The Need for PAs and NPs in Orthopedic Practice - PowerPoint Presentation

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The Need for PAs and NPs in Orthopedic Practice

Jason

Szpak

PA-C

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Disclosure

I am a PA

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Objectives

Understand the team based approach and the role of mid-level providers on the orthopedic team

Understand the requirements of a supervising/collaborative physician

Be aware of the future of direction of mid-level professions

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The Orthopedic Team

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The Physician/Mid-level Team

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What is a Mid-Level Provider?

The Wingman

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What is a Mid-Level Provider?

50 year old professions

Trusted health care providers

2014

Harris Poll found extremely high satisfaction rates among Americans who have seen a PA or have a family member who has seen a PA

.

93

percent regard PAs as trusted healthcare providers and 91 percent believe that PAs improve the quality of healthcare

Growing profession

PA – Ranked #2 Best Healthcare Job 2018 (US News and World Report)

Nurse Practitioner - #4 in demand job of 2018 (Forbes)

A potential solution for musculoskeletal care supply shortage

Relatively constant number of orthopedic residencies with a rapidl

y increasing demand for care by an aging population

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A Mid-level provider is NOT….

A replacement for physicians

Likely going to become an MD

A Physician

’s

Assistant

Settling because we couldn’t get into medical school

“Lenny who just came out of community college” – Bill

O’Rielly

2014

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History of Mid-Level Providers

PA

Established in 1967 – in response to shortage of primary care MDsFirst PA Program at DukeCurrently 123,000 PAs in practice, 13000 in ortho

NP

Nursing roles grew in 40’s and 50’s

Established

in

1965 – in response to shortage of primary care MDs

University of Colorado

Estimated 248,000 NPs in practice

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Mid-Level Role in Ortho (Team Approach)

Clinic

New patient evaluation and management

Ordering imaging, labs, prescribing, documentation

Performing H&Ps

Casting/splinting

Patient education

Office based procedures

Ultrasound guided injections, use of biologics,

veinipuncture

Phone calls

Hospital Rounds

Taking Call – Patient calls, ER/Hospital

Sports Event Coverage

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Mid-Level Role (Cont)

OR

1

st

assist. Second set of hands, eyes

Patient

positioning

Wound closure

Splinting

Equipment troubleshooting

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Mid-Level Role (Cont)

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Orthopedic Urgent Care/Ortho After Hours

Growing role for Mid-Level Providers

I

dentify patients that need more emergent care/referral to subspecialist

Increase access

Streamline patient visits

Decrease cost

Patients see a provider with extensive experience in musculoskeletal injury

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Advantages of Utilizing Mid-Level

Higher levels of patient satisfaction, higher quality care, increased access, decreased wait

times

Better patient education = better outcomes

Same surgical assistant, increase OR efficiency

Less disruption of practice when MD not present

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Requirements of MD

PA

Supervising Physician – must be identifiable at any given timeAvailability by phone (within 15 minutes by telecommunication or other means)No requirement for co-signature on charts or prescriptions in WI**Annual prescriptive review**4 PAs per 1 MD

NP

Collaborating Physician – relationship must be documented

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How should the provider be utilized

Single vs multiple surgeons

Independent vs collaborative vs hybrid

Level of experience

Same schedule vs separate schedules

Which patients?

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What do patients think mid-level providers should do?

Patient Perspectives of Midlevel Providers in Orthopedic Sports Medicine – 2018 Orthopedic Journal of Sports Medicine

Room for improvement – requires MD support

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Billing/Reimbursement

Clinic billing – May see new or established patients

Medicare pays 85% of physician fee when billed under mid level name

“Incident to” – Physician must be in the

facility

Must document

that patient was seen under supervision of MD

Co-signatures generally not helpful for billing

Surgical Assist Fees

Document in operative note the medical necessity of

assistant

Value is difficult to assess

Post op appointments – global fees

Value of efficiency (OR time)

Lifestyle of physician

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Education

PA – medical model2 ½ yr program after undergradOften experienced in other health care roles (athletic trainers)1st year didactic, 2nd year clinical rotationsGeneralist TrainingCurrently Master’s Degree5 programs in WIMarquette, UW Madison, UW Lacrosse, Concordia, Carroll

NP – nursing model

Multiple pathways

Typically 2 years of experience as RN

2-3 year program

Mix of classroom and clinical experience

population focus – family practice, geriatric, neonatal, women’s health, psych

Master’s or Doctorate

degree

10 programs in WI

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Education – cont

Orthopedic specific training (on the job)- usually takes 6-12 months to fully function, depending on experience

Ultimately, roles are very similar between PA and NP

Consider being a preceptor – PA Programs need surgical rotations

Possible employment

Educate the mid-levels that will be staffing

ER/Urgent care, family practice that will be referring

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CME – advanced orthopedic training

PAOS – Physician Assistants in Orthopedic Surgery

National Organization – offers

ortho

specific CME conferences

JBJS/JOPA – Journal of Orthopedics for Physician Assistants ($130/year)

JOPA and JBJS reviews

50 CME credits annually

Salary reports

Fluoroscopic Injection guide

AAOS

– Resident rates for conferences, JAAOS

subscription ($175)

PA’s Guide to the Musculoskeletal Galaxy

Lecture based and hands on (injection techniques,

splinting/casting

)

Opportunities for surgeons and PAs to learn new procedures together

WOS – Advance Practice Provider Membership

Practicing with active member, member discounts/conferences

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Recertification

PA

CME – 50 hours category 1, 50 hours category 2 (every 2 years)Recertify every 10 years (was previously every 7)Proctored examNew - computerized exam of 25 questions every quarter X 2 years assessing core medical knowledge

NP

CME – 100 hours of CME, 1000 clinical hours (every 5 years)

No recertification test

Multiple certifying bodies

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Post Graduate Education

Orthopedic Residency Programs

1 year of additional musculoskeletal training

PA- 6 programs nationally

NP – 2 programs nationally

No additional boards

Graduates awarded certificate

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Orthopedic Specific Certifications

PA

Certificate of Added Qualification (CAQ)2 yrs experience in ortho150 hours of ortho specific CMELetter from attending physician120 question testValid for 10 yrs

NP

Orthopedic Nurse Practitioner Certification (ONP-C)

3

yrs

experience as RN or NP

2

yrs

work experience as NP

Currently work as NP caring for patients with musculoskeletal conditions

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 0 certificants

1 – 5 certificants

> 6 certificants

ONP-C® – Orthopaedic Nurse Practitioner Certified

3 ONP-C in WI

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PA – Ortho CAQ

2 in WI

154 in US

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Why obtain additional credentials?

Patient Perspectives of Midlevel Providers in Orthopedic Sports Medicine –

Orthopedic Journal Of Sports Medicine 2018

62%

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Future of Professions

PALegislative changes in WIOptimal Team PracticeCollaborative instead of supervisoryScope of practice determined by individual experience and educationEliminate ratio requirements (currently 4:1)Authorize to participate in disaster/volunteer activities without supervising MD, but within scope of practiceUpdate relationship with WI examining board

NP

All programs converting to Doctorate in

2025

Seeking independent practice

in WI

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THANK YOU!