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Alternative Providers Could Help Bridge Gap in Primary Care

Steven Johnson can tell you how bad it was. He has been a physician assistant in Palo Alto for more than 28 years. Since the entire PA profession is barely 40 years old, that almost makes him a pioneer in his field. Physician assistants work under a doctor’s supervision and have the training to perform many physician tasks, from making diagnoses and running tests to deciding treatment. All of the work is done with a physician’s input and approval, with the doctor signing off on many things, including prescriptions.

Johnson remembers when the medical community didn’t always want PAs.

“In the old days, we were not looked at very favorably,” Johnson said. “The reality was, back then I was told, ‘You’ll never see a patient. We have doctors to do that.'”

He added, “We thought the PA profession might die on the vine. Both for the nurse practitioner and PA, it has been a very slow process, from sitting down with senior physicians and needing to literally defend myself — this is what I’m supposed to do, this is what I’m licensed to do — to now everybody wanting one.”

That slow path to acceptance in the medical community has become dependence. There now are about 75,000 physician assistants nationwide and about 10% of them are in California, according to the California Association of Physician Assistants.

An institutional need for PAs is part of what’s driving new legislation now making its way through the state Senate.

The new bill, SB 1069 by Sen. Fran Pavley (D-Agoura Hills), would allow some physician assistant tasks to be completed without the supervising physician’s signature. If it becomes law, a PA could sign off on physical exams and student athletic participation forms, certify disability, arrange home care and order durable medical equipment, such as crutches.

“SB 1069 does not conflict with current scope of practice policies. It is simply aimed at clarifying various inconsistencies and omissions in existing law relating to PA’s,” Pavley said.

“As we are all aware, there is an access-to-care crisis in California, and PAs are an invaluable resource for doctors, and increase Californians’ access to care, especially in underserved and rural areas of the state,” Pavley said.

There appears to be no organized opposition to the bill. The California Medical Association supports it.

“PAs are a valuable asset to the health care community, and we support legislation like this that clarifies their role and strengthens the interaction between physician and physician assistant. We think this is a really good bill,” said Andrew LaMar, spokesperson for CMA.

Acceptance of PA Work

The legislation is about recognition, according to Ann Davis, a former PA in Grass Valley, now director of State Government Advocacy and Outreach for the American Association of Physician Assistants.

“Really what it does is recognize what PAs are already doing,” she said. That is, PAs currently work with patients on their treatment plan — up to a point. Davis added, “So if a patient needs crutches, for example, the PA might have to say, we’ll send those to you in a couple of days, after we get the doctor’s signature.” With the bill, the PA would be able to just order the crutches, so the patient doesn’t have to wait while somebody tracks down the doctor for a signature.

“This is great, this is the kind of thing we need to remove barriers that don’t add any public protection,” Davis said.

There’s a bigger goal behind the bill, according to Davis. The point of a PA is to assist a physician and help avoid overburdening the supervising doctor with minutiae. “It’s simple: You want the patient treated by the right person in the right job. I mean, you don’t want hangnails treated in the ER or heart attacks in the student clinic. PAs allow the physicians to use their time in a more meaningful way, and that’s better in the long run for patients,” Davis said.

Bracing for More Patients

At the University of California-Davis, Richard Dehn is director of the Physician Assistant/Family Nurse Practitioner program. He has been heartened by the medical community’s acceptance of alternative providers and predicted that it’s just the start of the shift for the health care world in California.

PAs and NPs “have stepped into health care delivery gaps, particularly in the primary care arena. And demand (for PAs and NPs) will increase, because there aren’t enough providers,” Dehn said.

Dehn points to the estimated three million new primary care patients expected from implementation of federal health care reform.

“The reform act will place all kinds of patients into ambulatory primary care practices, and there’s already a health care delivery capacity shortage. Anyone who thinks both (PAs and NPs) aren’t vital to health care delivery, well, if they believe that, they believe in the tooth fairy,” Dehn said.

The View on the Ground

For both the establishment of alternative providers and for national health care reform, the wrangling over how to change the rules is actually the easy part, according to Johnson, the PA in Palo Alto.

Policymakers can alter laws and offer incentives, but the biggest hurdle is changing the culture of how medicine is practiced, he said.

In the case of physician assistants, the first cultural shift came in the medical community, followed by a loosening of patient attitudes toward PAs.

“In the first decade (I worked as a PA), I had five or six people just walk out of my office. Or they would excuse themselves to go to the bathroom, and just never come back,” Johnson said, laughing at the memory. 

“Now the PA is starting to be utilized more assertively in the medical community, that has changed, and now I find that many patients actually ask for an FNP (family nurse practitioner) or PA,” he said.

Johnson added, “In the same way, the medical culture in this country is undergoing a fairly dramatic change. We are entering a period of time where 30-plus million more people (nationally) will be seeking health care. We are also entering a time when primary care as a specialty is not being chosen by physicians. I think the number was 10% (of medical school graduates) last year went into primary care.”

“So that means a lot more patients to take care of, and we are going to need to use other clinicians to take care of all of those people,” Johnson said.

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