PAs welcome Medicare expansion, but don't want autonomy

Physician assistants aren't eager to sever their ties with physicians, despite moves to do so by other nonphysician practitioners.

By LaCrisha Butler, amednews staff. Jan. 31, 2000.

Washington -- The federal government has expanded Medicare reimbursement for physician assistants into new practice settings, but any notion that PAs want independent practice has been met by most in that field with rejection.

The reaction makes PAs a minority among nonphysician practitioners. Although the physician assistant and the nurse practitioner perform virtually the same function in some health care settings, NPs have sought more autonomy for their profession.

Those efforts have paid off. In November 1999, Medicare announced that NPs and certified nurse specialists could set up independent practice, without a collaboration agreement with a physician, in those states where they are allowed to do so. This move has angered the physician community, which argues that the move may jeopardize the quality of patient care.

In addition, the Health Care Financing Administration, which administers Medicare, broadened PAs' ability to be reimbursed at 85% of the physician fee schedule into a wider variety of practice settings. The payment will still have to go to the physician or the practice.

This broadening delights the PA community, which has never sought the same level of independence as their nursing counterparts.

"We believe completely in the team approach to health care, where the supervising physician is responsible for the provision and quality of care," said Stephen Crane, PhD, executive vice president of the American Academy of Physician Assistants. "We believe the team approach is a superior approach to the delivery of health care, because it emphasizes communication among providers, coordination of care and continuity of care for the patient over time."

Ina Cushman, a physician assistant active in the national organization, agreed. In her role as a surgical PA at Harvard Vanguard, a large multispecialty, multisite facility in Boston, Cushman works closely with her supervising physician and provides a range of services from diagnosing abdominal pain to draining abscesses to providing preoperative clearance and follow-up surgical care to patients.

"It's not in any way onerous," Cushman said of her dependent role. "It's a mutual relationship, a team relationship to make certain that we are delivering the care most appropriate to the patient."

And while the nursing profession was established independently from physicians almost from the start and has separate state licensing boards, the physician assistant field was created by doctors in the mid-1960s. PAs frequently are trained by physicians (often in PA programs at medical schools), receive their licenses from the same state boards that license physicians, and must be associated with a physician to be licensed.

"They [PAs] have declared from the outset that they wish to operate dependent under the supervision and authority of the physician," said E. Harvey Estes, MD, one of the creators, with Eugene Stead, MD, of the landmark PA program at Duke University Medical School, Durham, N.C. "And this has been a defining difference between PAs and nurse practitioners."

Stretching the boundaries

PAs may see their role as complementary to physicians, said Richard Cooper, MD, director of the Health Policy Institute at the Medical College of Wisconsin, Milwaukee, but "under that umbrella, [physician assistants] seek as much latitude as possible."

And, Dr. Cooper said that although the current leadership of the PA community adopts a dependent stance, tied to physicians, what is "fundamentally unknowable" is "how their successors will feel."

Even now, a small group of PAs has spoken out against the physician-dependent relationship, only to be voted down resoundingly by colleagues at national meetings, Dr. Estes said.

Joseph Marzucco, Portland, Ore., a PA for 27 years, is one who would like to see the culture change.

"From my perspective, being a PA who has been around a long time ... I tremendously respect the education of a physician, but I also know that I have something tremendous to offer, and I don't necessarily think what I have to offer has to be dependent on physicians," he said. He teaches in a PA program and has been involved in developing PA regulations.