Optimal Team Practice: A Q&A with AAPA President L. Gail Curtis
Optimal team practice (OTP) is a policy passed by the AAPA House of Delegates in May 2017 that allows its state chapters to seek changes in state laws that will, among other things, eliminate the legal requirement for PAs to have a specific relationship with a particular collaborating physician in order to practice. PAEA is generally supportive of OTP but believes more work needs to be done to determine how OTP might affect new graduates and therefore how PA education might need to change. A PAEA task force that includes representation from AAPA, as well as from other relevant stakeholder organizations, is working on its charge from the PAEA membership to “address the implications of OTP for PA education and for new graduates as raised in the 2017 PAEA OTP Task Force Report and report back to this body by next year.”
As that task force begins its work, PAEA invited AAPA President L. Gail Curtis, MPAS, PA-C, to respond to some questions on OTP, to help clarify AAPA’s perspective on the issue for the PA education community. Our thanks to her for taking the time to respond in detail to these questions.
PAEA: Since OTP was first announced, there’s been talk about whether OTP represents (or is a step towards) “independent practice” for PAs. AAPA has stated that OTP is not independent practice. What is your “elevator speech” on how OTP differs from independent practice?
CURTIS: Thanks for this important question. First let’s frame discussion about OTP based on what it is rather than what it isn’t. As the very title suggests, OTP or optimal team practice aims to create improved team practice environments. OTP provides a way to allow medical teams flexibility in their response to patient needs. OTP is also about true peer review by PAs on state regulatory boards, and payment for services rendered by PAs. OTP is a new AAPA policy that is being incorporated into the AAPA model state legislation. AAPA has always advocated for access to care for patients and an optimal PA legislative and regulatory environment to allow PAs to practice to the top of their education and experience. The health care environment in our country is changing. Updating our Guidelines for State Regulation of PAs to reflect OTP sets the stage for passage of laws and regulations that allow PAs to continue to effectively and efficiently meet patient needs in this changing environment.
The new policy calls for laws and regulations that:
- Emphasize PAs’ commitment to team practice
- Replace obsolete supervisory agreement laws with practice-level decision-making about collaboration
- Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs
- Authorize PAs to be directly reimbursed by all public and private insurers.
So as you can see, OTP is about team practice — not independent practice. PAs are not seeking to practice independently. The new policy simply seeks to enable a PA to practice without the legal requirement to enter into a supervisory agreement with a physician. OTP calls for a decision about the degree of collaboration between PAs and physicians to be made at the practice level, based on the patient’s condition, the standard of care, and the education and experience of the practicing PA.
PAEA: As you know, at its November meeting the AMA passed two resolutions related to this issue — one labelling OTP “physician assistant independent practice,” and one calling for a meeting of physician stakeholders to “create a consistent national strategy … to effectively oppose the continual, nationwide efforts to grant independent practice … to non-physician practitioners.” We also heard strong concerns about OTP voiced by medical directors at their retreat at the PAEA Education Forum. What are the next steps that the PA community can take with the AMA and the broader physician community to build shared understanding about how OTP might advance the physician-PA team relationship and improve patient care?
CURTIS: In regard to the AMA resolutions, Resolution 230 called on AMA to oppose “independent” practice by PAs. Resolution 214, which initially opposed an interstate compact for NPs, was amended to oppose independent practice by all “non-physicians” and called on AMA to convene a meeting to develop a national opposition strategy. Both resolutions were passed by the AMA House of Delegates in November. As we noted in our November 21 statement, Resolutions 230 and 214 confirmed existing AMA policy, so there is nothing new other than convening an in-person meeting. Prior to the adoption of OTP, we reached out to a number of physician organizations. Over the course of the many months of Task Force deliberations, changes were made to address concerns raised by physicians and other groups. Although we have seen some hesitation from organized medicine, individual physicians who practice with PAs should appreciate the benefits of OTP, which will allow more time to be spent on enhancing team-based patient care while not holding a physician responsible for PA-provided care.
Additionally, AAPA has strong working relationships with a variety of national physician and medical specialty organizations. AAPA’s medical liaisons — who are all PA volunteers — are important players in our ongoing relationships with these critical healthcare partners. We continue to discuss with our PA medical liaisons how best to communicate with physician organizations about this new policy. And we are providing them with the tools they need to do so.
We also understand that PAs across the country may want to talk to physicians they work with about the new policy. AAPA has developed materials to help, including infographics, fact sheets and issues-in-brief, which can be found on our website.
I think that sometimes we have the most productive communication with physicians when we talk about how things work in the clinical setting. Let me run through a couple of clinical scenarios with you.
Here’s the first: A group of PAs employed by a health system does home visits on patients post-discharge. The PAs communicate their findings and discuss treatment with the physician (or PA, for that matter) who cared for the patient in the hospital. The care is seamless and integrated and team-based.
Here’s another one: A new grad PA is employed by a hospitalist service. There is an extensive orientation and onboarding process for the newly hired PA who reports to the chief PA. All the PAs employed by the service work with the physician hospitalist team, collaborating and conferring as required by the patient’s condition and the experience and competence of each PA. Naturally the new grad PA will require more consultation than the seasoned members of the team, in most cases. However, if this new grad was a PT prior to PA school, this PA may be the “expert” on the team in some rehab matters. Again, that’s high quality team-based care, with each team member contributing at the top of their expertise and experience. How does having a legal supervisory agreement with a physician or group of physician improve the care in these two scenarios? If anything, these administrative burdens could slow down the care for patients.
PAEA: As shown by our surveys, there is some disconnect between AAPA and the PA education community regarding the potential impact of OTP on PA education. What do you think accounts for this disconnect?
Note: The results of PAEA’s surveys of program directors, medical directors, and past presidents can be found in the report, Optimal Team Practice: The Right Prescription for All PAs?
CURTIS: As an educator myself, I’m not sure, but perhaps it is a misunderstanding of the new policy and worry about the new graduate. In convening our task force, we wanted to ensure a broad perspective of views was represented. We included PA educators and rural and urban clinicians practicing in small and large healthcare settings, including the VA. Optimal team practice will not change the role of the PA, which is well established. PAs will continue to confer with, collaborate with, and refer patients to physicians just as they do now. PA practice has been extensively studied and evaluated, and found to produce high-quality patient outcomes. State laws and regulations have simply not kept pace, and this new policy is an opportunity to change that.
As for the new graduate, nothing will change here either. There must be more supervision of a new graduate and an onboarding period where everyone on a team learns the strengths of all team members. Let’s say a new graduate was a registered dietitian prior to PA school, I think everyone on the team would agree that this PA could offer superior nutrition counseling for patients on day one of practice, likely better than any other team member. On the other hand, if this new graduate had no experience other than that received in PA training; there may be a more capable team member to deliver that nutrition counseling. PAs are trained to recognize their knowledge base and when they need to consult. This will not change. Our current PA training programs graduate highly capable, compassionate PAs who deliver patient-centered care, make significant contributions to the healthcare community, and continually advance the PA profession.
While I do not believe that OTP requires a change to PA education, I do think we can expect that changing demographics in our applicant pool and the realities of the healthcare marketplace will drive changes to PA education. As the group gathered at PAEA’s 2016 Stakeholder Summit recognized, PA education must continually evolve to meet marketplace needs and practice realities.
PAEA: In 2018, PAEA will assemble a task force to further investigate this potential impact of OTP on PA education. From AAPA’s point of view, what are the three most critical policy points for the task force to consider as it begins its work?
CURTIS: Under OTP, PAs will have to determine when they need to seek input or backup. This is really no different from the way PAs practice now. I think one thing the task force could consider is whether or not we are selecting PA school applicants who have the requisite capacity for self-reflection and self-knowledge. We are all aware that applicants are younger and have less hands-on experience than in the past. And secondly, perhaps, how do we reinforce these skills among our students. Also, with increased competition for clinical rotation sites for all medical learners, we need to ensure that rotations are robust and offer our students comprehensive curricular objectives.
Under the new policy, new graduates and early career PAs, as well as PAs who are changing specialties, would continue to practice in teams with physicians, and their scope of practice would be determined at the practice level. Regardless of whether a PA is early career, changing specialty, or simply encountering a condition with which they are unfamiliar, the PA is and will continue to be responsible for seeking consultation as necessary to assure that the patient’s treatment is consistent with the standard of care. This is part of the definition of a professional — to take responsibility for assuring that the patient’s care is appropriate. As a profession, this is not new for PAs. New graduate PAs and PA employers are always responsible for assuring that there is adequate access to consultation and back-up. Just as a general internist would not practice neurosurgery, PAs will not practice outside of their education and experience. If they do, regulatory boards will take appropriate action (just as they would for the internist practicing neurosurgery). Finally, I think the task force could evaluate is how to teach our students the best methods for seeking input and what to expect of team members … what do you do in advance and how to best communicate critical information.
Note: AAPA will also be considering issues around how OTP will affect new graduates through its Early Career PA Commission, on which PAEA VP Sara Fletcher, PhD, participates in an advisory role.
PAEA: What are the milestones that AAPA has established for state implementation of OTP over the next 12, 24, and 36 months?
CURTIS: AAPA is not dictating the pace of OTP implementation. Each state PA chapter will decide whether and when to pursue these changes to state laws and regulation, at their own pace and as the environment in their state allows. In fact, some states were moving in this direction prior to passage of OTP and others are still working on obtaining key elements of the Guidelines for State Regulation of PAs. AAPA is already working with state chapters to provide resources, guidance, and support as they work to have these and all policies adopted into law.
OTP represents a natural progression for the profession, but new ground nonetheless. While we are working tirelessly to support this new policy, it would, in my view, be unwise to establish milestones in these early days.
PAEA: What does success for OTP look like and what role can the Four Orgs play in contributing to that success?
CURTIS: Success for OPT looks like success for patients. OTP creates strong capable teams where all team members can offer the best possible care for each and every patient. It is also important to ensure that our profession is positioned to continue the success of the first 50 years. It’s critical that PAs are not passed over for jobs because of the perception that NPs are easier to hire. Leaders in the Four Organizations can help with that by clear and consistent communication about OTP. But OTP isn’t just about the PA profession. When PAs and physicians can practice together without unnecessary administrative or liability concerns, it will expand access to quality medical care for people across the country.
L. Gail Curtis, MPAS, PA-C, DFAAPA, serves as president and chair of the American Academy of PAs. She is chair and associate professor at the Wake Forest University School of Medicine’s Department of PA Studies, where she has been on the faculty for more than 25 years.