Creating a Sub-specialty Certification

[jmj11]

Okay, here is the challenge:

 

I'm at the American Headache Society Scientific meeting in Beverly Hills. Today I became chair again for the PA section. Our group (combined PAs and NPs) gave a challenge to me and my NP chair counterpart to create a sub-specialty certification in headache medicine. The UCNS (United Council for Neurological Subspecialties) has a board exam for neurologists but would never allow NPs or PAs to sit for it. The NPs believe that they could get one of the NP specialty boards to create a certification for NPs in headache medicine but they would never allow PAs to sit for it. I'm doubtful if the NCCPA would ever consider a headache medicine exam because it is such a small group.

 

Having certification is very important. Can you imagine trying to get credentialed with insurance companies or hospital as a ER PA without ACLS cert? That is what we face. Insurance companies do not want to allow referrals to NPs or PAs for headache unless they are "certified in headache medicine" of which there is no such thing at this time.

 

So, are you aware of other certification boards that is independent and would consider something like this? We may have to create our own certificating board but that would be complex and expensive.

[EMEDPA]

I bet the nccpa would be happy to offer a caq(certificate of added qualifications) in neurology....the nephrology pa's asked for and got one. they also currently have psych, ortho, ct surg, and em.

[andersenpa]

Small group of HA PAs in the US, right?

 

If the goal is getting insurer/etc acknowledgment then the best choice would be a cert offered by the physician group you mentioned or the NCCPA. Do you think it would be harder to get an exam created by physician board? A CAQ would be nice but I wonder if they would put effort into it with so few headache PAs.

[jmj11]

Small group of HA PAs in the US, right?

 

If the goal is getting insurer/etc acknowledgment then the best choice would be a cert offered by the physician group you mentioned or the NCCPA. Do you think it would be harder to get an exam created by physician board? A CAQ would be nice but I wonder if they would put effort into it with so few headache PAs.

 

There is no way the physician group would consider it. We fought with them for years to allow us to sit for the exam, and this was back in the days that the exam was open to all physicians. Now, they have raised the bar that you can not sit for the exam unless 1. you are a neurologist and 2. you have completed year fellowship in headache medicine. Right now, only 3-5 people in the US are allowed to sit for this exam each year under those new guidelines. The huge problem with that is that headache is the most common pain problem in the world, so, if you are producing 4 specialist per year, then 99.9% of the population will go un-served.

 

The insurance companies (who are like parrots that only go by the manual) say that you can not claim specialty in an area without board certification. My masters was with neurology emphasis but that doesn't address the problem. Even a NCCPA cert in neurology would not address the problem. Being a neurologist is not synonymous with being a headache specialist. Most neurologists don't know much about headache medicine. Those you finished residency before the late 90s may have had one lecture on headache.

[andersenpa]

I was figuring you need to get an exam written specific to PA/NP, so it's either going to be by the NCCPA or the physician board. To an insurer the physician board would carry more weight. But that would require buy in from them to create the exam. If you can't get them to bite, then the next step is NCCPA I guess.

 

The question is who is going to invest the time for a small (?) # of providers. How many headache PA/NPs are there....do you guys keep a registry?

[jmj11]

I was figuring you need to get an exam written specific to PA/NP, so it's either going to be by the NCCPA or the physician board. To an insurer the physician board would carry more weight. But that would require buy in from them to create the exam. If you can't get them to bite, then the next step is NCCPA I guess.

 

The question is who is going to invest the time for a small (?) # of providers. How many headache PA/NPs are there....do you guys keep a registry?

 

Seventy two NPs and PAs combined are members of the American Headache Society.

[rev ronin]

The trick would be to sell it to the physicians as a way to regulate and provide assurance over the midlevels practicing in the specialty. The process, as far as I would develop one, would be to:

 

1) Scare the physicians that J. Random Midlevel is practicing headache medicine without any oversight or assurance.

2) Convince them that they can a) make money, b) exercise control, and c) improve quality and patient safety by sponsoring the test themselves.

3) Volunteer to chair a (physician controlled, of course) committee to draft competencies and practice standards for midlevels in headache medicine.

4) Get the same vendor who does their board exam to adapt a subset of their questions into a new exam. Since they're really just going to be reusing many of the questions from the existing board exam, it's a win for the vendor since they get to reuse content already provided by the society.

5) Create both grandfathering/beta testing standards for the 70ish of you already practicing, and then pathways for new midlevels to earn the right to sit for the exam. Recertification, CME, etc. requirements, too.

6) Watch every other medical board imitate you once 2) materializes.

 

Simple!

 

(For those of you not familiar with my background, I have held a dozen different IT and security professional certifications over the years, most of which I have since let lapse, and have helped beta-test or been an "early adopter" of three of those)

[jmj11]

I think all of what you said has merit and is worth considering. It is a bit of "reverse psychology." I've been reading legal documents about creating your own certification board. Both for my potential new board and for the established physician one, of course the biggest concern is liability. The physicians would not want to be named in a suit by a disabled NP who claimed that the test discriminated against her. But that is what insurance is for. I will let this rest unless someone else knows more. But thanks for the ideas.

[Just Steve]

So this lateral mobility thing that PAs have reportedly enjoyed since the inception of the program is on the way out, isn't it? Might as well just declare our desired field of practice before we enter our clinical year of training so we can maybe streamline our way into a residency instead of using that time to find a job.

[Guest JMPA]

I agree with you steve, more testing leads to more control, less lateral mobility. It is certifications beyond our PA cert that will ultimately destroy this profession by increasing "control" over us. We need less control and more autonomy. Physician Associate is the route to go. Long live the battle from Assistant to Associate. Stay strong my brethen.

[EMEDPA]

So this lateral mobility thing that PAs have reportedly enjoyed since the inception of the program is on the way out, isn't it? Might as well just declare our desired field of practice before we enter our clinical year of training so we can maybe streamline our way into a residency instead of using that time to find a job.

I think that is probably the future for good or bad.

I foresee increased adaptation of the CAQ's over the next decade to include all specialties other than primary care.. at some point they will require a residency to take the CAQ. several em pa residencies now state that they are preparing grads to take the CAQ and will require it as a condition of graduation.

I think lateral mobility for pa's 20 years from now will only be between primary care fields which will not require a CAQ.

this is the same pattern the physicians went through over the last 100 years. I have a great grandfater who trained as a physician by apprenticeship(he followed his father around from age 16-21 then hung out his shingle as a physician). he did everything including general surgery and never went to medschool. he later taught at a prestigious medical school and has a few things named after him. that doesn't happen any more. my grandfather(other side of the family) was a general surgeon. did a standard surgical residency but then did all surgical fields without subspecialty training. that doesn't happen anymore. my dad was a neurologist and trained in the typical fashion of his day with an internship and specialty residency. he never took his boards because they were considered optional at the time to practice as a neurologist. he practiced for 30 years as a full scope neurologist without board certification. that doesn't happen anymore. physicians my age are residency trained and board certified with appropriate subspecialty fellowships as well.

this same pattern will happen to the pa profession. it used to be that graduation from a pa program was enough. I have several friends who have never taken pance because they graduated before it existed and they are grandfathered indefinitely as long as they pay their state license fees. when that generation retires(and it will be soon) everyone will need pance, then a caq, then a residency and caq. just watch.

[andersenpa]

This is probably appropriate. I like the idea of SOME sort of cert beyond primary care if you plan to enter a specialty. Outside of residency there are no good tools to ensure a broad overview of general knowledge. There is also no standard for the PA Product in a given specialty (unlike physicians).

 

We can't cling to our "medical model" roots and insist on maintaining this apprentice style training. The entirety of medicine is moving toward subspec cert, fellowship etc. If we remain dependent medical providers we should follow suit.

[EMEDPA]

If we remain dependent medical providers we should follow suit.

I agree but wouldn't be even more important if we were independent like np's? we would need an objective criteria to say we were specialists in our given field, right?

[ventana]

FAQ in internal med geriatrics that would allow you to practice as a full pcp with OUT requirement for supervision

[Contrarian]

The trick would be to sell it to the physicians as a way to regulate and provide assurance over the midlevels practicing in the specialty. The process, as far as I would develop one, would be to:

 

1) Scare the physicians that J. Random Midlevel is practicing headache medicine without any oversight or assurance.

 

Yep...

Careful, cause what you suggest is just what needs to happen to have them (physicians) "run in the other direction" and lobby to STOP "mid-levels" from practicing headache medicine without the oversight or assurance that THEY decide we should have...

 

Can't "un-ring a bell"...!!!

[coloradopa]

Okay, here is the challenge:

 

I'm at the American Headache Society Scientific meeting in Beverly Hills. Today I became chair again for the PA section. Our group (combined PAs and NPs) gave a challenge to me and my NP chair counterpart to create a sub-specialty certification in headache medicine. The UCNS (United Council for Neurological Subspecialties) has a board exam for neurologists but would never allow NPs or PAs to sit for it. The NPs believe that they could get one of the NP specialty boards to create a certification for NPs in headache medicine but they would never allow PAs to sit for it. I'm doubtful if the NCCPA would ever consider a headache medicine exam because it is such a small group.

 

Having certification is very important. Can you imagine trying to get credentialed with insurance companies or hospital as a ER PA without ACLS cert? That is what we face. Insurance companies do not want to allow referrals to NPs or PAs for headache unless they are "certified in headache medicine" of which there is no such thing at this time.

 

So, are you aware of other certification boards that is independent and would consider something like this? We may have to create our own certificating board but that would be complex and expensive.

Creating your own board is not complex or expensive. You would simply need a business registration. You could even register it as a 501 ©(3) non-profit. In most states this would be fairly inexpensive. You could then develop your own test and administer it. If you did it by mail it would be fairly inexpensive.

 

The real question is what it would mean. There are essentially three levels of medical certification. The first arises off of a nationally recognized training program. Examples would be the PANCE or board certifications arising off the ACGME residencies. The second arises off of non-recognized GME programs that have become recognized or required by government organizations. For example Hepatology is a CAQ run by the AASLD. Medicare requires a transplant program to have a CAQ qualified hepatologist. The third is everything else. There are hundreds of unrecognized medical "certifications". Some are based on legitimate organizations others not so much. All it takes is a sign and a business license. I would put the NCCPA CAQs in this category. They are not normed and don't undergo the same rigorous development that the PANCE does. From an EBM perspective this is essentially level III evidence.

 

If you honestly think that "certification" matters then go for it. Realistically it won't matter. Either the insurance company will question the legitimacy of the certification or impose additional requirements such as fellowship training. They don't impose these requirements on the physician, they are simply looking for a reason not to pay you.

 

From an NCCPA standpoint here is there criteria:

"The NCCPA Board of Directors chose the specialties to include in the initial roll out of the CAQ Program in 2011. The specialties included in the initial launch were selected based on information about the need for specialty credentials that NCCPA received from PAs practicing in these specialty areas and from leaders of the specialty organizations serving those PAs. We also considered a host of other factors, including the number of PAs practicing in the specialty, mobility trends into and out of the specialty, the criticality of the patient population served, and the degree to which the specialty is hospital-based."

 

Looking at those criteria I think that its unlikely that they will develop a headache CAQ.

[jmj11]

I agree with you steve, more testing leads to more control, less lateral mobility. It is certifications beyond our PA cert that will ultimately destroy this profession by increasing "control" over us. We need less control and more autonomy. Physician Associate is the route to go. Long live the battle from Assistant to Associate. Stay strong my brethen.

 

I think this conversation just went down a rabbit hole, down which I am not even tempted to go. Ironically this whole thing is about seeking autonomy and the whole point is assuring lateral mobility. If you want to move in any direction you want to go, you can. But the industry wants you to prove that you have the skill set in those far corners. It is limiting and restrictive to PAs to declare to them that they can not move into specialties but must stay in the narrow scope of primary care. The autonomy that I want is owning my own specialty clinic and playing with the big-boys, like all PAs should have the right to do. But the insurance companies say, if you declare yourself to be a specialist, then you need some standard of proof. It is no different than what ACLS does for PAs in acute settings.