Physician Assistant - Legislative Coordinating Commission

PHYSICIAN ASSISTANT
EDUCATION & PRACTICE
DATA PRESENTATION- AUGUST 25, 2014
PHYSICIAN ASSISTANT (PA)
EDUCATION AND PRACTICE
Legislative Health Care Workforce
Testimony: Monday, August 25, 2014
Heather KT Bidinger MMS PA-C
Minnesota Association of Physician Assistants (MAPA)
Program Director: St. Catherine University PA Program
Presentation Addressing Key Questions Requested
From PA Profession Representation
~input provided by educational programs and
professional association members~
WHAT IS THE STATUS OF PA
TRAINING IN MN?
AUGUST 2014
MN PHYSICIAN ASSISTANT (PA)
PROGRAMS
• Augsburg College
• 1st Program accredited- Continued Accreditation
• Started in 1995 and has graduated approx. 475 students
• St. Catherine University
• 2nd Program accredited-Provisional; March, 2012
• Started 2012 – First graduation- December 2014; 24 students
• Bethel College:
• 3rd Program Accredited- Provisional; March, 2013
• Started 2013- First graduation-August 2015; 31 students
OTHER PA TRAINING PROGRAMS
*The University WI—LaCrosse/Mayo/Gunderson
Program often considered a WI and a MN Program
**College of St. Scholastica is in process of
developing a PA training program- Provisional
accreditation visit scheduled 2016.
PA GRADUATES NOW AND IN 5 YEARS
Program
2014
2015
2016
2017
2018
Augsburg College
50**
30
24
24
24
Bethel College
n/a
31
32
32
32
St. Catherine University
24
32
32
32
32
St. Scholastica*
n/a
n/a
n/a
n/a
24
University of WI;
18
19
19
19
19
Total Graduates
92
112
107
107
131
* Pending provisional accreditation visit
** Two cohorts due to change in calendaring and graduation
SPECIALTY CARE VS.
PRIMARY CARE
WH E R E M N P H Y S I C I A N A S S I S T A N T S P R A C T I C E
PA PRACTICE IN PRIMARY CARE
• PAs are educated for General Practice:
• Students Don’t Self Select Primary vs. Specialty Care as a standard of
education or training
• no required residency
• Certificates of Added Qualification (CAQ): new and only in specialties
• Primary Care Definition:
• AAPA standard definition includes the practices of: Family Medicine,
General Internal Medicine, General Pediatrics and OB/Gyn Practice
• Data is fluid and can be difficult to obtain
• PAs often change practice specialty
• Market availability- PAs preferring primary care often take specialty
jobs due to availability and location.
MN PA PRIMARY CARE PRACTICE DATA
• MN Department of Health
• MN Primary Care Workforce Report: “All PAs in Primary Care”
• National data on state specifics not current, no CAQ
• AAPA Annual Survey- MN Specific 2013
• 35.3% Primary Care- of which 30.9% were in Family Medicine
• PA Program Data
• Augsburg: Over the past 3 years- average is 56% in primary
care and 54% in specialty care.
• U of WI: estimates in last 3 years- 4-7 of each class of 19 are in
primary care: 22-36%
• New Programs: no graduates- first data available 2015
METRO VS. RURAL PRACTICE
• MN Department of Health
• MN Primary Care Workforce Report: 80% Urban; 20% Rural
• AAPA Data for MN (2013)
• 4.5% Practice Settings were at Certified Rural Health Clinic
• Program Specific Data:
• Definition of Rural Practice: greater than 50 miles from a major
metropolitan area and population less than 15,000)
- Augsburg:
- 12% of graduates/year: closer to 20% in earlier years, but since 2010, staying
at 12% of graduates go to rural practice.
- New Programs- no data until graduation and employment
LOCATION OF CLINICAL TRAINING
• MERC data- PA education is included in MERC data
Program Data
• Augsburg College Program Data
•
•
•
Not “rural” as not adequate number of adequate sites
“IN” or “OUT” of 7 county metro area
Predicting for the need of more OUT due to lack of access IN; also anticipating need for
more out of state
•
•
2013: 72% IN 28% OUT and 5% out of state
2014: 65% IN 35% OUT and 10% out of state
• Bethel
•
•
Students are instructed that 30% placements outside of metroFor students from rural or outlying areas- this % greater
• St. Catherine University
•
•
•
First class in clinic (24) 10% Rural and 90% Urban
Would desire more rural if site availability/opportunity existed
Unable to accommodate 2 students in rural practice from rural home regions
• University of WI; L/M/G
•
All Family Medicine placements rural; and “others”
WHAT ARE THE TRAINING
REQUIREMENTS
PHYSICIAN ASSISTANT EDUCATION
OVERVIEW OF PA TRAINING
• PA Programs are accredited by the Accreditation Review
Commission on Education for the Physician Assistant (ARC-PA).
• PAs are educated in a medical model
• PAs are educated in didactic and clinical programs; the
curriculum focuses on classroom and laboratory instruction
followed by clinical rotations or clerkships.
• PA Programs are considered intense and rigorous. The average
length of PA Programs is 28 months, the credit hour equivalents
range from 80-120, averaging around 100 credit hours.
• As of 2010, the ARC-PA requires all PA Programs in development
to award a masters degree. *Profession has grown from a
competency based training.
DIDACTIC TRAINING
• Classroom instruction includes courses in basic, medical and
behavioral sciences:
 Gross Anatomy
 Physiology
 Microbiology
 Biochemistry
 Pharmacology
 Pathology
 Ethics, Professionalism, Law and Medicine
 Clinical Medicine
 Physical Exam
 Diagnostic Processes
• Students are typically in class 36- 40 hours a week and are
delivered year round.
CLINICAL TRAINING
• Students avg. 2000 hours in clinical rotations. (AAPA)
• Clinical experiences must allow students to
participate in the care of patients of all ages and in
multiple healthcare settings. (ARC-PA)
•
•
•
•
Ambulatory
In-patient/hospital based
Surgical
Emergent
• Clinical experiences similar between programs:
• Family Practice, Pediatrics, Ob/Gyn, General Surgery, Internal
Medicine, Emergency Medicine, Psychiatry, Electives*
MN PROGRAM TRAINING TIMING
MN PA Programs
Total
Months
Didactic Months
Clinical Months
Augsburg College
31
18
13
Bethel College
27
15
12
St. Catherine University
28
14
14
University of WI: G/LC
24
12
12
St. Scholastica
24*
*projected
WHAT IS SPENT EDUCATING
A PA FROM START TO FINISH
WH E R E D O T H E S E D O L L A R S C O M E F R O M ?
THE COST OF PA EDUCATION
• Operational/Existing vs. Cost of Program Start Up?
• Operational
• Anticipated budget of 1 M to educate a cohort of 30
students (AAPA);
• This is in line with Augsburg and St. Kate’s data
• Start Up New Program
• Mean start up cost is 1.5 M (PAEA, 2013)
• Mean start up cost in 2010 data; (ARC-PA 11/12/10)
• .75-1 M without capital improvements
• 2-3 M with building or renovation needed for program delivery;
HOW IS PA EDUCATION FUNDED?
Funding of PA Education:
1. Mainly Funded by Student Tuition!
2. Small Amount from endowments or gifting
3. National funding- increasingly rare
• Ex: HRSA expansion grant – 2012, but included veteran
criteria, not awarded to MN programs
Cost of PA Program Development
• Funding by Academic Institution- budget/endowment
• Upfront cost 2-3 years prior to student matriculation
ADDITIONAL NEEDS IN PA EDUCATION
Human Resources
Physical Resources & Equipment
Program Director
Medical Director
Administrative Support
2-3+ min. Core Faculty
Adjunct Faculty- areas
of expertise,
• Many instructors- areas
of specialty practice
•
•
•
•
•
• Classrooms
• Laboratory or Physical
Exam Space
• Offices
• Anatomy Lab- if
dissection
==================
• Equipment
• Supplies
CLINICAL RESOURCE NEEDS
*Average PA Program has 12 month of clinical education and
on average 2000 clinical hours.
• Time and Workload intense: 2-3 faculty, admin support
• Can be a direct expense to programs as more clinical sites
nationally are requiring payment for training
• Program Specific:
• Augsburg: need 330 placements per year; use approximately 70
different sites and over 150 different clinical instructors during that time.
• St. Catherine University: 416 placements per cohort; 1st year of clinical
education not completed and will be evaluated in December, 2014
PHYSICIAN ASSISTANT
EDUCATION
CHALLENGES, ISSUES, TRENDS
CHALLENGES AND ISSUES
IN PA EDUCATION
Challenges:
• Quantity of Quality Clinical Education Sites!
• Availability of Qualified Faculty
• Faculty Demands
Issues:
• Local Market Readiness for Graduates
• Healthcare Reform; Implementation Unknowns
QUALITY CLINICAL SITE TRAINING
AVAILABILITY
• Competition with other HC Students; mainly medicine/APN
• Loss of access to rural educational opportunities
• Preference of HC facilities: to train one discipline over
another or from one academic institution over another
• Centralizing of placements- lost access to provider network
• Mergers of small clinics to larger institutions; providers say
yes, system says no
• Non-uniform onboarding/credentialing, EMR requirements
• Heavy administrative burden
• CMS regulations in documentation and billing
• Provider productivity; concern that having students impact
income potential; incorporating students into practice flow
• MERC money but… no direct revenue or incentive to
providers to train students; no direct funding or payment
PA PROGRAM FACULTY
• Recent Increase of Programs• Demand exceeding the supply of experienced faculty or those
in clinical practice who may choose income reduction to teach
• Pay scale discrepancies from practice to faculty
• New grads are projected to earn more than PA faculty
• Loan burden prohibitive to moving roles
• Academic degree requirements; Masters- Doctorate
• 1997-98 less than 5 programs offered Masters degrees
• (2010) requirement of PA Masters for all Programs
MERC MEETING SUMMARY OF PA
MAY 2014
Most Important Issues:
1.
2.
3.
Quality Clinical Sites
Quality PA Faculty
Primary Care Job Availability
Numbers of PAs in MN: 1878
Work Force Needs:
1.
2.
3.
Conflicting information on workforce needs as delivery of
healthcare is changing with team and home care models
The need is projected to exceed graduates but graduates
not finding primary care jobs.
Profession posed to assist in Mental Health shortage but
limited due to reimbursement issues
MERC MEETING SUMMARY
MAY 2014
Any Legislative/Practice acts pursued:
1. Request for reimbursement for outpatient mental health
patients with MA coverage
2. Ratio of MD/PA limit removed; alternate supervisor
Clinical Training Challenges:
1. Adequate quality sites
2. Heavy administrative burden
3. TCCP potential for help- needs work
Clinical Training Finance Issues
1. MN Programs in general, not paying for sites
2. Out of state students are paying in state for sites- concerning
PA WORK FORCE UNKNOWNS
Additional from MERC:
Sustainability of 4 PA Programs in MN?
1. 120 PA students per year in the clinic starting in
2017/18, in an already saturated clinical market.
2. Does this meet work plan in the state for where PA
can/should be employed
What are Healthcare Organizations Strategic Plans
for PA Employment and Models of PA Utilization ?
PHYSICIAN ASSISTANT
PRACTICE
CHALLENGES, ISSUES, TRENDS
MN PA PRACTICE:
CHALLENGES
• MN Landscape
•
•
•
•
Distribution of primary care vs specialty job availability
Regional & Organizational preferences between APPs
General misperceptions on supervision & scope of practice
Healthcare reform- unsure of PA utilization changes- when
and what? (Academia can adapt to prepare if known)
• Legislative Initiatives
• Rule of Physician to PA ratios removed from statute
• Alternate supervising physician at site, not state level
• Reimbursement for PAs outpatient MA mental health care
MN PA PRACTICE TRENDS
Trends:
• Fewer Primary Care positions available
• More PAs still pursing specialty practice
• Fewer PAs having worked with underserved
• Changes in utilization- unsure of how this will affect
scope of practice, delivery of care, etc.
• In the next 12 months- new to MN= multiple
programs graduating students- ? employment rates
CONCLUSION
• PA are trained in general medicine, poised for specialty
practice, trained in team based care and can be
adaptable to market needs
• primary care vs specialty (i.e. mental health, emergency med)
• Could better maximize utilization of PAs in practice
• In delivery of care models (primary, extension, panel)
• MN PA graduates will over double in the next 12 months.
• Unknowns as to the availability of jobs for graduates
despite the calculations of work force needs
• Primary challenge of educating PAs is having adequate
clinical education sites- already difficult, not sustainable