WAEPS Practice Management Program 2016 Rachel Reinhardt, MD Mill Creek, Washington AAO Leadership Development Program XIII, Class of 2011
I have no financial interests to disclose
The population is aging There will be a shortage of ophthalmologists Optometrists are expanding their scope Even if we increase our technicians. There is only so much one doctor can do
OUR GOAL: Deliver high quality care without compromising patient safety
The PA profession started in the 1960s PAs must work for an MD or DO PAs purpose is to practice delegated, supervised medicine with an MD or DO They cannot open an independent practice
PA education is based on the medical school model, which on average is 27 months PAs are taught to think like MDs PA programs are accredited PAs are licensed to practice medicine with physician supervision
Take patient histories Perform physical exams Order and interpret labs and imaging Order consults Generate differential diagnoses Choose and initiate treatment Prescribe all medications Provide follow-up care
83,466 PAs practice in all 50 states Median salary is $90,000 42% of PAs have 6+ years of experience in a single specialty (and 65% with 3+ years) Only 0.08% in ophthalmology Data from 2010 AAPA Census
PA Specialties Unknown 2% Pediatric subspecialties 1% General surgery 2% Other specialties 19% Internal Med specialies 11% ER 11% Primary Care 31% Surgical subspecialties 23% Data from 2010 AAPA Census
Current PA Practice Areas Primary Care: Family medicine Gen. Internal Med Gen. pediatrics OB/Gyn Internal Med. Subspecialty: Cardiology Critical care Endocrinology Gastroenterology Hematology Endocrinology Infectious disease Nephrology Neurology Pulmonology Rheumatology Oncology Other Pediatric Subspecialty: Adolescent medicine Allergy Cardiology Critical care Endocrinology Gastroenterology Hematology Infectious disease Neonatal-perinatal Neurology Pulmonology Rheumatology Oncology Emergency medicine Other Surgical Subspecialty: Cardiothoracic/ cardiovascular Colon and rectal Hand Neurological Oncology Orthopedics Otorhinolaryngology Pediatric Plastic Thoracic Transplant Trauma Urology Vascular Bariatric Spine Other Other: Addiction medicine Allergy Anesthesiology Dermatology Emergency medicine Genetics Geriatrics Occupational medicine Ophthalmology Pain management Pathology Physical medicine/ rehabilitation Psychiatry Public health Radiation oncology Diagnostic radiology Interventional radiology Hospital medicine Other Data from 2010 AAPA Census
State law Defined by the supervising physician s scope of practice The PA s education and experience The Practice Plan filed with the state
PAs currently practice in about 67 MD/DO fields Only ophthalmology (and perhaps anesthesia) have specific language that restricts PA scope Some states have minor restrictions, some major Roughly 10-12 states restrict a PA from doing refractions Roughly 8 states have more restrictive language Our experience in Washington State How much does it matter?
Urgent care visits Straightforward office visits Pre-op H&Ps Post-op exams First assist in surgeries Round on hospital in-patients Minor procedures Ultimately, PAs will do whatever is most useful for an individual physician practice And, remember The MD is now available to see more complex patients at the same time!
PAs may first assist in surgery Technically, a PA is licensed to perform any aspect of a procedure or surgery that the MD deems appropriate The typical physician first assist fee is 16% of the surgeon s fee Medicare will reimburse 85% of this fee (85% x 16% = 13.6% of surgeon s fee) The SAME restrictions that apply to physicians as surgical assistants apply to PAs: Not all surgeries allow assistants In teaching hospitals that have qualified residents available, PAs (and physicians) cannot bill as a surgical assistant
Is dictated by state law Usually does not require the MD to be on-site Requires physicians to be available Physicians must have an understanding of an individual PA s current capabilities, which will expand with time Requires commitment to the physician-led team The AMA has suggested guidelines
PAs can bill for any service for which the physician can bill UNLIKE TECHS Insurance carriers reimburse for services rendered by PAs in all practice settings Physicians do NOT have to see the patient during the same encounter Rate of reimbursement varies based on carrier and patient encounter PAs can first assist in surgery Bonus PAs are helpful for non-billable visits
When PAs see NEW patients or return patients with NEW problems: PAs bill the full amount under their own NPI which alerts Medicare to reimburse at 85% Advantage is supervising MD need not be on-site Many private carriers reimburse 90-100% for these encounters When PAs see RETURN patients with established problems: This is called incident to billing PAs bill under the MD NPI and are reimbursed 100% Supervising MD or designated alternate must be on-site (same suite of offices, but MD does not have to see patient during the same visit)
PAs have separate liability insurance But, ultimately, the supervising MD can be sued for a PA s medical error
Must be able to perform and bill for an independent exam Must be able to share the patient load Ideally has a medical and surgical education as the foundation Physician Assistants and Nurse Practitioners fall into this category
Will this help their argument to expand their scope? Two major differences between PAs and optometrists to consider: PAs practice SUPERVISED, DEPENDENT medicine PAs have a MEDICAL and SURGICAL education like MDs There is a role for optometrists and PAs on an ophthalmology-led team PAs can carve out a unique role, separate from optometry and technician Like all other medical specialties, PAs don t have specialty training in ophthalmology But, like all other medical specialties, supervising physicians provide specialtyspecific training Should we consider a specialty education program?
PAs are trained and licensed to practice medicine with physician supervision PAs have a broad-based medical and surgical education on which to build specialty specific duties Over 83,000 PAs are practicing in over 67 MD fields already this is NOT A NEW IDEA PAs can practice delegated, dependent medicine under supervision that best fits the needs of the supervising ophthalmologist You can do this today