Minnesota Physician Assistant Employment

Guide

Developed by the Minnesota Academy of Physician Assistants.

Revised June 2008

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Table of Contents

Introduction page 3

Facts about Physician Assistants page 4 Scope of Practice Spectrum of Practice Settings page 5 Spectrum of Practice Settings page 5 Benefits of hiring a PA page 5 Physician Assistant Registration

in Minnesota page 6 Prescriptive Authority page 7 PA Education page 7 Certification page 8

The Physician PA Team page 8Cost/Benefit Analysis page 9

Fee-for-Service Model page 9 Managed Care Model page 10

Medicare Coverage for Physician Services Provided

by PAs. Page 11 Billing Under “Incident To” Guidelines page 12

Updated Hospital Billing GuidelinesMedicare and Shared Visits page 12

Summary of Medicare Reimbursement page 13Practice Ownership by Physician Assistants page 14Medicaid Reimbursement page 14Private Insurance Reimbursement page 14TRICARE (formerly CHAMPUS) page 15Physician Assistants in Hospital Practice: page 15

Privileging Physician Assistants page 16 Credentialing Physician Assistants page 16 Reappointment/Reprivileging page 17 Information that may be gathered for

credentialing and privileging of physician assistants page 17

Medical Staff Membership page 18Employment Contracts and Agreements page 19Rural Health Clinic Guidelines

for Physician Assistants page 21Indian Health Service Employment

of Physician Assistants page 22Resource Guide page 24

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Minnesota Physician Assistant Employment Guide

This employment guide is designed to provide information that will help you in your efforts to employ or be employed as a physician assistant (PA) in the state of Minnesota. We have included information about PA education, scope of practice, reimbursement, insurance, salary and practice settings.

The benefits of having a PA in your practice are listed, as well as information from independent groups such as the Medical Group Management Association. (MGMA)An e-mail link to Minnesota Statute 147A, the statute governing PA practice in Minnesota, is also included for your reference, as are other links that may be useful to you.

We encourage you to contact the Minnesota Academy of Physician Assistants (MAPA) or the American Academy of Physician Assistants (AAPA) if you have further questions.

Contact information is at the end of this document.

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MINNESOTA PHYSICIAN ASSISTANT EMPLOYMENT GUIDE

FACTS ABOUT PHYSICIAN ASSISTANTSWhat is a Physician Assistant (PA)?

Physician assistants are health care professionals licensed (registered in Minnesota), to practice medicine with physician supervision. As part of their comprehensive responsibilities, PAs conduct physical exams, diagnose and treat illnesses, order and interpret tests, counsel on preventive health care, assist in surgery, in Minnesota, can write prescriptions. What a physician assistant does varies with training, experience, and state law. In addition, the scope of the PA's practice corresponds to the supervising physician's practice. In general, a physician assistant will see many of the same types of patients as the physician. The cases handled by physicians are generally the more complicated medical cases or those cases which require care that is not a routine part of the PA's scope. Referral to the physician, or close consultation between the patient-PA-physician, is done for unusual or hard to manage cases. Physician assistants are taught to "know our limits" and refer to physicians appropriately. It is an important part of PA training.

Scope of Practice

Physician assistants work in the context of a physician / PA team to offer a wide array of services in primary care, as well as specialty areas of medicine including surgery and the surgical subspecialties. Minnesota Statute 147A.09, Subdivision states “Physician assistants may perform those duties and responsibilities as delegated in the physician-physician assistant agreement….patient service must be limited to services within the training and experience of the physician assistant (or) services customary to the supervising physician”. A physician assistant works as a member of the medical team performing duties within the scope of practice of the supervising physician. This relationship allows for a broad range of services, including, but not limited to:

Patient histories and physical exams;

A variety of diagnostic studies to form a diagnostic impression; Initiation and management of

therapies for acute or chronic health problems; health screens, preventative care,

patient education and counseling;

minor surgical procedures assisting with surgery, ER, acute hospital and long-term care;

family planning, perinatal and gynecological care;

referral and follow-up care with physician specialists; and issuing prescription orders for

medications.

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An advantage of employing physician assistants is the ability of PAs to work in a diverse number of clinical and hospital settings. This is a consequence of the broad medical training all physician assistants receive, with the flexibility and capability to learn new areas of medicine as they develop in their careers.

The supervision requirements referred to above allow a PA to practice at sites remote from the supervising physician, as long as communication between team members is available for consultation. It is not uncommon for a physician assistant to practice at a facility some distance away from the supervising physician. The supervisory agreement also allows for alternate licensed physicians to serve as a supervising physician.

Spectrum of Practice Settings

Physician Assistants can be found in all areas of health care including specialty care. In clinic settings they perform physical exams, diagnose and treat illnesses, order and interpret diagnostic tests, and prescribe medications. Hospitals utilize PAs in the emergency room and urgent care settings as well as members of the hospitalist team. PAs are part of the collaborative effort in providing timely and high quality care to long-term care patients in outpatient and nursing home settings. As an integral member of the surgical team, PAs serve as first assistants during surgery, and perform routine preoperative and postoperative follow-up care for surgical patients

Physician Assistants are a part of the solution to address the unmet health care needs of millions of Americans. By working with licensed physicians in a family practice setting, a rural clinic or as a first-surgical assistant in the operating room, physician assistants offer an economical and efficient means of delivering high quality health care to many underserved patient populations.

Benefits of hiring a PA

This broad range of practice settings can help explain the strong demand for physician assistants and the tremendous growth in the number of practicing PAs from less than 1,500 in 1973 to more than 56,000 PAs today. Medical practice managers and physicians often cite the following benefits that physician assistants can bring to an organization:

Better patient flow. PA Education qualifies PAs to meet the unexpected needs of the clinic setting, including walk-ins, urgent care cases, and routine follow-up visits such as blood pressure checks and medication reviews.

Shorter waiting time for appointments. Patients have the option of seeing the PA when the physician is not available. This leads to greater patient satisfaction with greater availability of care.

Greater emphasis on prevention and patient education. PAs are recognized for their ability to spend time with patients on education, counseling, and preventative care for problems.

Ability to extend care into the community. Physician Assistants can extend care in rural communities, medically under-served communities, and nursing homes helping to extend access to physician services.

Enable physicians to focus on difficult problems. Perhaps one of the greatest benefits provided by a PA is the ability to shift the workload. He or she can handle routine office visits, freeing physicians to handle more complex or challenging problems.

Professional fellowship. For solo physicians, especially those in a rural or frontier setting, a physician assistant can provide a professional colleague that may otherwise be unavailable.

Easing physician workload. Achieving greater practice efficiency by employing PAs is supported by the American Medical Association’s Socioeconomic System survey, which in 1994 measured the benefits of employing “non physician practitioners” (NPPs) including PAs, nurse practitioners, clinical nurse specialists, and certified nurse-midwives. The survey found that solo practice physicians experienced expanded practice, greater efficiency, and greater access to care for their patients when they employed a NPP. Physicians who employed NPPs, were able to work one week less per year on average, while supplying more hours in office visits and patient care and increasing net income by 18 percent. Of the four NPP groups in the study, PAs rated highest in terms of patient productivity and patient acceptance.

Flexibility Because PAs receive strong clinical education, they are ready to serve in many health care settings.

Cost Effectiveness When PAs are fully utilized, the health care system, institutions and individual practices can realize considerable savings. According to the Medical Group Management Association (MGMA) PAs generate revenues covering far more than what their compensation costs employers. According to MGMA data from 2002, for every dollar of charges a primary care PA generates for the practice, the employer pays on average, 28 cents to employ the PA. For surgical PAs that cost is 32 cents.

Boosting Patient Satisfaction Recent studies by the Kaiser Permanente Center for Health Research found patient satisfaction levels with PAs high, ranging between 89 and 96 percent. Aspects of patient satisfaction examined by the study included interpersonal care, confidence in provider, and understanding of patient problems. (The Permanente Journal, Summer, 1997)

Physician Assistant Registration in MinnesotaTo practice medicine as a physician assistant in Minnesota, registration with the Minnesota Board of Medical Practice is required. The following requirements for permanent registration include: 1) current certification from National Commission on Certification of Physician Assistants; 2) physician-physician assistant agreement,

internal protocol and prescribing delegation (if prescribing authority is delegated) forms on file; and 3) is not under current discipline as a physician assistant unless Board considers condition for registration.

Forms for these agreements can be obtained via the internet at www.bmp.state.mn.us.

There are several options for a limited type of registration. A temporary permit is available to applicants who meet all the requirements for permanent registration and wish to practice before final approval is granted by the Board. Temporary registration is valid for a period of up to one year and is available to applicants who have recently graduated from a physician assistant program and meet all the permanent registration requirements, but have not yet taken and passed the National Commission on Certification of Physician Assistants examination. A locum tenens permit is available to registered physician assistants who wish to practice as a physician assistant in a setting other than the practice setting established in the physician-physician assistant agreement. The maximum duration of the locum tenens permit is one year and may be renewed annually.

Prescriptive AuthorityIn Minnesota, statutory authority enabling physician assistants to write prescriptions for legend drugs was passed in 1991. A license from the Drug Enforcement Agency is required for prescribing narcotics. The regulatory statute requires the physician-physician assistant team to review on a regular basis the prescribing practice of the PA.

PA EducationPhysician assistants are educated in intensive medical programs accredited by the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The average PA program curriculum runs approximately 26 months. The typical applicant already has a bachelor's degree (64% of entering PA students) and approximately 4 years of health care experience. There are currently more than 130 accredited programs. All PA programs must meet the same ARC-PA standards.

The relationship between PAs and physicians begins in PA school where physicians, PAs and others, provide instruction in a curriculum following the medical school model. PA students typically share classes, facilities, and clinical rotations with medical students. Because of the close working relationship PAs have with physicians, PAs are educated in a medical model designed to complement physician training. PA students are taught, to diagnose and treat medical problems.

Education consists of classroom and laboratory instruction in the basic medical and behavioral sciences (such as anatomy, pharmacology, pathophysiology, clinical medicine, and physical diagnosis), followed by clinical rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology, emergency medicine, geriatric medicine, psychiatry and other elective specialties.

Minnesota has one PA training program at Augsburg College. Thirty-six months in length, it accepts 28 students a year. The Augsburg Physician Assistant Program was granted re-accreditation in October 1999. With the class starting in May 2001 the program became a masters program. Graduates receive a Master of Science in Physician Assistant Studies and a PA Certificate.

Minnesota is also affiliated with the University of Wisconsin, La Crosse/Mayo PA program. This program also confers a Masters of Science Degree in Physician Assistant Studies.

Certification

Upon graduation, physician assistants take a national certification examination developed by the National Commission on Certification of Physician Assistants (NCCPA). The NCCPA is an independent organization, and the commissioners represent a number of different medical professions. It is not a part of the PA professional organization, the American Academy of Physician Assistants (AAPA). To maintain that "C" after "PA", a physician assistant must log 100 hours of continuing medical education every two years and pass the recertification exam every six years.

A number of postgraduate PA programs exist, with specialty training in Dermatology, Family Practice, Emergency Medicine, Neurosurgery, Oncology, Orthopedic Surgery, Pediatrics, Psychiatry, Rural Primary Care, Surgery and Urology.A PA’s education is ongoing after graduation through the continuing medical education requirements and continual interaction with physicians and other health care providers.

The Physician PA Team

The traditional relationship between PAs and physicians, the hallmarks of which are frequent consultation, referral and review of PA practice by the supervising physician, is one of the strengths of the PA profession.1 PAs are committed to the concept of the physician-PA team. The AAPA has this clearly stated in the AAPA policy on team practice: The AAPA believes that the physician-PA team relationship is fundamental to the PA profession and enhances the delivery of high quality health care. As the structure of the health care system changes, it is critical that this essential relationship be preserved and strengthened.2 Because they train using similar curriculum, training sites, faculties and facilities, physicians and PAs develop a similarity in medical reasoning

1 The Pew Health Professions Commission. Charting a Course for the Twenty-First Century- Physician Assistants and managed Care. San Francisco. USCF Center for the health Professions.2 American Academy of Physician Assistants. 2006-2007 Policy Manual. Alexandria, VA.

during their schooling that eventually leads to homogeneity of thought in the clinical workplace.3

Other organizations also have policies supporting team practice. In 1995 the American Medical Association adopted Guidelines for Physician/ Physician Assistant Practice. The 10 guidelines describe the roles of the physician and the PA, including the following:

The role of the physician assistant(s) in the delivery of care should be defined throughmutually agreed upon guidelines that are developed by the physician and the physicianassistant and based on the physician’s delegatory style. The American Academy of Family Physiciansrecognizes the value of team practice. AAFP policy states:

The AAFP recognizes the dynamic nature of the health care environment and the importance of an interdependent team approach to health care that is supervised by a responsible licensed physician.

Cost/Benefit AnalysisThe following tables provide two compelling examples of the financial benefits of a physician/PA team. Revenues for this analysis are from all professional services, excluding diagnostic services such as laboratory tests and radiology procedures. Only certain variable expenses are included, such as salaries and fringe benefits, for a physician, a PA and medical assistants. Malpractice premiums have also been included. This analysis has been simplified to clearly show the variability in contribution to overhead expenses under both a traditional fee-for-service operating environment and under a 100 per cent capitated payment arrangement.

Financial data for this analysis was drawn from the Medical Group Management Association 2000 Cost Survey, the 2000 Physician Compensation and Production Survey, and actual data from various medical practices.

Fee-for-Service ModelTable I below illustrates the traditional fee-for-service model. Column 1 with a single physician staff results in a contribution margin of $84,200. Table I, column 2 presents the same traditional fee-for-service arrangement but includes a physician assistant provider in addition to the original physician.

(1) (2) (3)Physician Only Physician/PA

TeamDifference

3 White GL, et al. Physician Assistants and mississippi. J Miss St. Med Assn 1994; 25:353.

REVENUES

Gross charges- Physician $395,000 $395,000 $-0-Gross charges-PA -0- 211,000 211,000Adjustments -Physicians (25%) (98,000) (98,000) -0-Adjustments-PA (30%) -0- (63,000) (63,000)

Total Net Revenue 296,200 443,900 147,700

VARIABLE EXPENSES

Salary & fringes-Physician 180,000 180,000 -0-Salary & fringes- PA -0- 73,600 73,600Salary & fringes-Medical Assistant

25,000 25,000 -0-

Malpractice insurance-Physician 7,000 7,000 -0-Malpractice Insurance-PA -0- 700 700Total Variable Expenses 212,000 311,300 99,300

Contribution to Overhead $84,200 $132,600 $48,400

Based on the data presented above, the PA can add $147,700 in net revenue, $73,600 in salary and fringe benefit cost, a medical assistant at $25,000 in annual cost, and roughly $700 in malpractice insurance premiums. The net computed increase in contribution margin as a result of adding a PA is $48,400. The new contribution to overhead for the two providers has increased to $132,600.

MANAGED CARE MODEL

Table II illustrates a much different environment consisting of a prepaid (capitated) HMO patient population. Revenue is depicted as fixed payments of $15 per member per month for the patient panel. In Table II, column I, with a panel of 2,400 health plan members, total net capitated revenue for the year is estimated at $432,000. Associated variable expenses are $212,000 leaving a net contribution of $220,000. In column 2, there is an addition of a PA, but together both providers are still managing the same panel size. Obviously the contribution will drop commensurate with the additional costs of the PA and support staff. In columns 3 and 4, the panel is shown to increase by 600 members each, resulting in increased capitated payments and a higher contribution margin. In column 4, representing a panel size of 3,600, the contribution has grown to $336,700 or more than 50 percent of the net revenue.

Medicare Coverage for Physician Services Provided by PAs.The first Medicare coverage of physician services provided by physician assistants was authorized by the Rural Health Clinic Services Act in 1977. In the following two decades, Congress incrementally expanded Medicare Part B payment for services provided by PAs authorizing coverage in hospitals, nursing facilities, rural Health Professional Shortage Areas and for first assisting at surgery. In 1997, however, the Balanced Budget Act extended coverage to all practice settings at one uniform rate.

As of January 1, 1998, Medicare pays the PAs’ employers for medical services provided by PAs in all settings at 85 percent of the physician’s fee schedule. This includes hospitals (inpatient, outpatient, and emergency departments), nursing facilities, home, offices and clinics, and first assisting at surgery. Assignment is mandatory and state law determines supervision and scope of practice.

As of October 25, 2002, CMS issued new rules giving PAs and their physicians increased latitude in hospital and office billing for E/M services. The new requirement (Medicare Transmittal 1776) will allow PAs and physicians who work for the same employer/entity to share visits made to patients the same day with the combined work of both billed under the physician’s provider number at 100 percent of the fee schedule. That is, if the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician.

Table IIManaged Care ModelSample Analysis

(1)Physician(2,400 Panel)

(2)Phys./PA(2,400 Panel)

(3)Phys./PA(3,000 Panel)

(4)Phys./PA(3,600 Panel)

REVENUESCapitated payments $432,000 $432,000 $540,000 $648,000Total Net Revenue 432,000 432,000 540,000 648,000

VARIABLE EXPENSESSalary & fringes-Physician 180,000 180,000 180,000 180,000Salary & fringes-PA -0- 73,600 73,600 73,600Salary & fringes-MedicalAsst.

25,000 25,000 25,000 25,000

Salary & fringes-Medical Asst -0- 25,000 25,000 25,000Malpractice Insurance-Physician 7,000 7,000 7,000 7,000Malpractice Insurance-PA -0- 700 700 700Total Variable Expenses 212,000 311,300 311,300 313,000

Contribution to Overhead $220,000 $120,700 $228,700 $336,700

This new rule does not extend to procedures. The practitioner who does the majority of the procedure is the one under whom the procedure should be billed. If the physician does not provide some face-to-face portion of the E/M encounter, then the service is appropriately billed at the full fee schedule amount under the PA’s PIN with reimbursement paid at the 85 percent rate.

Billing Under “Incident To” GuidelinesOutpatient services provided in offices and clinics may still be billed under Medicare’s “incident-to” provisions, if Medicare’s restrictive billing guidelines are met. This allows payment at 100 percent of the fee schedule if: (1) the physician is physically on site when the PA provides care; (2) the physician treats all new Medicare patients (PAs may provide the subsequent care); and (3) established Medicare patients with new medical problems are personally treated by the physician (PAs may provide the subsequent care). According to the Balanced Budget Act, PAs (using the 85 percent benefit) may be either W-2, leased employees or independent contractors. The employer would still bill Medicare for the services provided by the PA. All PAs who treat Medicare patients must have a provider identification number (PIN).

Updated Hospital Billing GuidelinesMedicare and Shared Visits

As of October 25, 2002, new rules championed by AAPA give PAs and their supervising physicians increased latitude in billing for evaluation and management (E/M) services provided in the hospital setting. Responding to concerns expressed by AAPA and other medical specialty groups, the Centers for Medicare and Medicaid Services (CMS) substantially altered its policy involving the coverage of E/M hospital services when provided jointly by a PA and a physician to the same patient.

The new policy, detailed in Medicare Transmittal 1776, allows E/M services provided by a PA and a physician in the hospital (inpatient, outpatient, or in the emergency department) to be combined for billing purposes when delivered to the same patient on the same day. The combined services may be billed under the name and Medicare provider identification number (PIN) of the physician at 100 percent of the fee schedule, as long as the physician provides some portion of the E/M service during a face-to-face encounter with the patient. The policy also requires the physician and PA to work for the same employer, practice, or hospital.

This allows PAs and physicians to share visits made to patients with the combined work of both covered at 100 percent of the fee schedule. That is, if the PA provides the majority of the service for the patient and the physician provides any face-to-face portion of the E/M encounter, the entire service may be billed under the physician’s name and PIN. The new rule does not extend to procedures performed in the hospital. The practitioner who does the majority of a procedure is the one under whose name and number the procedure should be billed.

Remember: To combine the professional work done by a PA and a physician, the following guidelines must be followed:

The PA and the physician must work for the same employer.

The regulation applies only to E/M services delivered in the hospital and not to procedures.

The physician must provide some face-to-face portion of the E/M services. Simply reviewing or signing the patient’s chart is not sufficient.

“Incident to” billing has never applied to the hospital setting – and still does not apply.

If the physician is not present for any of the face-to-face portion of the E/M encounter, the service is appropriately billed under the PA’s name and Medicare PIN, with reimbursement at the 85 percent rate. When billing for hospital services provided by PAs under the PA’s name and PIN, Medicare does not require the on-site presence of the supervising physician; access to telephonic communication is sufficient. AAPA has reimbursement specialists on its staff to answer specific questions concerning proper billing for services provided by PAs. If you have a reimbursement problem or question, write to michael@aapa.org.

Summary of Medicare Reimbursement

SETTINGSUPERVISION REQUIREMEN

T

REIMBURSEMENT RATE

SERVICES

Office/Clinic when physician is not on site

State Law85% of physician’s fee schedule

All services PA is legally authorized to provide that would have been covered if provided personally by a physician

Office/Clinic when physician is on site

Physician must be in the suite of offices

100% of physician’s fee schedule 1 Same As Above

Home visit/ House Call

State Law85% of physician’s fee schedule

Same As Above

Skilled Nursing Facility & Nursing Facility

State Law85% of physician’s fee schedule

Same As Above

Hospital State Law85% of physician’s fee schedule

Same As Above

First assisting at surgery in all settings

State Law85% of physician’s first assist fee schedule2

Same As Above

Federally Certified Rural Health Clinics

State Law Cost-based reimbursement

Same As Above

HMO3 State Law Reimbursement is on capitation basis

All services contracted for as part of an HMO contract

1 Using carrier guidelines for "incident to" services.2 i.e. 85% x 16% = 13.6% of surgeon’s fee.

Practice Ownership by Physician AssistantsEffective April 1, 2002, the Centers for Medicare and Medicaid Services issued new Medicare Carriers Manual instructions that expand employment and practice ownership opportunities for PAs. The new policy removes a restriction on PA ownership by allowing a PA to have up to a 99 percent ownership interest in an approved corporate entity (e.g., a professional medical corporation) that bills the Medicare program. Previously, CMS prevented payment to corporate entities in which a PA had any ownership interest. Medicare requires that at least one percent of the corporation be owned by someone other than the PA (e.g., the PAs spouse). There is no requirement for any degree of physician ownership of the corporation. The new policy also removes a provision that prohibited Ambulatory Surgical Centers from employing PAs.

Medicaid ReimbursementIn Minnesota, reimbursement under Medical Assistance is 90% of the physician reimbursement schedule, to those PAs who are registered with the Department of Health as qualified providers. If the PA is not registered with the Department of Health the reimbursement is 65%.

Private Insurance ReimbursementMost insurance companies now credential PAs and billing is done under their provider number. The reimbursement rate is negotiated in the contract the employer has with the insurance company. In most cases it is the same rate as the supervising physician.

Private insurers generally cover medical services provided by PAs when they are included as part of the physician's bill or as part of a global fee for surgery.

TRICARE (formerly CHAMPUS)TRICARE, formerly know as the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), covers all medically necessary services provided by a physician assistant. The PA must be supervised in accordance with state law. The supervising physician must be an authorized TRICARE provider. The employer bills for the services provided by the PA.

The allowable charge for all medical services provided by PAs under TRICARE Standard, the fee-for-service program, except assisting at surgery, is 85% of the allowable fee for comparable services rendered by a physician in a similar location. Reimbursement for assisting at surgery is 65% of the physician's allowable fee for comparable services.

PAs are eligible providers of care under TRICARE’s two managed care programs, TRICARE Prime and Extra. TRICARE Prime is similar to an HMO. TRICARE Extra is run like a preferred provider organization in which practitioners agree to accept a predetermined discounted fee for their services.

Physician Assistants in Hospital Practice:Credentialing and Privileging

Although PAs can be found working almost anywhere in a hospital, primarily they practice in emergency departments (25%), operating rooms (23%), outpatient units (20%), critical care or intensive care units (4%), and other inpatient units (18%). The level of physician supervision required is defined in state law and in hospital policy. All state laws allow the flexibility of off-site supervision by physicians as long as they are available to the PA via telecommunication. In developing their supervision policies, most hospitals choose to follow state law; however, they do have the option of being more stringent (but not less) than the requirements of law. (Federally employed PAs are governed by federal agency guidelines, rather than state law.)

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) medical staff

standards, that took effect in January 2004, require hospitals to credential and privilege PAs through the medical staff or by another “equivalent process.”Prior to January 2004, hospitals had the option of credentialing PAs through the human resources department and allowing them to practice with only a job description, rather than privileges.Bylaws should stipulate that all clinical privileges granted to PAs be consistent with all applicable state laws and regulations and that a PA may provide medical services that are within the scope of practice of the supervising physician. More detailedinformation about amending hospital bylaws is available at the American Academy of Physician Assistants web site www.aapa.org, and then by clicking on the PA Licensing link that leads to the Professional Issues link. A recent update on Hospital Practice and PAs is available at:  http://www.aapa.org/gandp/pro-issues.html#hosp

Privileging Physician Assistants

To provide patient care in the hospital, PAs and their supervising physicians must seek delineation of their clinical privileges. The criteria for granting clinical privileges to PAs should be outlined in the medical staff bylaws. The bylaws should include a definition of physician assistant, generally conforming to the definition used in state law and to the general definition of a PA used by the American Academy of Physician Assistants. An example might be as follows:A physician assistant (PA) is an individual who is a graduate of a physician assistant program accredited by the Accreditation Review Commission on Education for the Physician Assistant or by one of its predecessor agencies (the Committee on Allied Health Education and Accreditation or the Commission on Accreditation of Allied Health Education Programs); and/or who is certified by the National Commission on

Certification of Physician Assistants; and who is licensed, registered, or certified to

practice medicine with physician supervision.

Credentialing Physician Assistants

Hospitals that wish to grant privileges to a PA should verify that the individual is properly licensed, certified, or registered by the state and has adequate liability insurance. Credentials verification should include queries of the National Practitioner Data Bank (NPDB) for malpractice information and the Federation of State Medical Boards (FSMB) for records of disciplinary actions taken against the PA. The American Medical Association’s (AMA) Physician Profile Service also offers PA credentials verification. For a nominal fee, credentialing professionals can confirm a PA’s education program attendance and graduation date, national certification number and status, current and historical state licensure information, and AAPA membership status. JCAHO has deemed that the education information and national certification data are equivalent to primary source information. To credential PAs, many hospitals adapt their physician forms and criteria to create a parallel process for PAs. The criteria usually are defined in the medical staff bylaws or in an associated policy and procedures manual. On demonstration of satisfactory training and experience, and after approval by the hospital board or designated individual, a PA may be granted privileges with supervision of a physician(s) who has appropriate privileges.

Reappointment/Reprivileging

As with physicians, hospital bylaws should specify a time period for the renewal and revision of physician assistant privileges and reappointment to the medical staff.The medical staff should evaluate information provided by physician supervisors and physician assistant peers on the PA’s professional performance, including technical and clinical skills. They also should evaluate information on performance improvement, including continuing medical education and other courses completed. The PA’s scope of practice should be updated as changes in clinical privileges are made. Queries to the NPDB and FSMB should be made any time privileges are renewed, revised, or expanded.

Medical Staff Membership

Medical staff bylaws identify the categories of providers eligible for membership. AAPA believes that PAs should be members of the medical staff because they provide medical care. While their authority to provide care is delegated by a supervising physician, PAs exercise a high level of decision making and autonomy in day-to-day practice. The AAPA recommends that medical staffs credential and privilege all PAs and include them as members, with all of the committee involvement, quality measures, and peer review

that are part of medical staff oversight. Both Joint Commission standards and Medicare and Medicaid Conditions of Participation for Hospitals allow PA membership on medical staffs. For a review of Minnesota statutory regulations regarding staff membership, refer to: http:www.revisor.leg.state.mn.us/data/revisor/arule/2004/4640 .

Additional Resources

AAPA’s publication, Physician Assistants and Hospital Practice, offers a sample application for PA clinical privileges and detailed information about hospital bylaws, PAs and EMTALA, relevant Joint Commission standards, and more. The publication, providing nuts-and-bolts tools to ease the process of credentialing and privileging PAs, is available to AAPA members for $25 and to nonmembers for $50. Copies may be ordered online at www.aapa.org/aapastore or by calling 703/787-8044.American Academy of Physician AssistantsDepartment of Government & Professional Affairs950 North Washington StreetAlexandria, VA 22314-1552703/836-2272E-mail: aapa@aapa.org

Employment Contracts and Agreements

In most instances, a written agreement is presented to the employed physician assistant outlining the key terms of his or her employment status. This agreement may be in the form of an employment contract or may be less formally drafted in a “letter of employment”. However written, the following key areas are commonly addressed within the employment document:

Job Description Insurance

Scope of practice Malpractice insurance, including “tail coverage.”

Physician supervision Health/dental insurance

Administrative responsibilities Life/disability insurance Office location(s)

Hours of operation Professional Expenses

Expected hours per week CME paid time off Call schedule CME program and travel costs Holidays/weekends Membership dues to state and

national professional associations. Certification expenses: CME logging

and NCCPA fees.

State registration; DEA licensing;Compensation Package Contractual Provisions

Base salary Effective date Bonus arrangement Probationary period Annual salary adjustment Renewal Pension/retirement benefits Termination provisions Paid time off Notifications

The above items represent basic areas of employment that should be clarified when the PA, employer, and the supervising physician discuss the terms of employment. It is advisable to have a written contract or practice agreement that clearly spells out the terms of employment.

Rural Health Clinic Guidelines for Physician Assistants Rural Health Clinics (RHC) are located in areas designated by the Bureau of the Census as rural and by the Secretary of the Department of Health and Human Services or the State as medically underserved. Section 410 of the Medicare Prescription Drug, Improvement and Modernization Act of 2003 states that for services furnished on or after January 1, 2005, professional services provided by physicians, physician assistants, nurse practitioners, and clinical psychologists who are affiliated with RHCs are excluded from the skilled nursing facility prospective payment system, in the same manner as such services would be excluded if they were provided by individuals not affiliated with RHCs. To qualify as a Rural Health Clinic, a clinic must be located in:

A non-urbanized area AND ONE OF THE FOLLOWING: A medically underserved area; A geographic Health Professional Shortage Area (HPSA); or A population group HPSA.

Any area that is not defined as urbanized is considered non-urbanized. The U.S. Census Bureau defines an urbanized area as a central city of 50,000 or more and its adjacent suburbs. A RHC must also:

Employ a midlevel practitioner 50 percent of the time the clinic is open;

Provide routine diagnostic and laboratory services; Establish arrangements with providers and suppliers to furnish medically necessary services not available at the clinic; and Provide first response emergency care.

RHCs provide the following: Physicians’ services; Services and supplies incident to the services of physicians; Services of nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers; Services and supplies incident to the services of nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists, and clinical social workers; Visiting nurse services to the homebound; Services of registered dietitians or nutritional professionals for diabetes training services and medical nutrition therapy; and Otherwise covered drugs that are furnished by, and incident to, services of physicians and nonphysician practitioners of the RHC.

Payment for RHC services furnished to Medicare beneficiaries are made on the basis of an all-inclusive rate per covered visit with the exception of pneumococcal and influenza vaccines and their administration, which are paid at 100 percent of reasonable cost. A visit is defined as a face-to-face encounter between the patient and a physician, physician assistant, nurse practitioner, certified nurse midwife, visiting nurse, clinical psychologist, or clinical social worker during which a RHC service is rendered. Encounters at a single location on the same day with more than one health professional and multiple encounters with the same health professional constitute a single visit, except when the patient suffers an illness or injury requiring additional diagnosis or treatment subsequent to the first encounter. Payment is made directly to RHCs for covered services furnished to a patient at the clinic or center, the patient’s place of residence, or elsewhere (e.g., the scene of an accident). Laboratory tests are paid separately. A RHC cannot be concurrently approved for Medicare as both a Federally Qualified Health Center and a RHC.

Information above from: www.cms.hhs.gov/MLNProducts/downloads/rhcfactsheet.pdf

Indian Health Service Employment of Physician Assistants

The IHS does not require PAs to be licensed in the State(s) in which they will be performing their official duties. Based upon Federal sovereignty and supremacy principles, a State may not require that an IHS employee who provides health care within the State as part of his or her Federal duties be licensed in that State. However, Drug Enforcement Administration regulations require the PA be authorized to prescribe controlled substances by the jurisdiction (e.g., State) in which he/she is licensed, registered, or otherwise specifically recognized to practice his/her profession.

Physician Assistants who were hired prior to February 1, 1990, may remain in their present positions without certification; however, they must become certified in order to transfer to a new position.

Licensure: Health care professionals who are employedby the IHS are required to be licensed, registered, ornationally certified. Physician Assistants employed bythe IHS must be nationally certified (unless exempted).

Prescribing Privileges: Prescribing privileges that may include prescribing all classes of pharmaceuticals, shall be included in the PA medical staff privilegingprocess. All privileges shall be granted based on the PA’s education and clinical experience. Prescribing privileges include writing prescriptions, privileged inpatient chart orders (if so dispensing of medications as may be required in remote settings), and the administration of pharmaceuticals, where appropriate to do so.

Prescribing privileges for Drug Enforcement Agency(DEA) Controlled Substances (Schedules II-V) may be granted to PAs in accordance with the Indian Health Manual Part 3,Chapter 7, a Pharmacy, Section 3-7.3D (2a), dated 6/26/95:

a. The facility has authorized the PA to dispense or prescribe designated Schedules of Controlled Substances under its DHA registration. b. The PA-must be registered, licensed; or otherwise specifically recognized by any State as having authority to prescribe designated Schedules of Controlled Substances.c. The PA adheres to all local facility policies regarding-the prescribing of controlled substances.

The implementing regulations of the Controlled Substances Act-Title 21, CFR, Section 1306.03 state (in part): “A prescription for controlled substances may be issued only by an individual practitioner who is authorized to prescribe controlled substances by the jurisdiction in which he is licensed to practice his profession.”

The preceding information is taken from the Indian Health Service Circular No. 96-02 and may be accessed at the following web address: www.ihs.gov/PublicInfo/Publications/ IHSManual/Circulars/Circ96/9602.

Resource Guide

Minnesota Academy of Physician Assistants600 S. Hwy 169, Suite 1680St. Louis Park, Minnesota 55426

Phone: 952 562-8700Fax: 952 542-0130 mailto:office@mnacadapa.org

MAPA 2007 Membership Surveyhttp://www.mnacadpa.org/index_files/2007survey.htm

American Academy of Physician Assistants950 North Washington StreetAlexandria, Virginia 22314-1552Phone: 703 836-2272Fax: 703 684-1924www. aapa.org

Minnesota Board of Medical PracticeUniversity Park Plaza2829 University Avenue SE Suite 500Minneapolis, Minnesota 55414-3246Phone: 612 617-2166www.bmp.state.mn.us

National Association of Rural Health Clinics National Association of Rural Health Clinics 200 10th Street Des Moines, IA 50309 515-280-1944 info@narhc.org

National Rural Health Association National Rural Health AssociationHeadquarters One West Armour Blvd.; Suite 203Kansas City, MO 64111-2087(816) 756-3140mail@NRHArural.org