The Primary Care Crisis: Where Should PAs Go?
Vic Germino, PA-C one of the first three PAs trained recently said in an interview, "I feel that every PA should go into family medicine first, and then branch out". He thought this was the way we as a profession would be the best we could be, the way we would "pay our dues" and lamented the fact that so many PAs went directly into the specialties first.
Ladies and Gentlemen, we are in a family practice, primary care crisis in our country. The reasons are vastly different than they were in 1965 when the first PA program was created at Duke but the upcoming decisions that shape HOW and WHICH clinicians will provide primary care will shape healthcare and the way it is delivered for the next decade.
Vic is spot on. We need to go into the family medicine policy debate and not just stick out toes into it. We need to jump into the pool with both feet and when the whistle blows be one of the top finalists for the gold medal. If not, I fear, part of the soul of the PA profession may die.
Please allow me the few minutes of reading to elaborate.
America does not have the physicians it needs to provide basic primary care services. It will not have them in the foreseeable future. Physicians do not see primary are as a viable specialty to enter. They will not be going into primary care and those that are already practicing in it will be closing their practices with increased frequency. The reasons for this exodus are multifaceted, and if NPs and PAs could triple their primary care numbers tomorrow these problems would still exist. To review, Medicare reimbursement is too low. The primary care clinician must run interference between the insurance companies and the patient, which ultimately is a losing proposition. Malpractice keeps going up and consumers look at their clinician as part of the problem. These problems will not disappear if PAs and NPs take on a greater primary care role.
If PAs want to be left out of the new primary care delivery paradigm in the future, we can easily have that happen. We can just continue on as we are today. If we want to be included, we can also make that option come to life.
How? For PAs to take a leadership role as a profession that sees itself as a leader in the delivery of primary care services, we must start to act. This action must take place as soon as we can make it happen.
Firstly, we must come out publicly as a profession saying that we can provide primary care services as autonomous clinicians. NOT as independent practice clinicians, but as clinicians who can provide the broad spectrum of primary care services not as "assistants", but as providers in our own right. We must let the national and state primary healthcare policy leaders know we have earned the right to be included in the mix along with the NP/MD/DO clinicians that already have a seat at the "primary care delivery" table. We have the studies to back us up. Let us accelerate our education of others regarding our worth.
How To Start
Let's call in a few chips. For 45 years, PAs have worked long and hard under conditions which would have killed off any other profession. Our name mislabels us and has since we changed it from Physician Associate, the name Dr. Stead at Duke picked for our profession. As PAs, the barriers we have had to face just to practice medicine would have crippled any other profession. For years, organized medicine has chosen to minimize or negate our contributions while organized nursing has generally declared us invisible. My friends, we have not had an easy time proving our worth. But prove it we did. The examples are too numerous to detail here but the fact that there are now 85,000 of us in practice and the fact that we can prescribe, diagnose and treat at the level of a physician in all 50 states affirms the track record we have amassed. There is currently no doubt that we provide primary care and that we do it as well as any other group of clinicians.
Today PAs are not looked at as an answer to the primary care crisis by a significant number of policy makers. How do we increase the number of policy makers that will include us in their future plans?
Here are some ways;
-Educate the policy makers of the USA that PAs WANT and DESERVE to be included. Our professional societies should come out and say we are a cost effective deliverer of primary care services; that we will match our record of providing care with any other group. That we have excelled in the provision of care in undeserved and rural areas and that we want those who can shape future policy to take notice of this history and allow us to participate.
-The PA profession should call for a "National Conference on the Delivery of Primary Care” with representatives from any organization (PA/NP/MD/DO) that has clinicians who currently deliver primary care. We should then advocate for our equal status among these clinicians to create primary care policy in the future.
-Regarding education, we should do two things. One is to reimburse one year tuition to any new graduate who agrees to practice in an underserved area providing primary care for 2 years. For experienced graduates we endorse and ask for funding for one year residency in family medicine for PAs (and possibly NPs) funded by the federal government in as many hospitals that want to start them. If our government can give billions to the financial companies that were (by and large) failures, they can give us millions to see if PAs are a significant resource to solve this healthcare crisis. Create residency programs for PAs and NPs entering with a Master's level education. Twelve months in length awarding a doctorate upon graduation. These programs would also grant the graduate the status of "Primary Care Provider" and if the new PCP agreed to practice in an under served area their tuition would be repaid, along with a stipend. These new graduates would be designated a PA-PCP or NP-PCP.
Even with this increased schooling it will take us much less time and cost the system much less money and resources to educate us than it will to educate a physician, especially when we know they will not enter primary care. Along with this would be the request for funding of studies to see how good the graduates of this program were. If deemed worthy, the program could be expanded so that any family practice residency that gets federal funding would have to take a number of PAs and NPs in them, or lose their funding. Let's really start to cement our place in the system.
Lastly, let's have our state organizations start to lobby their respective state legislators to remove the barriers that prevent us from providing care in the areas that need primary care. Let's do away with chart counter signatures, decrease MD to PA ratios, scrutinize other regulations that are decades old and that have shown no evidence to insure quality care, but have clearly been a detriment to NPs and PAs providing care where it's needed. If we can show that these possible barriers enhance quality care, let's keep them and refine them to make them even more useful. My guess is that many of these "barriers" hinder the ability of good clinicians to practice in areas where we are needed. Let the evidence dictate the practice.
Primary care will be re-defined over the next two years. It is time for the PA profession to work with the NP profession and others to make sure we are all recognized as primary care providers and to highlight our profession as leaders in the delivery of primary care services. It is time we took a proactive rather than a reactive posture regarding the provision of these services. We call upon the state organizations and well as the family practice PAs to lead the way for us as a profession into this new era. Primary care residencies should be formed, new strategies put into place and barriers to practice scrutinized to allow PAs and NPs to further expand the provision of primary care to the people and communities that need them.
Blaine P. Carmichael, MPAS, PA-C, DFAAPA