Heavy patient volume? PAs may be the answer

They can perform MD duties at a lower cost

Do you often feel like you need to be in two places at once to take care of all your patients’ needs? Are you facing pressure to see more patients each day while your practice is squeezed by reimbursement cuts?

One prescription for relief may be to hire a physician assistant (PA) to work in partnership with your physicians to take care of patients.

If health plans are paying you less per patient, you’re going to have to see more patients in a day in order to stay in the black. To avoid rushing patients through, many practices are hiring physician assistants who can handle a caseload of patients on their own without commanding the salary of an additional MD. What’s more, reimbursement for PAs is becoming more widespread.

If you’re fully capitated, having a physician assistant care for patients still can have a positive effect on your bottom line.

"The physician/physician assistant team is an effective way for physicians to compete in the managed care environment," says Ron Nelson, PA-C, president of the American Academy of Physician Assistants (AAPA) in Alexandria, VA. "By working with a physician assistant, a physician can expand the scope of his practice and take care of more patients."

Physician assistants can provide the same type of services as a physician, but at a lower cost. The average salary for a physician assistant is $65,000 a year, according to the academy. New graduates start at about $55,000 a year.

PAs practice in every medical and surgical specialty. By law, physician assistants may take medical histories, perform physical examination, order and interpret laboratory tests, diagnose and treat illnesses, suture wounds, and assist in surgery. They are authorized to write prescriptions in most states.

"We like to tout ourselves as being the right-hand person of the doctor," says Diana McGill, PA-C. McGill, who has been a physician assistant for nine years, recently started Pro-Search Medical Placement, a Houston firm that specializes in placing physician assistants with Texas physicians. She works two days a week as a PA for a family practice, where she treats about 30 to 35 patients a day.

"We couldn’t imagine running our practice without physician assistants. They add tremendous clinical depth and bring terrific skills and orientation to the practice," says Peter Dreyfus, spokesman for Harvard Vanguard Medical Associates, where 500 physicians and 90 physician assistants treat 290,000 patients at 14 sites.

Physician assistants and other allied health professionals often are called "physician extenders" because they act as an extension of the physician.

"It’s almost like the surgeons can be two or three places at once," says Barbara Kahwaty, PA-C, of her role as a physician assistant in surgical specialties at Harvard Vanguard Medical Associates, a multispecialty group practice in the greater Boston area. For instance, if a patient is having a problem after surgery and the surgeon is not available, Kahwaty can see the patient, prescribe pain medication, and decide whether the patient needs to be seen by the physician. "If I can’t solve the problem, I page the surgeons," she says.

If a patient comes in with an acute injury, Kahwaty can deal with it in many cases. If the PA determines that the patient will need surgery, the PA calls the orthopedist, arranges for surgery, and meets the surgeon in the operating room.

Kahwaty, who has been a PA for 19 years, practices in three specialties: orthopedics, general surgery, and urology. She has her own case load and often is the only practitioner who sees a particular patient. She acts as first assistant in surgery and can perform minor surgery under local anesthesia.

As a PA specializing in surgery, Kahwaty is the exception rather than the rule. More commonly, PAs specialize in internal medicine, family practice, and pediatrics.

For instance, at Fort Collins (CO) Youth Clinic, three physician assistants and a nurse practitioner routinely see young patients for common childhood illnesses, says Jeannette Perich, CPA, administrator. The nine-physician practice hired its first physician assistant 15 years ago, added two more two years ago, and is hiring a fourth this year.

"There are so many childhood illnesses that aren’t life-threatening but need to be treated. Having extenders leaves the physicians available for more critical care," Perich says.

Parents are always given the option to have the child see a physician, and the PA will pull a physician in immediately if needed, she adds. In some cases, physicians utilize PAs as they would a resident or a fellow, McGill says. The PA works up a difficult case, then presents it to the physician.

As an example of a complicated case, McGill cites seeing a patient with abdominal pain.

"I work up the patient, get a good history, and do a thorough physical. Then I present that patient to the physician, who comes into the examining room with me," she says.

Developing a partnership

The success of a physician/physician assistant partnership depends on how well the two can work as a team and how well the patients accept the physician assistant.

"I’ve seen all sorts of successes with physician assistants, and some failures," says Marc Benoff, MBA, director of Dan Grauman Associates in Bala Cynwyd, PA, a management and data consulting firm specializing in the health care industry.

When an MD/PA relationship doesn’t work out, it may be because the physician doesn’t feel comfortable giving the assistant a lot of responsibility. That’s the reason the AAPA recommends that when a physician and a PA begin practicing together, they should discuss how they should work as a team. The physician with whom the PA will work must be involved in hiring the PA so their personalities will be a good match.

"Arranged marriages" often don’t work, points out Kahwaty. If you are an employee of a health plan that is hiring PAs, insist on being involved in the hiring process and carrying out the performance evaluation.

Suggestions to consider

If you’re considering hiring a PA for your practice, here are five more suggestions for making it a success:

1. Check on how your payers reimburse for physician extenders, suggests Benoff. You want to make sure you can recoup the cost of the PA salary. (For details on reimbursement issues, see story, p. 117.)

2. Have the PA candidate shadow the doctors they are going to work with for a day to get an idea of how they would function in your office, says McGill.

3. Consider hiring a PA on a temporary basis, McGill suggests. This allows the physician and the PA to get an idea of whether they can work together without a binding contract.

4. Have the physician introduce patients to his or her new PA partner and tell patients that the two of them will work as a team, says Dreyfus of Harvard Vanguard Medical Associates.

5. Give your patients a choice about which practitioner they prefer to see.

Never force patients to see a PA if they don’t want to. It’s a decision the patient has to make. Some patients want to see a doctor, not a PA. Some practices report that patients would rather see a PA sooner than wait for an appointment with their physician. Some patients see a PA because they can’t see their doctor and wind up asking for their next appointment to be with the PA.