A Call for a National Academy of Medicine Study:

Posted on 21st Feb 2022 00:53:11 in Technical Tutorial

Tagged as: primary care medicine, physician assistant, nursing groups, aapa, california acep, physicians, obama care, ama,

PAs for Tomorrow (PAFT) believes that PAs are the logical answer to America’s worsening and ongoing primary care crisis. We believe that the opportunities for PAs as primary care providers are vast and immediately accessible. The PA community has the responsibility to broadly define the future in this specialty.  

 Primary-care providers play a large role in reducing the seriousness of comorbidities. Primary-care providers also reduce emergency room utilization, improve outcomes, and even possibly reduce overall health care spending. Studies have found that higher continuity of primary care–a continuous relationship with a primary care provider–is associated with lower hospital admission rates.

We currently are experiencing a combination of several issues.  First and foremost, the practice of medicine itself has functionally changed. Physicians, physician assistants, and physician groups are frustrated because of NP independence. Physicians, physician organizations, and other groups (including some of our PA colleagues) tend to consider us as Advanced Practice Providers or midlevel providers.  Both terms lump us with advanced nurses, the latter is derogatory.  The time to lump us with medicine, not nursing, is now.

 We believe that for our profession, the passing of the Affordable Care Act (ACA) of 2010 (Obamacare) was an opportunity missed.  Suddenly, an estimated 13 million previously uninsured were required by federal law to have at least basic insurance.  As PAs, we are all trained in primary care medicine and all PA certifications are in primary care. Instead of the AAPA taking the lead and working with the AMA to move into this void, the leaders of AAPA elected to keep with the status quo.  Those early ACA years were the perfect opportunity for our profession to seek independence within primary care. Instead, Nurse Practitioners took advantage and left us behind.

 In 2011, The Institute of Medicine of the National Academies (now National Academy of Medicine) published The Future of Nursing.  The abstract reads in part, “The Future of Nursing explores how nurses’ roles, responsibilities, and education should change significantly to meet the increased demand for care that will be created by health care reform and to advance improvements in America’s increasingly complex health system.”  The nursing profession in general and the Nurse Practitioners, in particular, used this to their advantage, positioning themselves for full independence. 

 PAs are mentioned dozens of times in this report.  In the summary, the NAM hinted at what would eventually become OTP/FPAR, “Data collection and analysis across the health professions will also be essential because of the overlap in scopes of practice for primary care providers such as physicians, physician assistants, and nurse practitioners and the increasing shift toward team-based care.“ 

 While this report mentions PAs, its purpose was to look at the future of NURSING; it had a very slanted position toward nursing and NPs, despite our similar job descriptions. 

 When the AMA passed resolutions 230 and 214 (2017), the AAPA provided inadequate responses.  “Resolution 230, opposed legislation or regulation that allows physician assistant independent practice.” This resolution was offered in response to AAPA’s passing of Optimal Team Practice.

 Responding to AMA’s resolution 230; “Unfortunately, AMA sees Optimal Team Practice as PAs seeking to practice independently and that is simply not the case. With Optimal Team Practice, we are seeking to enhance team practice and patient outcomes by replacing archaic state-required supervisory agreement laws between physicians and PAs with practice-level decision-making about collaboration,” said L. Gail Curtis, PA-C, MPAS, DFAAPA, AAPA President and Chair of the Board.

 The second, Resolution 214, resulted in tasking AMA with convening an in-person meeting of relevant physician stakeholders to initiate the creation of a consistent national strategy to oppose the independent practice and “inappropriate scope of practice expansion” of “non-physician practitioners.”  According to the AAPA, “It is important to note that both these resolutions addressed what is already AMA policy so there is nothing new other than convening an in-person meeting.”

 Nursing, on the other hand, denounced the resolution as fearmongering, blatantly dishonest, and physician protectionist.  The ANA responded directly to the AMA, “This divisive tactic will directly impact the nation’s advanced practice registered nurses (APRNs), and perpetuate the dangerous and erroneous narrative that APRNs are trying to “act” as physicians and are unqualified to provide timely, effective and efficient care. APRNs practice advanced nursing, not medicine, in which they regularly consult, collaborate, and refer as necessary to ensure that the patient receives appropriate diagnosis and treatment.” 

 When it comes to PAs and OTP/FPR, deceit is a way of life of organized medicine.  When the California Academy of PAs was pursuing OTP/FPR in 2019, the California ACEP responded in opposition to the proposed changes.  PAFT responded directly to CA ACEP.  We wrote, in part, “There is a significant difference between legislatively-mandated supervision and collaboration requirements set at the medical organization level.  In fact, legislatively-mandated supervision takes away from the medical director’s and department head’s ability to manage an emergency department, clinic, private practice, urgent care center, or hospital in the manner the medical staff deems best for that practice.”

No matter how we slice and dice the PA future, we will always be in a symbiotic relationship with physicians.  The AMA, AOA, and state medical societies are opposed to FPA in any way shape, or form.  Nursing groups are opposed to PA independence (probably a turf issue), and we saw how this recently played out in Florida.  State medical and nursing lobbies are more politically powerful and influential than ANY PA group, including PAFT, special interest groups, constituent organizations,  and AAPA.  Our PA colleagues tend to be the most apathetic group of medical professionals–many want the changes, but do nothing to work for that change. Advocates for PA “advancement” often say we should work with NPs to move forward; again, I point to Florida–NPs could easily have stated primary care independence should include PAs as well–instead, they threw us under the bus. 

 The changes in medicine overall are significant and go beyond the scope of a “Future of PAs” report.  It is time for the National Academy of Medicine to look at all things medical–an in-depth study on “The Future of Primary Care Medicine.”