Health Care Payment System Reform: Impact on Physician Assistants

Health Care Payment System Reform: Impact on Physician Assistants Clearly, the Massachusetts universal coverage health care initiative has been a success in providing increased coverage to citizens of Massachusetts. Data continues to show that well over 90% of Massachusetts residents are covered. But that accomplishment is just the first, and some would argue the easiest, step in a very complicated and arduous process of reforming health care in the state, and in the country. Two equally important pieces of the puzzle include finding appropriate ways to control rapidly escalating costs while at the same time achieving improvements in the quality of the care being delivered. The Massachusetts Association of Physician Assistants (MAPA) appreciates the opportunity to provide input into the discussion as policy makers seek to further develop the frame work and methodology of payment system reform. MAPA is strongly committed to participating in health reform activities that will lead to improved health outcomes for the citizens of the Commonwealth. Caring for our patients remains the overarching goal and focus of our efforts. Thoughts on accountable care organizations (ACOs) are included in our comments. We also focus on the specific impact that such care models and potential payment reform activities will have on the ability of physician assistants (PAs) to maintain and increase their role as key providers of care in the state, and what changes could be made in state policies to enhance patient care by strengthening the PA role. PAs are part of the physician PA team and share many of the same concerns as physicians. However, there are some unique challenges faced by the PA profession as part of these reform activities. Access and Maximum Utilization of Health Care Professionals Any successful care model requires an adequate supply and mix of health care professionals. There has been an acknowledged decline in the primary care work force making it all the more important to fully engage health care professionals who can deliver primary care services. The Physician Workforce Study published by the Massachusetts Medical Society has shown that close to fifty percent of internists are not accepting new patients. Physician assistants are educated and trained in the generalist model making them ideally suited to be important players in integrated and interdisciplinary teams, and coordinated care models. PAs increase access to primary care services, provide continuity of care to some of the sickest patients within the healthcare system and provide high quality care in many cases at a lower cost. As the health care system seeks to reform payment methodologies and promote new models of care, it is imperative that the contribution of all health care professionals be recognized and supported within the system. One factor that hinders efficiency in the health care arena occurs when health care professionals are not authorized and enabled to deliver care to the full extent of their education and training. (Please see Appendix A for a summary of barriers to PA practice and how PAs fit into payment reform in Massachusetts) Recognition of the medical skill set that PAs offer and their ability to deliver care autonomously as part of the physician PA team Recognition of PAs as eligible professionals in all programs (e.g., medical home, ACOs). Removal of barriers in state law and federal regulations to allow PAs to deliver care to the highest level of their license. Practice friendly supervision and co signature requirements. Hospital physician gainsharing arrangements and necessary anti trust exemptions being extended to PAs. 12/6/2010 1

Assistance in the education of PA students (rotation sights/loan forgiveness). Examples/Consequences When PAs Were Excluded from Health Care Programs Several years ago, when state Medicaid programs shifted to managed care type plans through the waiver process, PAs were not listed by the federal government as primary care providers (PCPs). The federal government allowed, but did not mandate, that PAs be considered as PCPs. States often assigned a certain number of Medicaid patients to a practice based on the number of PCPs (i.e., 1500 patients per PCP). This was often known as a panel of patients. A practice that had a physician and a PA had the capacity to treat 3,000 Medicaid patients. However, if the particular state did not recognize PAs as PCPs, the state often assigned only 1,500 patients to the practice, severely underutilizing the physician PA team and often limiting access to Medicaid patients. State officials assumed that because PAs worked closely with physicians there was no need to separately list them in health care programs. This was an incorrect assumption and we do not want to repeat that scenario as the net effect is to limit patient access to needed medical care services. ACOs Accountable care organizations (ACOs) have the ability to marshal the resources to provide the wide spectrum of care required by patients. Coordination of care principles and a reliance on best practices guidelines maintained across the ACO would, in theory, bring about higher quality, consistent care. The federal health care reform bill, the Patient Protection and Affordable Care Act, includes PAs in its definition of eligible providers in ACOs. State guidelines/language should also specifically include PAs as authorized or eligible health care professionals. Better care coordination will improve patient health status and lower health costs, but results may not be immediate. ACOs and other arrangements are, for the most part, theoretical entities that need time to develop efficiencies and create effective interdisciplinary teams among the health care professionals and the organizations that will be affiliated with the ACO. It may take some time before substantial cost savings are realized. 12/6/2010 2

Global (Bundled) Payments We acknowledge that the predominant payment systems currently in use, those based on a fee forservice (FFS) model, improperly incentivize volume of care as opposed to quality of care and quality outcomes. The FFS model, almost by design, encourages gaps in care or fragmentation in the system with little incentive for coordinated care. Global payments for episodes of care or care encounters in and of themselves will not reduce health care cost or improve the quality of care. Policy makers must determine, not necessarily utilizing the traditional fee for service fee schedules, a reasonable payment for an episode of care that covers the true cost of delivering care. Using the fee for service model as a template will simply perpetuate a payment system that has traditionally overpaid specialty and procedure based care and underpaid primary care services. A step by step analysis of the actual steps and professionals delivering services or episodes of care (including all professionals who play a medically necessary role) might be the only method to properly determine a reasonable cost of providing care. Competition over payments may lead to the trickledown theory. PAs are potentially at a disadvantage when compared to hospitals and physicians in terms of who controls the payment and how it will be divided. PAs may be employed by the hospital, by a physician group, or as independent contractors. No matter which arrangement is in place, appropriate coverage of the professional services delivered by the PA must be maintained, even within an ACO type of delivery model. Exposure to risk (and reward) will likely be an important component of global payments with rewards due to savings in the system being available for incentivizing optimal outcomes. Simply being an efficient health care professional or practice will not guarantee success. If other players who share in the responsibility for patient care (hospitals, physician practices, physical therapy, home health agencies, etc.) are not efficient providers of care then the expected savings of coordinated care could be lost for all involved. Good clinical behavior by some could go unrewarded if other parts of the ACO fail in their attempts to deliver high quality care. Recognizing PAs as providers creates a mechanism to properly collect and measure quality data on the care being delivered by the PAs. Right now the system is only able to track those providers billing under their specific identifiers, most of the work done by PAs is silent to the system because it is captured under a physician identifier. PAs saw 257 million patients nationwide in 2009. Most health care professionals are not accustomed to dealing with risk. Under fee for service there is little risk since variables such as patient outcomes were not factored into payment. There will need to be certain financial safeguards built into global payments to assure that there are appropriate limits on downside risk due to inadequate global payments or inaccurate patient acuity assessments (risk adjusters). If payments are artificially low and fail to cover the cost of delivering care, access issues will only be exacerbated as more health care professionals will leave medicine, leave the state, or potentially limit the care they provide. 12/6/2010 3

The concept of attempting to align traditionally dissimilar entities, such as hospitals and health care professionals, is one that historically has been difficult to manage. A lack of trust permeates the atmosphere whenever there is a discussion about changing rates or methodologies related to payment all sides want to know who will win or lose. Many health care professionals and institutions are experiencing a type of déjà vu. Unsuccessful familiar concepts utilized in the 90s include managed care models, hospitals buying physician practices, then called PHO or physician hospital organizations, and capitated payments. Irrespective of the type of delivery and payment systems that are ultimately adopted in the state, there will be a need for appropriately trained health care professionals. PAs are an essential component of the provider infrastructure and it is imperative that they be included among those who deliver primary medical care to patients. 12/6/2010 4

Appendix A: Summary of Barriers to PA Practice and how PAs fit into payment reform in Massachusetts Define PAs as eligible providers in ACOS; federal health care reform bill, the Patient Protection and Affordable Care Act, includes PAs in its definition of eligible providers in ACOs. State guidelines/language should also specifically include PAs as authorized or eligible health care professionals. Hospital physician gainsharing arrangements and necessary anti trust exemptions should be extended to PAs. Recognize the role of PAs as primary care providers; this has been made at the federal level, with passage of the landmark Patient Protection and Affordable Care Act. PAs are recognized as providers within the primary care team and allows PAs to lead a home based primary care team as part of an independence at home medical practice. This is not to be interpreted as independent practice but should be viewed as autonomous practice within a team oriented physician PA team. Maximize the number of necessary providers of primary care creating much needed access to primary care services which lowers the overall cost of healthcare. Recognize and reimburse for services provided by PAs based on quality measures and outcome data. No matter which arrangement is in place, appropriate coverage of the professional services delivered by the PA must be maintained, even within an ACO type of delivery model. All providers will need to accept risk within the system. Federal health care reform bill, the Patient Protection and Affordable Care Act, creates a 5 year 10% Medicare bonus for select primary care codes furnished by PAs, as well as other primary care providers. This holds all providers to equal and high quality medical practice standards. Assess how PAs will fit into a new payment structure by reviewing data provided to state entities like the Roadmap to Cost Containment presented by the Rand Health Corporation to the Massachusetts HCQCC which states the average cost of a PA visit is 20% to 35% lower than the average cost of an office visit with a physician with an estimated savings range of $4.2 billion to $8.4 billion over ten years. A stepby step analysis of the actual steps and professionals delivering services or episodes of care might be the only method to properly determine a reasonable cost of providing care. There is much literature out there in regards to the high quality care PAs provide, by reviewing and understanding this data, decisions for including PAs will be based on sound data analysis. Eliminate the restriction specifying the number of PAs a physician can supervise; the American Medical Association (AMA) has officially supported the principle that the appropriate ratio of physician to PA should be determined by the physicians at the practice level as long as its consistent with high quality medical practice. This was a recommendation included as a barrier to increased utilization of PAs in the state by the Rand Health Corporation Study aforementioned above. Many PAs provide off hours coverage for patients keeping them out of hospitals and emergency rooms. Removing this barrier ensures efficient health care delivery based on the needs of the practice and patients. 12/6/2010 5

Include PAs in loan repayment programs and institutional recruitment efforts; Chapter 305 of the Acts of 2008 initiated the creation of Workforce Center which was tasked with addressing the workforce shortage in part through loan repayment programs and support for institutional recruitment efforts for physicians and nurse who serve in primary care and underserved areas. PAs were NOT included in this effort and should be. Increases much needed access in underserved areas and community centers for patients. Modernize Medicaid regulations to be inline with current Medicare standards to include; mandate the credentialing and enrollment of PAs reimburse for first assisting when Medicare standards are met, remove the requirement for physician co signature on hospital medical records, PT/OT/Speech referrals. Removes unnecessary barriers to MD and PA practice, encouraging more efficient practice. Appoint PA representation from the Massachusetts Association of PAs to appropriate health reform committees moving forward. PA representation was not included when the Advisory Committee to the Health Care Quality and Cost Council was formed after the passage of Chapter 305. Both MD and NP representation were included. The Advisory Committee members serve on other committees involved in state healthcare and payment reform like the Committee on the Status of Payment Reform Legislation. Having PA representation and input on reform policy and legislation would allow for expert input to PA practice moving forward. Make PAs a licensed profession, rather than registered ; 46 states and D.C. use the term licensure for PAs. Only Massachusetts and New York use registered, while Ohio and Vermont use certified. Both New York and Vermont are planning legislative action to move to licensure in 2011. Avoid patient confusion and recognition of what the actual credentials are for PAs. Eliminate requirement for chart co signature on all Sch. II prescriptions by PAs within 96 hours; this can cause inefficiencies in the delivery of patient care and creates an unnecessary burden on the supervising physician. Decisions about chart co signature should be made at the practice level to allow for maximum practice efficiency. Prescriptive practice guidelines which are already in place provide the necessary communication between PA and MD regarding the prescribing of medication. 12/6/2010 6