Physician Assistant Education & practice

1. Physician Assistant Education & practice Data Presentation- August 25, 2014

2. Physician Assistant (PA) Education and Practice Legislative Health Care Workforce Testimony: Monday, August 25, 2014 Heather KT Bidinger MMS PA-C Minnesota 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~

3. What is the status of PA Training in MN? August 2014

4. MN Physician Assistant (PA) Programs • Augsburg College • 1stProgram 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: • 3rdProgram Accredited- Provisional; March, 2013 • Started 2013- First graduation-August 2015; 31 students

5. 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.

6. PA Graduates Now and in 5 YEARS

7. Specialty Care vs. Primary Care Where MN Physician Assistants Practice

8. 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.

9. 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

10. 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

11. 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”

12. What are the Training Requirements Physician Assistant Education

13. 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.

14. 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.

15. 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*

16. MN Program Training Timing

17. What is Spent Educating a PA from Start to Finish Where do these Dollars Come from?

18. 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;

19. How Is PA Education Funded? Funding of PA Education: • Mainly Funded by Student Tuition! • Small Amount from endowments or gifting • 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

20. Additional NEEDs in PA Education Human Resources Physical Resources & Equipment Classrooms Laboratory or Physical Exam Space Offices Anatomy Lab- if dissection ================== Equipment Supplies • Program Director • Medical Director • Administrative Support • 2-3+ min. Core Faculty • Adjunct Faculty- areas of expertise, • Many instructors- areas of specialty practice

21. 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

22. Physician Assistant Education Challenges, Issues, Trends

23. 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

24. 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

25. 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

26. MERC MEETING Summary of PA May 2014 Most Important Issues: • Quality Clinical Sites • Quality PA Faculty • Primary Care Job Availability Numbers of PAs in MN: 1878 Work Force Needs: • Conflicting information on workforce needs as delivery of healthcare is changing with team and home care models • The need is projected to exceed graduates but graduates not finding primary care jobs. • Profession posed to assist in Mental Health shortage but limited due to reimbursement issues

27. MERC Meeting SummaryMay 2014 Any Legislative/Practice acts pursued: • Request for reimbursement for outpatient mental health patients with MA coverage • Ratio of MD/PA limit removed; alternate supervisor Clinical Training Challenges: • Adequate quality sites • Heavy administrative burden • TCCP potential for help- needs work Clinical Training Finance Issues • MN Programs in general, not paying for sites • Out of state students are paying in state for sites- concerning

28. PA Work Force Unknowns Additional from MERC: Sustainability of 4 PA Programs in MN? • 120 PA students per year in the clinic starting in 2017/18, in an already saturated clinical market. • 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 ?

29. Physician Assistant PRACTICE Challenges, Issues, Trends

30. 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

31. 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

32. 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