DATA P R E S E N TAT I O N - A U G U S T 2 5 , 2 0 1 4

PHYSICIAN ASSISTANT EDUCATION & PRACTICE

PHYSICIAN ASSISTANT (PA) EDUCATION AND PRACTICE

Legislative Health Care WorkforceTestimony: Monday, August 25, 2014

Heather KT Bidinger MMS PA-CMinnesota Association of Physician Assistants (MAPA)Program Director: St. Catherine University PA Program

Presentation Addressing Key Questions Requested From PA Profession Representation

~input provided by educational programs and professional association members~

WHAT IS THE STATUS OF PA TRAINING IN MN?

AUGUST 2014

MN PHYSICIAN ASSISTANT (PA) PROGRAMS

• Augsburg College • 1st Program accredited- Continued Accreditation• Started in 1995 and has graduated approx. 475

students

• St. Catherine University• 2nd Program accredited-Provisional; March, 2012• Started 2012 – First graduation- December 2014; 24

students

• Bethel College: • 3rd Program Accredited- Provisional; March, 2013• Started 2013- First graduation-August 2015; 31

students

OTHER PA TRAINING PROGRAMS

*The University WI—LaCrosse/Mayo/Gunderson Program often considered a WI and a MN Program

**College of St. Scholastica is in process of developing a PA training program- Provisional accreditation visit scheduled 2016.

PA GRADUATES NOW AND IN 5 YEARS

Program 2014 2015 2016 2017 2018

Augsburg College 50** 30 24 24 24

Bethel College n/a 31 32 32 32

St. Catherine University 24 32 32 32 32

St. Scholastica* n/a n/a n/a n/a 24

University of WI; 18 19 19 19 19

Total Graduates 92 112 107 107 131

* Pending provisional accreditation visit** Two cohorts due to change in calendaring and graduation

SPECIALTY CARE VS. PRIMARY CARE

WHERE MN PHYSICIAN ASSISTANTS PRACTICE

PA PRACTICE IN PRIMARY CARE

• PAs are educated for General Practice: • Students Don’t Self Select Primary vs. Specialty Care as a standard of

education or training• no required residency• Certificates of Added Qualification (CAQ): new and only in specialties

• Primary Care Definition: • AAPA standard definition includes the practices of: Family Medicine,

General Internal Medicine, General Pediatrics and OB/Gyn Practice

• Data is fluid and can be difficult to obtain • PAs often change practice specialty • Market availability- PAs preferring primary care often take specialty

jobs due to availability and location.

MN PA PRIMARY CARE PRACTICE DATA

• MN Department of Health• MN Primary Care Workforce Report: “All PAs in Primary Care”• National data on state specifics not current, no CAQ

• AAPA Annual Survey- MN Specific 2013• 35.3% Primary Care- of which 30.9% were in Family Medicine

• PA Program Data• Augsburg: Over the past 3 years- average is 56% in primary

care and 54% in specialty care.• U of WI: estimates in last 3 years- 4-7 of each class of 19 are

in primary care: 22-36% • New Programs: no graduates- first data available 2015

METRO VS. RURAL PRACTICE

• MN Department of Health• MN Primary Care Workforce Report: 80% Urban; 20% Rural

• AAPA Data for MN (2013)• 4.5% Practice Settings were at Certified Rural Health Clinic

• Program Specific Data: • Definition of Rural Practice: greater than 50 miles from a major metropolitan

area and population less than 15,000)

- Augsburg: - 12% of graduates/year: closer to 20% in earlier years, but since 2010, staying at

12% of graduates go to rural practice.

- New Programs- no data until graduation and employment

LOCATION OF CLINICAL TRAINING

• MERC data- PA education is included in MERC data

Program Data• Augsburg College Program Data

• Not “rural” as not adequate number of adequate sites• “IN” or “OUT” of 7 county metro area• Predicting for the need of more OUT due to lack of access IN; also anticipating need for more out of

state• 2013: 72% IN 28% OUT and 5% out of state• 2014: 65% IN 35% OUT and 10% out of state

• Bethel• Students are instructed that 30% placements outside of metro-• For students from rural or outlying areas- this % greater

• St. Catherine University• First class in clinic (24) 10% Rural and 90% Urban• Would desire more rural if site availability/opportunity existed• Unable to accommodate 2 students in rural practice from rural home regions

• University of WI; L/M/G• All Family Medicine placements rural; and “others”

WHAT ARE THE TRAINING REQUIREMENTS

PHYSICIAN ASSISTANT EDUCATION

OVERVIEW OF PA TRAINING

• PA Programs are accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA).

• PAs are educated in a medical model

• PAs are educated in didactic and clinical programs; the curriculum focuses on classroom and laboratory instruction followed by clinical rotations or clerkships.

• PA Programs are considered intense and rigorous. The average length of PA Programs is 28 months, the credit hour equivalents range from 80-120, averaging around 100 credit hours.

• As of 2010, the ARC-PA requires all PA Programs in development to award a masters degree. *Profession has grown from a competency based training.

DIDACTIC TRAINING

• Classroom instruction includes courses in basic, medical and behavioral sciences:

Gross Anatomy Physiology Microbiology Biochemistry Pharmacology Pathology Ethics, Professionalism, Law and Medicine Clinical Medicine Physical Exam Diagnostic Processes

• Students are typically in class 36- 40 hours a week and are delivered year round.

CLINICAL TRAINING

• Students avg. 2000 hours in clinical rotations. (AAPA) • Clinical experiences must allow students to participate

in the care of patients of all ages and in multiple healthcare settings. (ARC-PA)

• Ambulatory• In-patient/hospital based• Surgical• Emergent

• Clinical experiences similar between programs: • Family Practice, Pediatrics, Ob/Gyn, General Surgery, Internal

Medicine, Emergency Medicine, Psychiatry, Electives*

MN PROGRAM TRAINING TIMING

MN PA Programs Total Months

Didactic Months

Clinical Months

Augsburg College 31 18 13

Bethel College 27 15 12

St. Catherine University

28 14 14

University of WI: G/LC 24 12 12

St. Scholastica 24*

*projected

WHAT IS SPENT EDUCATING A PA FROM START TO FINISH

WHERE DO THESE DOLLARS COME FROM?

THE COST OF PA EDUCATION

• Operational/Existing vs. Cost of Program Start Up?

• Operational• Anticipated budget of 1 M to educate a cohort of 30

students (AAPA);• This is in line with Augsburg and St. Kate’s data

• Start Up New Program• Mean start up cost is 1.5 M (PAEA, 2013)• Mean start up cost in 2010 data; (ARC-PA 11/12/10)• .75-1 M without capital improvements • 2-3 M with building or renovation needed for program delivery;

HOW IS PA EDUCATION FUNDED?

Funding of PA Education: 1. Mainly Funded by Student Tuition! 2. Small Amount from endowments or gifting3. National funding- increasingly rare• Ex: HRSA expansion grant – 2012, but included veteran

criteria, not awarded to MN programs

Cost of PA Program Development • Funding by Academic Institution- budget/endowment• Upfront cost 2-3 years prior to student matriculation

ADDITIONAL NEEDS IN PA EDUCATION

Human Resources

• Program Director• Medical Director• Administrative

Support• 2-3+ min. Core Faculty• Adjunct Faculty- areas

of expertise,• Many instructors-

areas of specialty practice

Physical Resources & Equipment

• Classrooms• Laboratory or Physical

Exam Space• Offices• Anatomy Lab- if

dissection==================• Equipment• Supplies

CLINICAL RESOURCE NEEDS

*Average PA Program has 12 month of clinical education and on average 2000 clinical hours.

• Time and Workload intense: 2-3 faculty, admin support

• Can be a direct expense to programs as more clinical sites nationally are requiring payment for training

• Program Specific:• Augsburg: need 330 placements per year; use approximately 70

different sites and over 150 different clinical instructors during that time.

• St. Catherine University: 416 placements per cohort; 1st year of clinical education not completed and will be evaluated in December, 2014

PHYSICIAN ASSISTANT EDUCATION

CHALLENGES, ISSUES, TRENDS

CHALLENGES AND ISSUES IN PA EDUCATION

Challenges:• Quantity of Quality Clinical Education Sites!• Availability of Qualified Faculty• Faculty Demands

Issues: • Local Market Readiness for Graduates• Healthcare Reform; Implementation Unknowns

QUALITY CLINICAL SITE TRAINING AVAILABILITY

• Competition with other HC Students; mainly medicine/APN• Loss of access to rural educational opportunities • Preference of HC facilities: to train one discipline over

another or from one academic institution over another• Centralizing of placements- lost access to provider network• Mergers of small clinics to larger institutions; providers say

yes, system says no• Non-uniform onboarding/credentialing, EMR requirements• Heavy administrative burden • CMS regulations in documentation and billing• Provider productivity; concern that having students impact

income potential; incorporating students into practice flow• MERC money but… no direct revenue or incentive to

providers to train students; no direct funding or payment

PA PROGRAM FACULTY

• Recent Increase of Programs- • Demand exceeding the supply of experienced faculty or

those in clinical practice who may choose income reduction to teach

• Pay scale discrepancies from practice to faculty• New grads are projected to earn more than PA faculty• Loan burden prohibitive to moving roles

• Academic degree requirements; Masters- Doctorate• 1997-98 less than 5 programs offered Masters degrees• (2010) requirement of PA Masters for all Programs

MERC MEETING SUMMARY OF PA MAY 2014

Most Important Issues:1. Quality Clinical Sites2. Quality PA Faculty3. Primary Care Job Availability

Numbers of PAs in MN: 1878

Work Force Needs:4. Conflicting information on workforce needs as delivery of

healthcare is changing with team and home care models5. The need is projected to exceed graduates but graduates not

finding primary care jobs.6. Profession posed to assist in Mental Health shortage but limited

due to reimbursement issues

MERC MEETING SUMMARYMAY 2014

Any Legislative/Practice acts pursued:1. Request for reimbursement for outpatient mental health

patients with MA coverage2. Ratio of MD/PA limit removed; alternate supervisor

Clinical Training Challenges:3. Adequate quality sites4. Heavy administrative burden5. TCCP potential for help- needs work

Clinical Training Finance Issues6. MN Programs in general, not paying for sites7. Out of state students are paying in state for sites- concerning

PA WORK FORCE UNKNOWNS

Additional from MERC:Sustainability of 4 PA Programs in MN?1. 120 PA students per year in the clinic starting in

2017/18, in an already saturated clinical market.2. Does this meet work plan in the state for where

PA can/should be employed

What are Healthcare Organizations Strategic Plans for PA Employment and Models of PA Utilization ?

PHYSICIAN ASSISTANT PRACTICE

CHALLENGES, ISSUES, TRENDS

MN PA PRACTICE: CHALLENGES

• MN Landscape • Distribution of primary care vs specialty job availability• Regional & Organizational preferences between APPs• General misperceptions on supervision & scope of practice• Healthcare reform- unsure of PA utilization changes- when

and what? (Academia can adapt to prepare if known)

• Legislative Initiatives• Rule of Physician to PA ratios removed from statute• Alternate supervising physician at site, not state level• Reimbursement for PAs outpatient MA mental health care

MN PA PRACTICE TRENDS

Trends:• Fewer Primary Care positions available• More PAs still pursing specialty practice• Fewer PAs having worked with underserved • Changes in utilization- unsure of how this will

affect scope of practice, delivery of care, etc.

• In the next 12 months- new to MN= multiple programs graduating students- ? employment rates

CONCLUSION

• PA are trained in general medicine, poised for specialty practice, trained in team based care and can be adaptable to market needs• primary care vs specialty (i.e. mental health, emergency med)• Could better maximize utilization of PAs in practice• In delivery of care models (primary, extension, panel)

• MN PA graduates will over double in the next 12 months.• Unknowns as to the availability of jobs for graduates

despite the calculations of work force needs• Primary challenge of educating PAs is having adequate

clinical education sites- already difficult, not sustainable