Dialogue on Optimal Team Practice

[ProSpectre]

In light of the upcoming AAPA elections, I thought it would be interesting to see what Optimal Team Practice means to the PAs on this forum. I've seen healthy debate about the title change in a number of threads, which I think is a good sign. However, I haven't seen as much debate about the specifics of what OTP should be and how it should be implemented. So I thought I would pose some questions to generate some dialogue on this issue. 

AAPA's summary of OTP is outlined here: http://news-center.aapa.org/wp-content/uploads/sites/2/2017/05/OTP_FAQ_FINAL.pdf 

 

Should there be a set number of years that establishes when an early career PA is able to move from supervision to collaboration? Should completion of a residency modify this time?

 

Does anyone anticipate any unintended consequences from removing the rule for a PA to be tied to a specific supervising/collaborating physician? 

 

How important is it to have autonomous state boards? Is there some compromise position wherein more PAs (and physicians that work with PAs) are represented on the medical boards?

 

Are there certain states that may be more friendly to legislative changes that support OTP and that can lead the charge?

 

Are there stakeholder groups outside of physician organisations that may be allies in the push for OTP? And on that note, how important is it to woo physician groups on this issue? 

 

How can support for OTP be broadened in general, among PAs, physicians, legislators, etc? How can we address apathy among PAs for these types of changes?

 

Will creating a new certifying organisation or lessening the re-certification requirements in any way hurt the push for OTP? 

 

Should there be any changes to the PA model of education (length, residency requirement, etc), or is OTP not going to effect early-career PAs in a way that makes this necessary? (This is an important question since PAEA took the time to draft a lengthy document in opposition to parts of OTP last year: http://paeaonline.org/wp-content/uploads/2017/05/PAEA-OTP-Task-Force-Report_2017_2.pdf) 

 

And finally, If you had to make an elevator pitch in support of OTP to present it to PAs or physicians who were unfamiliar (or in opposition), how would you frame it? 

 

 

These are just some questions to create a dialogue on changes related to Optimal Team Practice, so I don't expect anyone to give their opinion on every question, although that is certainly welcome and encouraged. If there are other issues that I didn't mention, please feel free to add them. 

 

[LT_Oneal_PAC]

19 hours ago, ProSpectre said:

In light of the upcoming AAPA elections, I thought it would be interesting to see what Optimal Team Practice means to some of the PAs on this forum. I've seen healthy debate about the title change in a number of threads, which I think is a good sign. However, I haven't seen as much debate about the specifics of what OTP should be and how it should be implemented. So I thought I would pose some questions to generate some dialogue on this issue. 

AAPA's summary of OTP is outlined here: http://news-center.aapa.org/wp-content/uploads/sites/2/2017/05/OTP_FAQ_FINAL.pdf 

 

Should there be a set number of years that establishes when an early career PA is able to move from supervision to collaboration? Should completion of a residency modify this time?

Does anyone anticipate any unintended consequences from removing the rule for a PA to be tied to a specific supervising/collaborating physician? 

How important is it to have autonomous state boards? Is there some compromise position wherein more PAs (and physicians that work with PAs) are represented on the medical boards?

Are there certain states that may be more friendly to legislative changes that support OTP and that can lead the charge?

Are there stakeholder groups outside of physician organisations that may be allies in the push for OTP? And on that note, how important is it to woo physician groups on this issue? 

How can support for OTP be broadened in general, among PAs, physicians, legislators, etc? How can we address apathy among PAs for these types of changes?

Will creating a new certifying organisation or lessening the re-certification requirements in any way hurt the push for OTP? 

Should there be any changes to the PA model of education (length, residency requirement, etc), or is OTP not going to effect early-career PAs in a way that makes this necessary? (This is an important question since PAEA took the time to draft a lengthy document in opposition to parts of OTP last year: http://paeaonline.org/wp-content/uploads/2017/05/PAEA-OTP-Task-Force-Report_2017_2.pdf) 

 

And finally, If you had to make an elevator pitch in support of OTP to present it to PAs or physicians who were unfamiliar (or in opposition), how would you frame it? 

 

These are just some questions to create a dialogue, so I don't expect anyone to give their opinion on all of them, although that is certainly welcome and encouraged.

 

 

We can look at the NPs who have done this already and can answer a lot of these questions.

1.) No. People in our field are typically risk averse and not going to go out there being cavalier in any greater number than they do now. NPs in independent states have done just fine.

2.)No. Haven’t seen any from the NPs (this is going to be a pattern).

3)  Very important. While state legislation could be very broad, whatever board your under would be within its legal right to be more restrictive. Though they might get in trouble with the FTC.

I wouldn’t mind having one, just like we usually have one public member to represent the general public. But honestly I really rather not have them at all. We need to be solely responsible for governing and policing our own.

4) I would think NC. California or Washington would also be good choices.

5) Healthcare administrator and hospital associations. These have been big propents of NPs and CRNAs. AARP as well.

6) I don’t think we need to woo them. Not saying purposely step on their toes, but basically just explain that we won’t tolerate restraint of trade. The fact of the matter is you will NEVER sell them on it, so why bother. Going to talk to them about it IMO just gives them a heads up to begin their opposition early.

7) ugh. Let me know when you find out. I don’t understand the apathy out there.

8)Don’t know. I think unlikely, but it’s not my priority. 

9) I don’t think it should change anything. Personally I think everyone should do a residency now, but I think that even without OTP.

10) to physicians I would emphasize that it removes them from all liability. No more rubber stamping charts days or weeks after the care is done for that PA who has been doing this for 25 years.

for PAs, especially the apathetic ones, I would emphasize how this will increase there employment opportunities and increase salaries because they’ll be able to see how much they are making for their employer when we can bill directly and can better compete with NPs.

[Guest HanSolo]

Curious as to how some of these statements translate to new grads. Sure, an MD may not have to co-sign a PA that has been doing it for 25 years, which is great, but what about that PA that has been on the job for 25 days? What's the best solution there? There's not nearly enough residency opportunities for that to be the answer for everyone, and many folks don't want to specialize. Most new PAs still needs significant OTJ training. Would this be jeopardized with OTP?

I think the NP fight for independent practice has really given us an opportunity to do this thing right. We can learn from their mistakes. If anything, an outside consulting agency should be brought in to help us with this process. It's important to have outside, unbiased viewpoints. 

 

[lkth487]

No one asked me so feel free to ignore but I'll say this: informal on the job training  (outside of an official residency whose requirements and rules are set and standardized by a state or national body) is a HORRIBLE way to ensure capablity in medicine. There are MANY good reasons why we don't do that with physician training anymore.   As much as residency training has worn me down, and as much has I think It can be improved and streamlined - its necessary.   

 

I understand the need to compete with other professions but that doesn't make it a good idea. 

[LT_Oneal_PAC]

16 minutes ago, HanSolo said:

Curious as to how some of these statements translate to new grads. Sure, an MD may not have to co-sign a PA that has been doing it for 25 years, which is great, but what about that PA that has been on the job for 25 days? What's the best solution there? There's not nearly enough residency opportunities for that to be the answer for everyone, and many folks don't want to specialize. Most new PAs still needs significant OTJ training. Would this be jeopardized with OTP?

I think the NP fight for independent practice has really given us an opportunity to do this thing right. We can learn from their mistakes. If anything, an outside consulting agency should be brought in to help us with this process. It's important to have outside, unbiased viewpoints. 

 

Nothing is stopping employers from having a training period for new grads. Nurses are independent in every specialty in what they do from day one, but no hospital let’s them function in critical care or the ED without some training. It also does not prevent PAs from working for employers who desire to place more restrictions. Even in the states where NPs have independent practice, training still occurs, people aren’t hurt, and you have more training than they do.

what mistakes have NPs made? They’ve done it perfectly. Evidence to the contrary?

[LT_Oneal_PAC]

9 minutes ago, lkth487 said:

No one asked me so feel free to ignore but I'll say this: informal on the job training  (outside of an official residency whose requirements and rules are set and standardized by a state or national body) is a HORRIBLE way to ensure capablity in medicine. There are MANY good reasons why we don't do that with physician training anymore.   As much as residency training has worn me down, and as much has I think It can be improved and streamlined - its necessary.   

 

I understand the need to compete with other professions but that doesn't make it a good idea. 

I’m not sure how OTP would make the need for residencies any more necessary. I see them necessary as it is, (I chose to do a residency after 3 years of military practice when I could have probably gotten most any job I wanted) but OTP does not make it more so. Chart review is already done long after care is provided at a point when it makes no difference.

[ProSpectre]

14 hours ago, LT_Oneal_PAC said:

 

We can look at the NPs who have done this already and can answer a lot of these questions.

1.) No. People in our field our typically risk averse and not going to go out there being cavalier in any greater number than they do now. NPs in independent states have done just fine.

 

I agree with most of your points, but wanted to elaborate on why I asked this question. As I understand it, one of the tenets of OTP is to remove the legislative barriers that tie a PA to a specific physician, which can be problematic for the PA's job security in the event that their specific collaborative physician retires, dies, moves away, etc (apparently not an uncommon problem); it's also fueling the preferential hiring of NPs in some locales, and potentially restricts access to care due to unnecessary restrictions on how many PAs a physician can supervise (meaning PA numbers may be restricted in areas where there aren't enough supervising physicians).  

I have seen mention of a window of time (anything from 2-4 years has been brought up) in which a PA would still have direct supervision, though not necessarily by a specific doctor (it could be decided that any physician in the practice or department could do chart review or whatever is deemed "supervision"). One benefit of this is that it would alleviate opposition from those who argue against OTP for fear that new PAs would be "unsupervised". The downside is that the issue with preferential hiring of NPs over PAs due to administrative burden could still be an issue, especially for early career PAs.  

 

I also wanted to bring up the issue of PAs working for the VA, which is the largest single employer of PAs nationwide. I know with the change in the VA rules for NPs, many were wondering how this will will effect PAs going forward. This seems like a great place to concentrate efforts in making a change that could have ramifications for OTP as well. 

[rev ronin]

Washington is ripe to collapse two PA professions into one.  I have two jobs, one working for a DO and one for an MD.  I have two PA licenses (Osteopathic PA and PA), and pay twice into the drunk doc.. err, impaired practitioner fund.  The Osteopathic PA regulations and practices, run by the DOH itself, are far less streamlined than those of PA licensing run by the medical commission. Oh, and the cost to renew is the same, but for my Osteopathic PA license, it's only good for one year, not two.

Somewhat tangential to the main discussion, but yes, there is a good reason to dive into a complete rewrite of Washington's PA laws.

[SedRate]

What about the effect on malpractice premiums? Do you think with the removal of physician liability comes an increase in ours monetarily? Will that increase our overhead and thus affect our salaries since we'll now be more expensive to employ?

Will insurance reimbursement stay at 85%?

[pafrankc]

On 3/30/2018 at 6:51 PM, ProSpectre said:

In light of the upcoming AAPA elections, I thought it would be interesting to see what Optimal Team Practice means to the PAs on this forum. I've seen healthy debate about the title change in a number of threads, which I think is a good sign. However, I haven't seen as much debate about the specifics of what OTP should be and how it should be implemented. So I thought I would pose some questions to generate some dialogue on this issue. 

AAPA's summary of OTP is outlined here: http://news-center.aapa.org/wp-content/uploads/sites/2/2017/05/OTP_FAQ_FINAL.pdf 

 

Should there be a set number of years that establishes when an early career PA is able to move from supervision to collaboration? Should completion of a residency modify this time?

 

Does anyone anticipate any unintended consequences from removing the rule for a PA to be tied to a specific supervising/collaborating physician? 

 

How important is it to have autonomous state boards? Is there some compromise position wherein more PAs (and physicians that work with PAs) are represented on the medical boards?

 

Are there certain states that may be more friendly to legislative changes that support OTP and that can lead the charge?

 

Are there stakeholder groups outside of physician organisations that may be allies in the push for OTP? And on that note, how important is it to woo physician groups on this issue? 

 

How can support for OTP be broadened in general, among PAs, physicians, legislators, etc? How can we address apathy among PAs for these types of changes?

 

Will creating a new certifying organisation or lessening the re-certification requirements in any way hurt the push for OTP? 

 

Should there be any changes to the PA model of education (length, residency requirement, etc), or is OTP not going to effect early-career PAs in a way that makes this necessary? (This is an important question since PAEA took the time to draft a lengthy document in opposition to parts of OTP last year: http://paeaonline.org/wp-content/uploads/2017/05/PAEA-OTP-Task-Force-Report_2017_2.pdf) 

 

And finally, If you had to make an elevator pitch in support of OTP to present it to PAs or physicians who were unfamiliar (or in opposition), how would you frame it? 

 

 

These are just some questions to create a dialogue on changes related to Optimal Team Practice, so I don't expect anyone to give their opinion on every question, although that is certainly welcome and encouraged. If there are other issues that I didn't mention, please feel free to add them. 

 

1)  There should not be a specific amount of time between graduation and the transfer from "supervision" to "collaboration.:  If collaboration is determined at the local level then a new graduate is more likely to require more collaboration and less autonomy.  Same would happen if a 15 year Family Practice PA decided to move into a specialty field--more collaboration and less autonomy at the beginning.

2) I see two unintended consequences.  First, an increase in malpractice insurance since the physician will not automatically be at fault for PA actions or inactions.  Second, we have already seen states attempt legislation calling for independence (West Virginia) or the creation of a new profession for those with clinical doctorates (Tennessee).  As soon as that happens, organized medicine starts campaigns (https://www.aafp.org/news/government-medicine/20180326dmsscope.html) resulting in physicians (and probably nurses as well) inundating their reps with "vote no" messages.  On both Tennessee and West Virginia, the bills never made it out of committee.

3) How many professions are not overseen at the state level by their peers?  In Colorado, there are 9 physicians on the medical board, 1 PA.  The nine physicians have a combined total of 3 PAs--and two of them work with the same family physician.  Part of the issue (see answer 2) is that those in healthcare do not have a clue about our training, education, capabilities, and our evidence-based outcomes.  Some states still have separate MD and DO boards--MDs do not understand DO training, etc.

4)  Sadly, we are in this by ourselves.  Does anyone think that NPs or any other nurse will help us?  They are after our jobs.  When the task force on FPAR(OTP) sent out a survey last year, over 45% of PAs know of a NP being hired over a PA.  As seen in a couple of states so far, if the physician community isn't on board, their more powerful lobby keeps legislation from moving forward.

6)  Whether a new certification body comes into place, or NCCPA continues its monopoly, change must occur.  I don't think OTP changes certification.  Realizing that NCCPA will never back away from "core" (read primary care) nor testing, what I would propose, if I were on the NCCPA board

               PANCE continues as a primary care exam
               PANRE is split into two exams.  First is primary care and passing that portion allows for the -C designation.
               Do away with CAQ.  Part 2 of PANRE would be a specialty exam (including an exam in primary care).  Passing the specialty exam allows for a (specialty) designation.  For example, an ER PA might have a signature block of "John Doe, PA-C (Emergency Med)".  That would indicate certification in both core and EM.

8)  PAEA and OTP.  I think PAEA is way off base!  The job of all PA educators is to prepare students to enter the advanced world of healthcare.  It is not to influence the student's future profession.  Consider this corollary:  A professor is preparing students to enter the engineering field.  When engineering standards change in the field, do the engineering programs say they cannot prepare students to practice in the manner the engineering field demands?  

Perhaps it is time for the PA educators to evaluate PA educators.  Take a look at your own objections to OTP, “PA programs may not currently prepare new graduates to practice without “a supervisory, collaborating, or other specific relationship with a physician."  Now compare it with OTP’s statement on collaboration (emphasis added).  OTP requires collaboration, it is just the clinic that decised how much and when, not the education system.

BTW PAEA based their opposition after surveying program directors and medical directors.  50% of the survey respondents were physicians that already want to control our profession.

[pafrankc]

On 3/30/2018 at 8:06 PM, HanSolo said:

Curious as to how some of these statements translate to new grads. Sure, an MD may not have to co-sign a PA that has been doing it for 25 years, which is great, but what about that PA that has been on the job for 25 days? What's the best solution there? There's not nearly enough residency opportunities for that to be the answer for everyone, and many folks don't want to specialize. Most new PAs still needs significant OTJ training. Would this be jeopardized with OTP?

I think the NP fight for independent practice has really given us an opportunity to do this thing right. We can learn from their mistakes. If anything, an outside consulting agency should be brought in to help us with this process. It's important to have outside, unbiased viewpoints. 

 

If collaboration is determined at the practice level, it is up to the collaborating physician how much time the new PA requires before being "turned loose."  States could create more stringent guidelines for new grads (a couple of us in Colorado have even tossed around the idea of a "training license" similar to what new medical school grads get.

[sas5814]

"First, an increase in malpractice insurance since the physician will not automatically be at fault for PA actions or inactions"

 

I need to speak to this based on my experience doing medico-legal chart reviews. In order for a physician to be liable for a PAs action (or inaction) automatically they have to have some knowledge of it and the action has to be outside good medicine.

Now that is the legal truth...not the reality. In reality everyone gets sued and the deepest pockets are the biggest target. I'm not sure OTP will change the reality though it may still have an impact on our premiums.