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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. 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 2006, approximately 231 million patient visits were made to PAs and approximately 286 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. Within each branch of the Armed Services, a Chief Consultant for PAs is assigned to the Surgeon General. 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.

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 AAPA believes that a full-time Director of PA Services within the VA Central Office is necessary to recruit and retain PAs in the Department of Veterans Affairs. PAs are in high demand in the private market place.

  • The US Bureau of Labor Statistics (BLS) projects that the number of PA jobs will increase by 50 percent between 2004 and 2014 and has ranked the profession as the fourth fastest growing profession in the country.
  • US News and World Report named the PA profession within its 2007 list of 25 best careers.
  • Money magazine ranked the PA profession number five in its 2006 list of top careers; CNN listed the PA profession as number four in its 2006 list of top US careers.

The growth in PA jobs is in the private sector, not the federal government. AAPA believes that the federal government, including the Department of Veterans Affairs, will not be able to compete with the private market unless special efforts are made to recruit and retain PAs. According to the AAPA’s 2006 Census Report, an estimated 3,545 PAs are employed by the federal government to provide medical care. Unfortunately, AAPA’s Annual Census Reports of the PA Profession from 1997 to 2006 document an overall decline in the number of PAs who report federal government employment. In 1991, nearly 13.4% of the total profession was employed by the federal government. This percentage dropped to 6% in 2006.

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.