TESTIMONY OF

THE AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS

AND

THE VETERANS AFFAIRS PHYSICIAN ASSISTANT ASSOCIATION

SUBMITTED TO THE

COMMITTEE ON VETERANS AFFAIRS

U.S. SENATE

IN SUPPORT OF S. 1155, A BILL TO ELEVATE THE VA’S PA ADVISOR TO A
FULL-TIME DIRECTOR OF PA SERVICES IN THE VA CENTRAL OFFICE

October 21, 2009

Good Morning.

Chairman Akaka, Ranking Member Burr, and other Members of the Committee of Veterans Affairs, thank you for inviting the American Academy of Physician Assistants to present testimony on S. 1155, 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.

My name is Bill Fenn. I’m a physician assistant, and I’m Vice President of the AAPA. I received my training as a physician assistant while I was in the Air Force. I’m familiar with the VA from two fronts. Since I have an active-duty related disability, I have received care, from time to time, from the VA. In addition to being a patient, I’ve also been employed as a clinician through the VA. I worked in one of the first VA rural health demonstration programs.

The AAPA represents the more than 75,000 clinically practicing physician assistants in the United States. My testimony today also represents the views of the Veterans Affairs Physician Assistant Association. The VAPAA represents physician assistants who are employed by the Department of Veterans Affairs.

AAPA and VAPAA are very appreciative of Senators Susan Collins and Daniel Inouye for their leadership in introducing this important legislation. We thank members of the committee who have added their names as cosponsors and/or have indicated their support for the legislation. And, we also thank the veteran service organizations who have urged passage of S. 1155. (The annual Veteran Service Organizations Independent Budget, endorsed by 35 professional and veteran service organizations, has recommended enactment of this legislation.)

AAPA and VAPAA believe that enactment of S. 1155 is essential to improving patient care for our nation’s veterans, ensuring that the nearly 1,900 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 associations believe that enactment of S. 1155 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 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 2008, over 257 million patient visits were made to PAs and approximately 332 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 142 accredited PA educational programs across the United States. Nearly 1,900 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.  They provide care in all levels of medical facilities throughout the military. 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 Geisinger 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. In fact, Money magazine recently ranked the PA profession as its #2 best job. The challenge for the VA is that the growth and demand for PAs is in the private sector, not the VA.

Despite the fact that the VA PA workforce has risen by 19% in the last 5 years, the PA percentage of the VHA mid-level practitioner workforce has dropped to 30%. We believe that this directly relates to recruitment and retention.
The VA has acknowledged that an increasing physician shortage, especially in primary care, is expected at a time when the number of VA patients is expected to increase significantly. Recruitment and retention of non-physician patient care providers, especially, physician assistants, will be critical to meeting VA’s patient care needs. Stationing the PA Advisor in the field creates a barrier to effectively addressing VA recruitment and retention issues, as well as to ensuring patient care initiatives and policies do not create additional, unintended barriers to optimal utilization of PAs.

According to the AAPA’s 2008 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 2008 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 approximately 9% in 2008. New graduate census respondents were even less likely to be employed by the government (17% in 1991 down to 5% in 2008).

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. This is particularly critical because it is happening at a time when the U.S. and the VA are facing a primary care workforce shortage. 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. The position functions without any designated administrative support. Prior to P.L. 106-419, 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.

The PA Advisor currently reports to the Chief Consultant for Primary Care. The numbers of VA PAs currently assigned to primary care has decreased to less than 35%. Considering that the majority of PAs practice in all disciplines of medicine in VHA, it is reasonable that the Director of PA Services report to the Under Secretary for Health. This reporting mechanism would be consistent with all other federal agencies and the Department of the Defense.

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 cannot use PAs and will not hire PAs.  These unfortunately common events are not based on any cohesive policy decision, but rather, a lack of appropriate PA utilization input at the Central Office level.  These restrictions needlessly 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 very much for the opportunity to testify in support of S. 1155. Both AAPA and VAPAA are eager to work with the Committee on Veterans Affairs to improve the availability and quality of medical care to our nation’s veteran population.