Interview

Maintaining the highest standards of care

MAJ(R) Jenifer Detert, PA-C, MPAS, DFAAPA, CAQ: ER

President of the Minnesota Academy of Physicians Assistants (MAPA)

Please tell us about the education and training a Physician Assistant receives.

Physician Assistants (PAs) are clinicians with a minimum master’s level medical education. PA training is on average 110 graduate hours, which is more than all other non-physician professions. PA training focuses on general medicine and includes core clinical rotations inpatient and outpatient, family medicine, internal medicine, general surgery, emergency medicine, women’s health, pediatrics, and behavioral health. PAs receive more than 2,000 hours of supervised clinical education–this amount is second only to physicians. In fact, PAs have more rigorous credit hours and hands-on clinical training than any other non-physician health care provider. After graduating from an accredited PA program and passing the National PA Certifying Exam, a PA earns a certification and use of the PA-C in credentials.

PA training and practice involve physicians at every level; there is no other profession that has as much physician interaction as PAs do. Each PA program is required to have a licensed physician as its medical director. There are physician board members on both the Accreditation Review Commission for PA (ARC-PA) Education, which accredits PA programs, and the National Commission for the Certification of PAs (NCCPA), which administers the PA certification exam. In Minnesota, PAs are regulated by the physician-led state board of medical practice.

There are over 275 programs nationwide that offer PA programs. What can you tell us about how they differ and how they are the same.

All PA programs must provide a comprehensive curriculum that is reminiscent of physician training, which must be maintained and regulated by rigorous national accreditation standards. PA programs are sponsored by various institutions which create inherent differences. PA program sponsoring institutions can include academic or health systems, state, or private organizations, plus an approach to medicine, such as allopathic or osteopathic. PA programs vary in their curriculum formats and delivery methods, which offer choices to meet the student’s learning style. The formats include traditional lecture, case-based learning, body system progression, and integrated curriculum models. Regardless of educational format and delivery methods, the ARC-PA ensures each program complies with all specified evidence-based content.

No other profession has as much physician interaction as PAs do.

What can you tell us about the public perception of PAs?

The public perception of PAs has evolved over the last 50 years and now recognizes PAs as professional, competent, and trusted medical care clinicians. Patients cared for by a PA have a better understanding of the PA profession; those who have not been cared for by a PA are usually the ones confused about the PA role in the delivery of health care. At times, the public may confuse the title Physician Assistant with a medical assistant. To better clarify to the public our role in medicine, the PA profession in the U.S. is beginning a process to return to the original title of “Physician Associate”.

Please tell us about the licensing and credentialing process for PAs in Minnesota.

A PA must pass and maintain certification to be licensed in Minnesota. PA licensing in Minnesota is regulated by the Board of Medical Practice, which is led by physicians. Minnesota PAs are required to have current certification and complete 100 hours of continuing medical education (CME) every two years. To maintain licensure, Minnesota PAs are required to recertify every ten years by passing the NCCPA exam. The CME credit requirements for a PA are similar to a physician and are often the same courses. 

Credentialing is a process at the health care or practice level to assess and ensure each clinician is qualified to practice medicine in their specialty area. All insurance and accrediting bodies recognize PAs as licensed health care providers and have basic standards regarding credentialing. PAs have the same or similar requirements as physicians to obtain and maintain privileges.

What are some of the payer reimbursement issues that impact PAs?

Medicare reimburses claims for PA services but does not allow PAs to “direct bill” or receive payment. Instead, payments have been directed to the employer, health care organization or the physician. Direct payment to the clinician recognizes the work done by the health care professional as a revenue-generating licensed provider. The inequity of reimbursement practice resulted in PAs not being recognized as revenue-generating licensed providers. The 2022 Physician Fee Schedule will now authorize direct payment to PAs which takes effect January 1, 2022. However, this does not affect the reimbursement rate for PA services from Medicare, State Medicaid, “Incident to”, or splitshared billing practices.

How are Physician Assistant organizations addressing the issues of recruiting and training an increasingly diverse and inclusive PA workforce?

The Minnesota Academy of PAs (MAPA) is the voice and advocate of PAs practicing in Minnesota. MAPA recognizes diversity, equity, and inclusion are priorities across all medical professions and health outcomes improve when the treating clinicians reflect the community served. MAPA created a Diversity, Equity, and Inclusion (DE&I) committee to enlighten Minnesota PAs about how acknowledging differences in history, background, inclusion, and the understanding of all perspectives will strengthen the future of health care and the profession.

MAPA focuses on providing mentoring opportunities for PA students and those seeking PA school admission to our five Minnesota-based PA programs to support DE&I initiatives. MAPA, with the national American Academy of PAs (AAPA), has partnerships with national organizations to elevate the voices and actions of PAs from minority groups. Many national PA organizations have dedicated substantial resources to fund diversity scholarships, research efforts and expand outreach to potential PA students to promote diversity within the PA profession. MAPA seeks Minnesota-based partnerships with key stakeholders to broaden the PA network, including Minnesota Doctors for Health Equity and the Minnesota Medical Association (MMA).

What are some of the variations in how PAs can practice state to state?

State variations are as widely diverse as the local health care needs and the laws governing PA practice. A PA’s education and training–by intention and design–affords them the opportunity to make changes in practice based on the needs of the health care community. The practice of medicine shared by PAs and physicians varies greatly from state to state with some state laws allowing broader autonomy than others. In Minnesota, PAs have a “practice agreement” with the health care system under physician-led leadership. Two states (North Dakota and Utah) have recently passed legislation that allows the most flexibility for physician-PA collaborations. All 50 states recognize PAs as licensed providers with prescriptive practice. Knowing the state laws is critical for a clinician when seeking to practice in a different state as limitations exist in a PA’s ability to practice in a select specialty.

How do you see the role of Physician Assistants changing as health care delivery continues to evolve?

The wide acceptance of team-based medicine is evolving and presents an ideal opportunity to achieve high-quality health care. Successful teams have a greater capacity to improve patient outcomes that increase the safety and quality of care yet reduce costs while maintaining the satisfaction and well-being of both the patient and clinician. One of the basic tenets of PA education is teamwork. The broad-based PA training and education allows the profession to be flexible and adaptable while actively engaging in the ever-changing delivery of health care. Moving forward, PAs will continue to be models of adaptability, leaders in team-based care delivery, innovators in new care delivery models–and vital to the success of healthcare reform.

What are some of the workplace-imposed barriers to PA-positive environments?

Misunderstandings regarding PA practice cause unnecessary practice burdens and barriers to care. Some of the most common misinterpretations either have never existed or do not reflect current Minnesota practice laws. Minnesota law does not require a physician co-signature on patient charts. Also, PAs are not limited from seeing new patients in any practice or setting. There is no PA to physician ratio nor is a physician required to be onsite. It is important for physicians and administrators to know that the Minnesota PA Modernization Act that took effect August 1, 2020, removed physician liability for the care provided by PAs and allows PA practice to be determined at the practice level. Under state law in Minnesota, PAs may care for patients autonomously and without liability to physicians.

There is confusion about PA practice when compared against advanced practice registered nurses (APRN). PA training, education, and credentialing are under the direction of physicians. There is no difference in the scope of practice between PAs and APRNs,; the main difference is in administrative regulation. PAs maintain a regulatory tie to physicians through the annual practice agreement. In contrast, APRNs are regulated by the board of nursing and have no physician involvement in practice or licensing.

Extensive administrative paperwork and documentation is another barrier that limits PA clinical time with patients, which is felt by all clinicians.

The PA professional title includes the word “assistant” which creates other barriers that do not reflect the level of medical education and training, the scope of clinical knowledge, and autonomy of practice. The national PA organization, AAPA, is leading the efforts to return the title of PA in the U.S. to the original “Physician Associate” to help with clarification of our abilities to practice medicine.

Addressing and resolving these barriers and ensuring compliance with the PA Modernization Act maximizes PA practice potential and is essential to maintaining an adaptable clinical workforce.

What would you like physicians to know about PAs?

We want to remind physicians that PAs are trusted partners in the medical care of the population. PAs are educated and trained in the physician-based medical model but clinically focused on team-based care. PAs are held to the same standards of care, quality measures, and credentialing requirements as physicians. PAs are experts at adapting to meet patient care delivery needs in any setting or specialty.

In the last 50 years, the PA profession has significant evidence-based studies demonstrating improvement in access to care, care outcomes and reduced healthcare delivery costs. PAs are underutilized clinicians and partners of physicians in the shared goal of expanding high-quality care delivered safely.

PAs practice autonomously but are committed to the collaborative practice setting. PAs collaborate with physicians and members of the care team to maintain the highest standard of care that patients seek and deserve.

MAJ(R) Jenifer Detert, PA-C, MPAS, DFAAPA, CAQ: ER, has a solo rural emergency medicine practice that serves communities surrounding St. Joseph, Minnesota, is President of the Minnesota Academy of PAs (MAPA) and is a retired combat veteran.