Mission Statement
The Nevada Academy of Physician Assistants is dedicated to the advancement of its members and the physician assistant profession through academy support, education, public awareness, and legislative action.
GOALS
- To enhance the profession by developing collegial relations with other healthcare professionals
- To promote the value of the physician assistant profession through public awareness
- To protect the physician assistant through legislative action and reform when necessary
- To encourage collaboration with supervising physicians and other professional colleagues to provide medical care in a variety of practice settings
- To encourage networking and the sharing of knowledge and opinion among the Nevada PAs
- To promote the development of Nevada PAs by sponsoring quality continuing medical education
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GOVERNMENT AND CONSTITUENTS COMMITTEE NEWS:
Nevada Physician Assistants,
During 2011, the Nevada Academy of Physician Assistants opened a dialogue with the Nevada State Board of Medical Examiners. NSBME has asked for our input about how ratio restrictions, and NSBME policies, affect day to day practice for Nevada PAs. The questions at hand are how NAC 630.495 can be improved permitting appropriate supervision while still protecting the public. Feedback from NAPA and Nevada PAs will be submitted to NSBME for consideration.
(Public protection issue); NSBME has a concern about which physician is supervising a given PA, during any particular patient encounter. One possible suggestion that has been made is that the PA can be required to note, in the medical record, the name of the supervising physician for each patient encounter. This policy has been adopted in California, and other states, as part of good medical - legal management, and documentation. The PA simply writes, or dictates, the name of their supervising physician with each patient encounter. This language would be simple to draft into the Nevada Administrative Codes and help alleviate concerns by NSBME.
(Ratio restriction issue); the current regulation makes this restriction;
NAC 630.495 Limit on number of advanced practitioners of nursing for collaboration or physician assistants for supervision. (NRS 630.130)
- Except as otherwise provided in subsection 2, a physician shall not “Simultaneous”
(a) Supervise more than three physician assistants;
(b) Collaborate with more than three advanced practitioners of nursing; or
(c) Supervise or collaborate with a combination of more than three physician assistants and advanced practitioners of nursing.
Under this current statute, a physician may only supervise a combination of 3 PAs or NPs “Simultaneously.” Many organizations have determined PA / Physician ratios should be determined at the practice level. Nevada PAs have raised concerns about cross coverage and employment opportunity issues and given a few examples.
Example #1 A single physician currently has three PAs and wishes to add a fourth. He intends to supervise no more than three pursuant to statutes but wonders if he will be in compliance with the law if the fourth PA is not of record. Current NSBME policy does not permit this physician to add a fourth PA of record even though he intends to only supervise no more than three simultaneously.
Example #2 A group of over 20 surgeons has 8 PAs with rotating call schedule. Although only a single surgeon may be supervising the “on call” PA, that surgeon may not necessarily be a supervising physician of record with the NSBME. Several such surgical groups of Orthopedic, Neurosurgeon, OB, & CV exist in Las Vegas.
Example #3 Valley Health Care system has five hospitals in Las Vegas. Each has its own ER with 70 +/- ER physicians and 15 +/- PAs. All of whom cross cover on a rotating shift schedule. Mathematically impossible for each physician to be a supervising physician of record with the NSBME.
Questions for consideration and discussion?
- How can the PA / Physicians team address issues of “cross coverage” while still maintaining documented compliance with NAC?
NSBME has an “exemption” policy, to extend the limit of 3, but such permission appears to be random, on a case by case basis, with no mutually understood policy, rationale, or ground rules. Nevada PAs have reported inconsistencies with the acceptance or rejection of such “exemption” requests. Please contact NAPA to let us know how the ratio issue impacts your current or future practice and access to care. We also want to hear your concerns, issues and other topics that are relevant to PA practice in Nevada. Contact us at (Rick O’Bringer, PA-C, rick@passist.net or Blanca R. Tenhet, PA-C at brtenhet@yahoo.com)
Policy Statements regarding ratio restrictions
Many states are moving away from a ratio restriction at all – deferring to the practice to determine how many PAs a physician can appropriately supervise. AMA staff has recently confirmed that the AMA believes that the number of PAs supervised should be determined at the practice. In addition:
ACP/AAPA Joint Statement
Internists and Physician Assistants: Team-Based Primary Care
AAPA and ACP encourage flexibility in federal and state regulation so that each medical practice determines appropriate clinical roles within the medical team, physician-to-PA ratios, and supervision processes, enabling each clinician to work to the fullest extent of his or her license and expertise.
http://www.acponline.org/advocacy/where_we_stand/policy/internists_asst.pdf
AAPA Issue Brief: Ratio of Physician Assistants to Supervising Physicians
In 1996, the American Academy of Family Physicians revised its policy on the ratio of PAs to supervising physicians. The AAFP deleted a sentence in its Guidelines on the Supervision of Certified Nurse Midwives, Nurse Practitioners and Physician Assistants policy that recommended a physician supervise no more than two “nonphysician” providers.
The American College of Emergency Physicians also supports the practice level determining its own ratios of PAs to supervising physicians. In 2007, ACEP approved a policy stating that the medical director of an emergency department should define the number of PAs whose clinical work can be simultaneously supervised by one emergency physician.
http://www.acep.org/content.aspx?id=29492
The Federation of State Medical Boards also supports ratios being determined at the practice level. In their 2010 Essentials of a Modern Medical and Osteopathic Practice Act, FSMB recommends that state laws simply require that “no physician should have under their supervision more staff, physician assistant or otherwise than the physician can adequately supervise.” FSMB does not recommend the inclusion of a specific number in state law.
http://www.fsmb.org/pdf/GRPOL_essentials.pdf
Federal Trade Commission, “The FTC is charged under the FTC Act with preventing unfair methods of competition and unfair or deceptive acts or practices in or affecting commerce. Because of the importance of health care competition to the economy and consumer welfare, anticompetitive conduct in healthcare markets has long been a key target of FTC law enforcement, research, and advocacy. Recently, FTC staff have urged several states to reject or narrow restrictions that limit health care access and raiser prices to consumers by limiting competition among health care providers and professionals.“
Edward S. Salsberg, MPA
Director of National Center for Health Workforce Analysis
DC Board of Medicine Physician and PA Symposium, September 28th, 2011
When asked the question, “what is the optimal PA/NP to physician ratio at a District of Columbia Board of Medicine Symposium on the Physician and Physician Assistant Workforce, Edward “Ed” Salsberg replied, “I don’t know. But it seems to me that such a decision should be based in part upon the physician’s training and education at the practice level.”
Other Facts:
- No state that has increased the physician to PA supervision ratio or eliminated it has reinstated the previously stricter standard.
- Eliminating the supervision ratio does not increase medical malpractice insurance premiums.