Stephen H. Hanson, PA-C

’s blog features contributions from members of the medical community. These blogs are an opportunity for professionals to engage with readers about a topic that is top of mind, whether it is practice management, experiences with patients, the industry, medicine in general, or healthcare reform. The opinions are that of the writers and do not necessarily reflect the opinions of 

Having recently returned from the annual meetings of the American Academy of PAs (AAPA) and the AMA House of Delegates (HODs), I find myself pondering our professions’ histories and futures, individually and together.

Of course, these musings all come through the filter of my life experiences, including 20 years in the two Houses, which does, I think, give me some authority to comment. I have attended a dozen AMA HODs as an AAPA leader, and since the early 1990s, I have attended the AAPA HOD either as a delegate or a house officer, including three years as Speaker. Currently, I attend the AMA House as AAPA liaison, where my role is to develop and expand ties between the PA and physician professions.

In mid-May of this year, I attended my own HOD, where AAPA reaffirmed its policy on 

 (OTP), a policy that has been a bone of contention with some of our physician colleagues. Last year, PAs were the focus of an AMA resolution opposing independent practice by PAs, introduced largely in response to OTP, which, incidentally, is not about independent practice. The OTP policy calls for laws and regulations that:

Emphasize PAs’ commitment to team practice;

Authorize PAs to practice without an agreement with a specific physician-enabling practice-level decisions about collaboration;

Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and

Authorize PAs to be directly reimbursed by all public and private insurers.

I have always had great respect for my physician colleagues and am proud to work in concert with them. The AMA HOD consists of over 600 delegates from across the nation, 

. It is interesting to note that the leadership of the AMA continues to diversify with the elections of Barbara L. McAneny, MD, the fourth woman to serve as AMA president, and Patrice Harris, MD, the first African-American woman to hold the office of president-elect.

In addition, the breadth and depth of the AMA’s interest in community and public health is unparalleled by any other medical professional organization. The AMA’s HOD considers hundreds of policies twice yearly, including new policies and updates to old policies. Topics include healthcare reform, diversity, healthcare disparities, LGBTQIA+ issues, reproductive issues, poverty, immigration policy, and gun safety, among others. The detail and the passion of testimony in reference committees is inspiring and is a testament to physicians not only doing their homework but standing up to protect and defend those in our society who are not powerful and cannot defend themselves. 

This brings me to the point of my musings and this blog. The commonalities between PAs and physicians far outweigh the few differences that we have. In fact, the history of physicians and PAs working together in teams spans more than half a century and will continue into the foreseeable future, as far as I can see. Over my history of attending the policy setting body of the AMA, it has been my desire to partner with physicians on the many health issues confronting our communities and nation much more often than not

In my personal opinion, and in the opinion of the AAPA, OTP makes health care teams more efficient and less burdensome to physicians. This allows for more time to do what really matters in medicine-which is to care for patients and make their lives and the lives of their families better. By now, PAs have a long history of service and have proven our utility and flexibility in the health care systems of the United States and the world.

I love going to the AMA HOD to renew past acquaintances, make new physician friends, and to help my physician colleagues better understand the PA role in our health care system. The job is getting easier, given that there are 123,000 PAs now practicing in the United States in virtually all of same settings and specialties as physicians.

Many AMA delegates now have first-hand experience working with PAs and on teams with PAs, and this can only be a harbinger of good things to come for the future of medicine in the United States.

Articles

The commonalities between PAs and physicians far outweigh the few differences that we have.

Musings about the strengths of teams

 since 2011. I write about a wide variety of interests (I hope) to the physician profession. My favorite topics are EHRs and, of course, physician assistant practice and what physicians should know about PAs and their role on the healthcare team.

This past week, I have been as far removed from the U.S. healthcare system as one can get in the world. I am with the HELPS International Bakersfield surgical team in CobÃ¡n, Guatemala. This is my third annual mission with HELPS, and the second trip to CobÃ¡n. We completed hundreds of surgeries and procedures and saw thousands of clinical patients onsite and in outreach to remote villages.

Keep in mind that we have no diagnostics aside from mainly ultrasounds and MRI / CT scans that patients bring with them. There is no blood bank. The only resources and supplies that we have at our disposal are the ones that we bring with us. The “heavy” equipment (OR tables, anesthesia machines, monitors, kitchen equipment, furniture, racks, etc.) reside permanently in Guatemala City, and is brought to the site and set up by the HELPS advance team.

The team itself brings the consumables (gowns, gloves, medications, sutures, etc.) in scores of “dive bags” that have to be checked by the team as extra luggage. Every member of the team pays their own way to live in a barracks situation, eat cafeteria food (which was great by the way), and endure plumbing that can only be described as “interesting.”

We travel all day Saturday and Sunday, and then furiously unpack and set up onsite Sunday night, to begin screening surgical patients late Sunday to begin major surgery and minor procedures first thing Monday morning. By Monday morning, we have created a fully functional field hospital with pre-op, five ORs (which this year and last were 

 in the same room, and adjacent procedure room (That I staffed most of time when not doing main OR procedures and first assist), a post-anesthesia care unit, and a small observation unit for overnight stays.

One advancement this year is that Stryker donated a laparoscopic set up, and we were able to do all of the cholecystectomies laparoscopically, eliminating the need for overnight observation. This was a huge positive shift in our operation.

For me as a PA, and for the NPs, it is great to work in an environment where I am not judged by my license, or constrained by state regulation, but by my training, experience, and knowledge. I have worked in plastics and reconstructive surgery for nine years. It is the highlight of my year each time I am on mission to practice at the very top of my training, experience, and scope of practice, and be respected by all the members of the surgical team beyond my status as a PA. This is what 

The people of Guatemala are simply amazing. They come by the thousands to a mission site, with hope in their eyes and prayers in their hearts that we somehow, someway will be able to help their physical conditions, and alleviate their suffering. All too often, we have to turn away people that have problems just too complex to help due to the limitations of the team.

That said, we helped hundreds. We changed lives. And, many times, the lives that we changed the most were our own. No one can go away to a place like CobÃ¡n, or Tejutla in Guatemala and not come away changed forever in a way that you will 

 forget. In our great United States of America, we take for granted that which the majority of the world has never experienced. Great healthcare, clean water, education, public health infrastructure, community infrastructure, etc.

So, today, we are packing, decompressing, and taking stock of the things that went well, and the things that didn’t, so that we can improve of operation for next year. There are always key long-term volunteers that mentor and guide the many rookies who are part of every team.

One thing always remains a constant, and that is each member of the team is a selfless, sacrificing individual who is here for the right reasons and considers being a member of the team a privilege. Every American should go on mission once in their lives to the third world.

“Travel is fatal to prejudice, bigotry, and narrow-mindedness, and many of our people need it sorely on these accounts. Broad, wholesome, charitable views of men and things cannot be acquired by vegetating in one little corner of the earth all one's lifetime.”

A mission to Guatemala provides insight on the PA profession and introspection on what it means to work in healthcare.

The true value of medical missions

The practice of medicine by physician assistants (PAs) has evolved significantly during my professional career. Supporting a trajectory that began in 1967 with one-on-one physician-to-PA oversight, gradually arcing upward to 2018 when dynamic clinical teams provide sophisticated patient care, the American Academy of PAs (AAPA) recently adopted policy regarding the future of that PA practice.  Commonly referred to as Optimal Team Practice (OTP), the new policy calls for laws and regulations that:

• Emphasize PAs’ commitment to team practice;
• Authorize PAs to practice without an agreement with a specific physician - enabling practice-level decisions about collaboration;
• Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and
• Authorize PAs to be directly reimbursed by all public and commercial insurers.

Having addressed the first three OTP points in previous blog posts in 

. Today, I am blogging about point four, the need for laws and regulations to authorize direct reimbursement for medical services provided by PAs from all payers, both public, and commercial.

PAs are the only health professionals billing Medicare who are not entitled to direct reimbursement. Medicare allows physicians, advanced practice registered nurses (APRNs), and other health professionals to receive payment directly; payment for services provided by PAs must be made to the employer. In the commercial insurance market, nearly all third-party payers follow the Medicare approach, making payments to PAs’ employers. This outdated policy limits PA employment opportunities, particularly with staffing companies and other healthcare delivery arrangements whose providers “reassign” their reimbursement to the company that employs them. 

Because PAs can’t receive reimbursement directly, they can’t reassign their reimbursement in the same manner as physicians and APRNs. Allowing direct reimbursement for PAs would level the employment playing field and simplify administration for staffing companies in order to employ PAs.  Whether they work for a staff agency or a hospital or private practice, in most cases, PA reimbursement will be assigned to the employer, similar to physicians and APRNs. The inability to be paid directly also hinders PAs from being recognized in certain value-based payment arrangements and emerging models of innovative healthcare delivery.  If PA services are not tracked and billed separately, they cannot be counted toward revenue.

Even ore important, the failure to allow PAs to be directly reimbursed  makes our contributions to patient care from a quality and productivity perspective more difficult to recognize by health systems, researchers, and policy makers. In many situations and organizations, PAs are hidden under the NPI numbers of physicians or organizations. This creates data inaccuracies as it misrepresents who actually delivered care.

It makes no sense to treat PAs differently from any other health care provider delivering direct patient care in our health care system. PAs and the services that we deliver need to be properly accounted for within every organization, practice, and health care setting, Allowing an accurate accounting of the PAs’ contribution to health care will contribute to making a stronger, more accountable system of care.

PAs, along with potential employers, are adversely affected by the inability of PAs to be eligible to receive direct payment. Direct payment and the contingent ability to reassign benefits provide the necessary flexibility to meet the clinical needs of patients in a variety of practice settings and care models. Traditional practice models of one physician employing one PA have been replaced by models in which PAs, physicians and other healthcare team members practice in hospitals, health systems, and emerging healthcare delivery venues in more innovative, patient-centered arrangements.

The proposals for changes to laws and regulations included in OTP make sense and have many benefit physicians too by reducing administrative burdens and increased flexibility in team care.  They also eliminate physician liability for care provided by the PA unless the physician was involved.  OTP empowers teams to make decisions about team practice and team design at the practice level and eliminates the threat of disciplinary action for physicians and PAs involved in “paperwork infractions” unrelated to patient care.

Informed regulation of the PA profession makes PAs more valuable team members for physicians. OTP is the right prescription for our evolving healthcare world.

Unlike physicians, APRNs, and other health professionals, physician assistants do not receive direct reimbursement from insurers.

PAs Deserve Direct Reimbursement for their Services

In my day job, I practice as a PA in both general, plastic, and reconstructive surgery. I have also had a long career of serving in my profession’s leadership on the state, national, and specialty level.

During my career, I have personally witnessed the transition from “What is a PA?” to PAs being a vital and indispensable part of the health care system in the U.S. and around the world. Saying that the PA profession of 1981 is nothing like the PA profession of 2018 is a massive understatement.

My current role in leadership is to serve as the American Academy of PAs’ (AAPA) liaison to the American Medical Association. The AAPA and AMA have a longstanding and mutually beneficial relationship. We have grown together as organizations and as professions.

Optimal Team Practice (OTP) is a policy initiative by the PA profession that seeks to remove the administrative hassles and shared liability currently faced by physicians who practice with PAs. As PAs, we have always and will always be committed to team practice. We are trained and acculturated to the medical and surgical team practice environment, and we thrive in that environment. Part of OTP is removing requirements that every physician and PA who practice together document their relationship in a manner that is acceptable to the state. It's also about freeing physicians from vicarious liability for the care PAs provide. Removing these requirements will not change the PA profession’s commitment to practice with physicians.

At the 2017 Interim House of Delegates, in response to AAPA’s OTP initiative, the AMA essentially reaffirmed long standing policies as they relate to PAs and other non-physician providers. They also requested an in-person meeting to look at trends in scope of practice for providers who are not physicians.

The Physician Assistant Education Association's role is to represent those responsible for educating and preparing PAs to take their place in the health care system. Recently, AAPA President Gail Curtis participated in a Q&A with PAEA about OTP.

While there are many elements to OTP that I will discuss in future blogs, the question of how a “new grad” would handle this loosening of the tie to a specific physician vs. a seasoned PA is one I hear a lot. This is not unlike every element of the team practice of medicine. We don’t throw first year residents to the wolves any more than we throw a new PA graduate into the fire on their first day on the job.

All clinicians learn to become effective team members and competent, knowledgeable providers one step at a time. At the beginning of training and experience in practice, physicians in training, new PA graduates, and other providers have limited autonomy and responsibility for a reason. It takes experience to recognize disease patterns and their presentations. Learning to be an effective team player takes time, too.

As physicians, PAs, and other providers gain clinical experience, they shoulder more responsibility and autonomy because the team recognizes their experience and progression. That is what OTP is all about - allowing decisions about provider autonomy and responsibility to be made at the practice / team level, and not at a state law level. One size does not fit all for either physicians or PAs.

As a longstanding PA, I can tell you, AAPA President Gail Curtis has it exactly right when she says:

“Under the new (OTP) policy, new graduates and early career PAs, as well as PAs who are changing specialties, would continue to practice in teams with physicians, and their scope of practice would be determined at the practice level. Regardless of whether a PA is early career, changing specialty, or simply encountering a condition with which they are unfamiliar, the PA is and will continue to be responsible for seeking consultation as necessary to assure that the patient’s treatment is consistent with the standard of care. This is part of the definition of a professional - to take responsibility for assuring that the patient’s care is appropriate. As a profession, this is not new for PAs.”

This is the way in which experienced PAs have been operating for decades. It is not a “scope of practice” issue, but an efficient “team practice” issue. PAs have always been a solution to the quality of physician life issue. Just ask any physician with experience working on teams with PAs. Removing the administrative hassles associated with working with PAs improves patient safety, quality of care, quality of life for all, and is in the best interest of physicians working with PAs.

If you have any comments on this article email 

An explainer of the AAPA's Optimal Team Practice (OTP) initiative and why it's important to improving care.

Remove Administrative Hassles for Collaborating PAs, Docs 

I have practiced as a physician assistant for more than 37 years, from handwritten medical records to the most modern EHR system available.

When I started in medicine, protecting the confidentiality of the patient was much less complicated. You had to physically secure the record at all times to protect from inadvertently disclosing protected patient information. You had to ensure that conversation with other health care professionals were confidential, and served the purpose of sharing only information that was necessary to the care of the mutual patient.

Fast forward to 2018, and the vast majority of patient information and the documentation of the care of the same patients is largely digital. Vast amounts of information is collected daily and stored digitally on millions of servers world-wide.
Unfortunately, the technology and safeguards that protect that information is lagging behind. As providers of patient care, we have to trust systems that we can see to protect the confidentiality of our patients. I don’t know about you, but I’m not entirely confident that the system protects data at a level at a sufficient level.

I try to balance my fears with the knowledge that I have better informational and safety tools than ever before. I am one of a growing minority of people who actually like the EHR and feel it makes my job easier. Just like we learn everything in medicine by experience and pattern recognition, we all have to invest time in learning the new technology in service to our patients.

Part of that training has to be a renewed perspective on HIPAA, and how the digitization of health care changes our jobs, our patients, and the personal and sensitive patient data we are duty bound to protect. We can compromise patient data faster than the speed of light.

One example that creates angst for me is communication with patients. Isn’t it great that more and more health care organizations are developing and implementing patient portals? I see an internal medicine physician for my own care and love her digital patient portal. I can access a significant amount of my patient data, labs and diagnostics, via a secure website.

I can also deal with certain provider - patient activities without even setting foot in the office. This puts a lot of pressure on my physician and her staff. Not only do they have to deal with the patients on the schedule for the day, they have to monitor the flow of digital communications from patients and deploy resources to deal with the steady stream of messages from the patents.

Her organization uses an industrial strength enterprise-level patient portal, which is secure and encrypted. Yet, I can think of a number of ways that sensitive and confidential patient information can be compromised in their situation, by the vulnerable nature of the internet in general. I had to sign an agreement when I joined the patient portal, which governed expectations and rules on both sides of the equation.

Another vulnerability is social media. We know have hundreds, if not thousands of patients who rate comment on our care and the care of our organizations. What do you do when a patient airs their grievances against you as a health care provider on Twitter, Facebook or Yelp?

The tendency is to defend yourself, but publicly discussing anything about a patient and their care is a clear HIPAA violation. What a world we live in. We need to understand the implications of how we collect and use data, and carefully craft policy and best practices that protect the sensitive and confidential patient information entrusted to us, while still allowing us the freedom to do our jobs as health care providers effectively.

The digitization of health data is a good, but it brings concerns over how hard it is to protect patient data.

Data Security in the Digital Age a Lingering Concern

After 37 years of practice in multiple specialties as a physician assistant over tens of thousands of patient encounters, I feel I have a pretty good handle on sensing the status of the patient-provider relationship, sometimes from the moment I enter the room. I look at body English, the patient's chart, family members who are in the room, and a multitude of other clues that gives me a sense of the wants, needs and preferences of the patient.

Patients who are known to me in the practice are much easier to gauge as we have a history together. One of the most difficult things to learn as a healthcare provider is making sure you deal with the primary reason as to why the patient has presented to you for care. This is not always evident and not always found in a "chief complaint."

It's also never ceased to amaze me how many times a patient's satisfaction and quality of care have nothing to do with each other. As clinicians, we can all provide examples of where the quality of care was horrible, but the patient satisfaction was high.  The inverse is also true. I can give numerous examples, both from personal experience as well as observed behavior where the quality of care was excellent, but the patients and/or their families perceived it to be sub-par.

This is maddening for any clinician, especially for folks that are in the early stages of their career, and are not yet confident in their approaches to patient care. In reading a recent  article in Medical Economics on patient satisfaction, the five most important areas (to patients) were:

1. Shorter wait times (50 percent)
2. Advance knowledge of treatment costs (49 percent)
3. Not feeling rushed during an appointment (47 percent)
4. Providers having a high level of expertise treating a specific illness (44 percent)
5.  Easy-to-schedule appointments (41 percent).

It was reported that providers are only working on shorter wait times and appointment scheduling. It is interesting to note the other three. In this day of higher co-pays and out of network penalties, patients have a lot of angst about what their care costs. It would surprise me if a patient delayed getting care for the simple reason of economics. This is not really a failing of the provider, except that they do have access to insurance information that could be more freely shared with the patient on the front end.

The third one I have learned to gauge by careful observation and by my body language. I always completely enter the room and sit down. I am fortunate to have a scribe, so I can take a history and focus all my attention on the patient. It is important to let the patient talk as much as they need to. In my experience, this has been the single most important thing to do to make the patient feel like you are listening to them. This works against wait times, but I also have a sixth sense for patient in a hurry, who don’t want a lot of "hand holding. It balances out most days. Other days are bad, and you get behind no matter your best intentions. Apologize to the patients and let them know that you value their time.

Number four has not been a problem for me except for those who don’t know me (I’m a PA) and expect to see the physician. They don’t know that I have worked with surgeons hand-in-hand for 10 years, and have developed a significant level of expertise in our specialty. The way in which I handle this always put the patient’s needs ahead of my own, and work to involve the surgeon in their care early on in the new patient encounter to reassure them and to put them at ease. I have never failed to win over a patient, and carry a full consult, pre- and post-op case load comprised of satisfied patients.

While there are a lot of definitions around "quality," we have a long way to go in understanding what constitutes patient satisfaction in medicine. The goal is to listen to the patients who give purpose to our lives and strive for both “quality” and “patient satisfaction” in our daily rounds. Understanding what is important to patients is a good first step.

While there are a lot of definitions around "quality," we have a long way to go in understanding what constitutes patient satisfaction in medicine.