to patient care. Limiting the ability of PAs to treat their patients will unquestionably harm patient access to care without improving the way we pay for care.
Due to the growing healthcare workforce needs, as well as the growing importance of team-based medical care and the need for healthcare workforce efficiencies, I believe that the new admissions requirements are simply headed in the wrong direction and will create an unnecessary barrier to clinically appropriate medical care.
This blog was provided in partnership with the American Academy of Physician Assistants.