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Submission For The Record of American Academy of Physician Assistants

On behalf of the nearly 65,000 clinically practicing physician assistants (PAs) in the United States, the American Academy of Physician Assistants (AAPA) is pleased to submit comments in support of H.R. 2790, a bill to amend title 38, United States Code, to establish the position of Director of Physician Assistant Services within the office of the Under Secretary of Veterans Affairs for Health. The AAPA is very appreciative of Representatives Phil Hare and Jerry Moran for their leadership in introducing this important legislation. The Academy also wishes to thank Chairman Filner and Representative Berkley for cosponsoring HR 2790.

AAPA believes that enactment of HR 2790 is essential to improving patient care for our nation’s veterans, ensuring that the 1,600 PAs employed by the VA are fully utilized and removing unnecessary restrictions on the ability of PAs to provide medical care in VA facilities. Additionally, the Academy believes that enactment of HR 2790 is necessary to advance recruitment and retention of PAs within the Department of Veterans Affairs.

Physician assistants are licensed health professionals, or in the case of those employed by the federal government, credentialed health professionals, who—

  • practice medicine as a team with their supervising physicians
  • exercise autonomy in medical decision making
  • provide a comprehensive range of diagnostic and therapeutic services, including performing physical exams, taking patient histories, ordering and interpreting

laboratory tests, diagnosing and treating illnesses, suturing lacerations, assisting in surgery, writing prescriptions, and providing patient education and counseling

  • may also work in educational, research, and administrative settings.

Physician assistants’ educational preparation is based on the medical model. PAs practice medicine as delegated by and with the supervision of a physician. Physicians may delegate to PAs those medical duties that are within the physician's scope of practice and the PA’s training and experience, and are allowed by law. A physician assistant provides health care services that were traditionally only performed by a physician. All states, the District of Columbia, and Guam authorize physicians to delegate prescriptive privileges to the PAs they supervise. AAPA  estimates that in 2007, approximately 245 million patient visits were made to PAs and approximately 303 million medications were prescribed or recommended by PAs.

The PA profession has a unique relationship with veterans. The first physician assistants to graduate from PA educational programs were veterans, former medical corpsmen who had served in Vietnam and wanted to use their medical knowledge and experience in civilian life.  Dr. Eugene Stead of the Duke University Medical Center in North Carolina put together the first class of PAs in 1965, selecting Navy corpsmen who had considerable medical training during their military experience as his students.  Dr. Stead based the curriculum of the PA program in part on his knowledge of the fast-track training of doctors during World War II.  Today, there are 139 accredited PA educational programs across the United States. Approximately 1,600 PAs are employed by the Department of Veterans Affairs, making the VA the largest single employer of physician assistants.  These PAs work in a wide variety of medical centers and outpatient clinics, providing medical care to thousands of veterans each year.  Many are veterans themselves.

Physician assistants (PAs) are fully integrated into the health care systems of the Armed Services and virtually all other public and private health care systems. PAs are on the front line in Iraq and Afghanistan, providing immediate medical care for wounded men and women of the Armed Forces. PAs are covered providers in Tri-Care. In the civilian world, PAs work in virtually every area of medicine and surgery and are covered providers within the overwhelming majority of public and private health insurance plans. PAs play a key role in providing medical care in medically underserved communities. In some rural communities, a PA is the only health care professional available.

Why are PAs so fully integrated into most public and private health care systems? We believe it’s because they foster the use and inclusion of their PA workforce. Each branch of the Armed Services designates a PA Consultant to the Surgeon General. And, many major medical institutions credit their integration of PAs in the workforce to a Director of PA Services. To name just a few, the Cleveland Clinic, the Mayo Clinic, the University of Texas MD Anderson Cancer Center, and New Orleans’ Ochsner Clinic Foundation all have Directors of PA Services. We believe that what works for the Armed Services and the private sector will also work for the VA.

How does the lack of a Director of PA Services at the VA relate to recruitment and retention of the VA workforce? As far as  the AAPA can tell, there are no recruitment and retention efforts aimed towards employment of physician assistants in the VA. The VA designates physicians and nurses as critical occupations, and so priority in scholarships and loan repayment programs goes to nurses, nurse practitioners, physicians, and other professions designated as critical occupations. The PA profession has not been determined to be a critical occupation at the VA, so monies are not targeted for their recruitment and retention. PAs are not included in any of the VA special locality pay bands, so PA salaries are not regularly tracked and reported by the VA. We’ve been told that this has resulted in lower pay for PAs employed by the VA than for health care professionals who perform similar medical care. Why are PAs not considered a critical occupation at the VA? Is it possible they were overlooked, because there was no one to raise the issue?

The outlook for PA employment at the VA does not differ from that for nurse practitioners and physicians. Approximately forty percent of PAs currently employed by the VA are eligible for retirement in the next five years, and the VA is simply not competitive with the private sector for new PA graduates. The US Bureau of Labor Statistics, US News and World Report, and Money magazine all speak to the growth, demand, and value of the PA profession. The challenge for the VA is that the growth and demand for PAs is in the private sector, not the VA

According to the AAPA’s 2007 Census Report, PA employment in the federal government, including the VA, continues to decline. AAPA’s Annual Census Reports of the PA Profession from 1991 to 2007 document an overall decline in the number of PAs who report federal government employment. In 1991, nearly 22% of the total profession was employed by the federal government. This percentage dropped to 9% in 2007. New graduate census respondents were even less likely to be employed by the government (17% in 1991 down to 5% in 2007).

Unless some attention is directed toward recruitment and retention for PAs, the AAPA believes that the VA is in danger of losing its PA workforce. The elevation of the PA Advisor to a full-time Director of PA Services in the VA Central Office is the first step in focusing the VA’s efforts on recruitment and retention of PAs.

The current position of Physician Assistant (PA) Advisor to the Under Secretary for Health was authorized through section 206 of P.L. 106-419 and has been filled as a part-time, field position. Prior to that time, the VA had never had a representative within the Veterans Health Administration with sufficient knowledge of the PA profession to advise the Administration on the optimal utilization of PAs. This lack of knowledge resulted in an inconsistent approach toward PA practice, unnecessary restrictions on the ability of VA physicians to effectively utilize PAs, and an under-utilization of PA skills and abilities. The PA profession’s scope of practice was not uniformly understood in all VA medical facilities and clinics, and unnecessary confusion existed regarding such issues as privileging, supervision, and physician countersignature.

Although the PAs who have served as the VA’s part-time, field-based PA Advisor have made progress on the utilization of PAs within the agency, there continues to be inconsistency in the way that local medical facilities use PAs. In one case, a local facility decided that a PA could not write outpatient prescriptions, despite licensure in the state allowing prescriptive authority. In other facilities, PAs are told that the VA facility can not use PAs and will not hire PAs. These restrictions hinder PA employment within the VA, as well as deprive veterans of the skills and medical care PAs have to offer.

The Academy also believes that the elevation of the PA Advisor to a full-time Director of Physician Assistant Services, located in the VA central office, is necessary to increase veterans’ access to quality medical care by ensuring efficient utilization of the VA’s PA workforce in the Veterans Health Administration’s patient care programs and initiatives. PAs are key members of the Armed Services’ medical teams but are an underutilized resource in the transition from active duty to veterans’ health care. As health care professionals with a longstanding history of providing care in medically underserved communities, PAs may also provide an invaluable link in enabling veterans who live in underserved communities to receive timely access to quality medical care.

Thank you for the opportunity to submit a statement for the hearing record in support of H.R. 2790. AAPA is eager to work with the House Committee on Veterans Affairs Subcommittee on Health to improve the availability and quality of medical care to our nation’s veteran population.