C A L I FOR N I A H EALTH C ARE F OU NDATION Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work June 2009 Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work Prepared for California HealthCare Foundation by Catherine Dower, J.D. Sharon Christian, J.D. Center for the Health Professions University of California, San Francisco June 2009 About the Authors Catherine Dower, J.D., is the associate director for research, and Sharon Christian, J.D., is a senior research analyst at the Center for the Health Professions, University of California, San Francisco. The Center’s mission is to transform health care through workforce research and leadership development. For more information, visit www.futurehealth.ucsf.edu. The authors gratefully acknowledge the numerous study participants and individuals who provided information for this report. About the Foundation The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. ©2009 California HealthCare Foundation Contents 2 I. Executive Summary 3 II. Introduction and Background Specialty PA and NP Workforce Data General Education Specialty Training Programs 5 III. Methodology 6 IV. Findings Practice Models Patient Caseload Level of Supervision and Independent Practice Training Reimbursement and Sustainability Effect on Access, Quality of Care Few Regulatory Hurdles Physician Acceptance and Perspectives Six Examples of Specialty Practices 1 8 V. Conclusion 2 0 Endnotes I. Executive Summary I n C alifornia , as in other states , Dermatology. Some practices employ PAs as consumers are having difficulty getting access clinical providers for routine cases, allowing to physicians in some specialties, including supervising physicians to focus on complex cases gastroenterology, orthopedics, and dermatology.1 and surgeries. The challenges may be particularly acute for patients of community clinics and public hospitals. Many The study found that these models generally specialty medical practices have incorporated improved access, reduced wait times, and proved physician assistants (PAs) and nurse practitioners financially sustainable. Although quantitative (NPs) into their outpatient settings to improve access evidence is scarce, qualitative information points to to care, reduce wait times, and improve quality of maintenance or improvement in quality of care. care. The successful models have implications for A study by the Center for the Health Professions practitioners and delivery site managers, including at the University of California, San Francisco, those at community clinics and public hospitals examined these emerging models to evaluate where some patients experience significant delays their success and identify strategies that could be in getting specialty care. Some sites might want to replicated. The study focused on outpatient care in develop a system relying on teams of physicians, three specialties with particularly high demand rates: NPs, and PAs to provide specialty care. Others could orthopedics, gastroenterology (GI), and dermatology. benefit from fully understanding how such systems The research found that utilization of physician work to facilitate efficient and effective referrals. assistants and nurse practitioners varied across these There are challenges to implementing these specialties. For example: models. Most PAs and NPs must be trained on the job because of the small number of postgraduate Orthopedics. Orthopedic practices commonly medical specialty programs. In addition, all rely on physician assistants to do many practitioners — physicians, PAs, and NPs — must be orthopedic assessments and procedures. The aware of everyone’s strengths and limitations, must be prevalence and long track record of this model able to work collaboratively, and must keep lines of throughout the United States suggests it will communication open. become even more widely adopted. Sustainable financing can be accomplished Gastroenterology. A growing number of GI with attention to the details of the practice model, practices employ NPs and PAs to increase follow- including incorporating time for supervision and up patient volume, freeing physicians to do high- mentoring into the daily routine. Although state laws level procedures. The business model is strong, and regulations regarding legal scopes of practice suggesting that this approach will become more for NPs and PAs should be considered, the legal widespread. environment was not found to be a significant barrier to implementing these models. 2 | C alifornia H ealth C are F oundation II. Introduction and Background Limited access to specialty care calls D elays in getting access to specialists in gastroenterology, orthopedics, and dermatology are primarily driven for new thinking around provider by changing disease patterns and gaps between physician supply roles and practice models. and population demand. When demand for care exceeds capacity, practices typically look to add another doctor. But this is not always feasible, due to either a shortage of specialists or prohibitive salary requirements, so new thinking has emerged regarding provider roles and practice models. This study was designed to explore medical practices across the United States that are integrating physician assistants and nurse practitioners to provide high-level specialty care and reduce backlogs. The movement appears to have gained some traction, as evidenced by workforce data and education and training opportunities. Specialty PA and NP Workforce Data Approximately 80,000 PAs practice in the United States. The American Academy of Physician Assistants (AAPA) estimates that over 60 percent of physician assistants practice in specialty (non- primary) care areas, and most of these are in surgery — including orthopedics — and emergency medicine. An estimated 10 percent of PAs practice in internal medicine (which includes the subspecialty of gastroenterology) and 4 percent in dermatology.2 An estimated 140,000 NPs were practicing in the U.S. in 2004.3 Given the current NP data collection methods, it is difficult to estimate how many NPs practice in medical specialties. A limited but growing body of workforce analysis confirms the integration of PAs and NPs into specialty care practices. One study predicted that increased demand by older patients for specialist gastroenterology treatment will put significant pressure on the existing workforce. It argued that research is urgently needed to determine the best practice model for delivery of gastroenterological care, including looking at models that utilize NPs and PAs in clinic and hospital settings.4 A 2008 study concluded that U.S. dermatologists are increasingly employing NPs and PAs, though with significant variations in supervision and utilization patterns.5 Data from the Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 3 American Academy of Dermatology indicate that California Nursing Practice Act an unmet demand for NPs and PAs likely persists, Nurse practitioners in California must work in as practice patterns differ significantly among collaboration with a supervising physician under dermatologists of different ages.6, 7 written standardized procedures. Within parameters spelled out in the standardized procedures, they may diagnose patients, order tests, and order or furnish General Education drugs.8 California law requires that a physician may The rationale for integrating PAs and NPs into supervise no more than four NPs who are furnishing drugs. There is no legal limit on the number of NPs a medical specialty practices is grounded in an physician may supervise if the NPs are not furnishing understanding of the education, training, and drugs. competence of these practitioners. The average physician assistant curriculum is 26 months of California PA Practice Act Physician assistants in California work with physician didactic and clinical education under a generalist supervision under a delegation of services agreement medical model of care. Students may participate in that allows physicians to delegate duties within the specialty rotations, typically a few weeks in duration, physician’s scope of care, the PA’s competencies, and state law. PAs may take patient histories, perform while in school. PAs receive a general license and physical exams, order laboratory tests, establish may practice in primary care or in any specialty. treatment plans, prescribe medications, and provide California requires national certification for initial patient education.9 A physician may supervise no more than four PAs at a time. licensure and continuing education for re-licensure. Physician assistants who choose to maintain national certification must pass the national PA examination every six years. Specialty Training Programs Nurse practitioners in California must have While NPs have responded to specialty opportunities at least a master’s degree in nursing. They are and physician shortages with comprehensive educated and trained to practice independently doctoral-level training programs, PAs have focused and collaboratively with other practitioners such on establishing specialty-specific programs.10, 11 The as physicians. With few exceptions (such as nurse Association of Postgraduate Physician Assistant anesthetists and nurse midwives), NPs are not Programs (APPAP) lists over 40 postgraduate licensed in any particular specialty. NP specialty programs in 16 specialties, with the large majority certifications tend to be in primary or hospital- in surgery, emergency medicine, and other hospital- based care, including such areas as family practice, based specialties.12 Two postgraduate programs in pediatrics, geriatrics, women’s health, and acute care. dermatology and three in orthopedics are available They are not usually certified in medical specialty to PAs. The APPAP does not recognize any areas. Licensed NPs must meet general continuing postgraduate training programs in gastroenterology, education requirements every two years for re- although, as discussed below, some industry- licensure. sponsored GI fellowships have been offered. 4 | C alifornia H ealth C are F oundation III. Methodology T he literature review was conducted In 2008, staff compiled a list of potential using electronic searches for relevant publications interview subjects based on the literature and queries in health care and health policy databases such to the Center for the Health Professions’ professional as PubMed and the Cochrane Collaboration. network, including senior fellows, advisory The Google Scholar database was searched for committee members, leadership fellowship program professional association information, popular representatives, and partner institutions. Potential literature, and examples of interdisciplinary teams. interview subjects were primarily physicians, NPs, Collectively, the searches generated hundreds of and PAs in medical specialty practices that included potentially relevant documents, which were then NPs or PAs as providers, as well as knowledgeable reviewed for direct applicability. The priority in this stakeholders. Over 50 letters of invitation to study was to examine literature on practices offering participate were sent in late 2008 and early 2009, and high-demand outpatient specialty services. Interview more than 30 telephone interviews were completed. subjects provided background information and Structured interviews and data management were direction regarding the literature search. conducted in accordance with UCSF Committee on Regulatory review sources included the California Human Research guidelines. Business and Professions Code and the California Code of Regulations. Work previously published by the authors regarding scope-of-practice regulation of NPs and PAs was also reviewed for relevance.13 Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 5 IV. Findings At the specialty practice sites in To complement existing data and to gain new information, in late 2008 and early 2009, UCSF staff interviewed this study, NPs and PAs generally over 30 individuals in more than a dozen medical specialty practices shared responsibilities with specialist across the United States that used PAs and/or NPs to provide advanced clinical care to patients. Most participants reported that NPs physicians and saw both new and or PAs were an integral part of their specialty practice because they follow-up patients. significantly eased the bottleneck of patients awaiting care. Although interviewees noted some challenges, which are explored below, the overwhelming majority reported positive outcomes from utilizing NPs and PAs. Most agreed that their care delivery model should be widely adopted, given the increased patient satisfaction and improved quality of care credited to the assistance of these clinicians. Acting as both communication links between patients and specialists and as care providers themselves, NPs and PAs improved coordination, reduced wait times, and increased access to care. Further, NPs and PAs helped free physicians to attend to more complicated cases, which translated to a positive bottom line for practice revenue. Many study participants reported that their practices successfully expanded to meet increasing patient populations. Practice Models At the specialty practice sites in this study, NPs and PAs generally shared responsibilities with specialist physicians and saw both new and follow-up patients. NPs and PAs commonly ordered tests, devised treatment plans, and assisted with surgeries and procedures. Specific practice duties differed among the specialties, as outlined below. Orthopedics Study participants reported that PAs and NPs were already widely used in many orthopedic practices. PAs were more deployed than NPs, although supervising physicians noted no other reason besides tradition. Ten percent of PAs (6,900 in the United States) who practice in a surgical specialty are in orthopedics.14 Orthopedic PAs typically see patients, order and interpret diagnostic studies, rotate in hospitals, set fractures, apply casts, and inject steroids. 6 | C alifornia H ealth C are F oundation Some community clinics host a weekly or monthly clinicians interviewed for this study did not receive orthopedic clinic staffed by a nurse practitioner formal GI training but were trained on the job. employed by a local orthopedic group. These NPs To keep up with colon cancer screening demand generally perform nonsurgical orthopedic services, that is exceeding GI physician supply, some hospitals such as injecting joints; setting broken bones; run small, very efficient endoscopy centers using assessing the severity of strains or sprains on hips, PAs to help handle the patient volume. One care shoulders, and knees; and evaluating the need for provider suggested developing a colonoscopy center surgery.15 PAs practicing in orthopedic outpatient model with one gastroenterologist on-site while NPs settings may also have local hospital privileges. These or PAs performed concurrent colonoscopies. The hospitalist PAs’ responsibilities typically include specialist would be in a control room with monitors performing minor surgical procedures, such as to supervise each patient, enabling the physician to debridement and pin removal; first assisting in the communicate verbally with clinicians or attend to operating room; conducting post-surgery rounds; patients with problems.17 and ordering X-rays. Dermatology Gastroenterology Study participants reported that PAs were more PAs and NPs in gastroenterology and hepatology likely than NPs to be working in dermatology. perform a wide range of diagnostic and therapeutic Dermatology PAs typically manage chronic procedures, including flexible sigmoidoscopies, conditions such as psoriasis, rosacea, vascular paracentesis, liver biopsies, esophageal studies, abnormalities, eczema, and acne. Since all PAs receive assisting with percutaneous endoscopic gastrostomy suture training, they are well suited to perform tube placement, and ongoing counseling for patients biopsies and simple excisions in dermatology offices. with diseases such as hepatitis. Many evaluate They may also perform skin cancer screenings patients for colon cancer. They treat patients for and minor surgeries, and assist in major medical gastroesophageal reflux disease, pancreatic diseases, procedures such as Mohs surgery.18 Additionally, hepatitis, cirrhosis, and inflammatory bowel some PAs perform cosmetic procedures including diseases.16 laser resurfacing, dermabrasion, and chemical peels. Both NPs and PAs were employed equally in One care provider said dermatology is a great gastroenterology; physicians sought competent field for PAs, since roughly 25 percent of her practice clinicians, preferably with some prior experience in covers primary care skin conditions.19 She believes the specialty. Study participants reported that NPs the repetitive nature of dermatology — especially in and PAs typically require six months of training in cases of acne, warts, and psoriasis — means PAs may core gastroenterology conditions, such as stomach quickly become proficient. It can be an excellent bleeding, colon cancer, and nausea and vomiting, specialty for PAs to handle the bulk of simple cases, to handle their own patients. Years of additional allowing physicians to attend to more complex training, however, are required for proficiency in surgical or cosmetic procedures. advanced GI areas such as pancreatic issues, cirrhosis, and inflammatory bowel disease. Most of the Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 7 Patient Caseload medical specialties of this study are not offered. Some PAs and NPs carried their own patient To supplement their skills and fulfill re-licensure loads from start to finish, allowing for continuity requirements, nurse practitioners and physician of care. Other NPs and PAs shared patients to assistants often take continuing medical education evenly distribute the burden of caseloads. Practices courses alongside specialist physicians. Study reportedly functioned optimally when specialists participants in California noted the Orthopaedic were confident in both the clinicians’ skills and their Surgery Physician Assistant Residency Program discretion in knowing when to bring complex cases at Arrowhead Regional Medical Center. It is a to supervising physicians. Also key was respecting 12-month intensive didactic and clinical training patients’ and referring physicians’ requests to program designed to prepare PAs for careers in see a physician specialist, particularly for initial orthopedic surgery. Several care providers said they workup. Study participants also reported that some prefer to hire graduates of this program. highly specialized NPs and PAs (in liver disease, Given the limited availability of postgraduate for example) served as resources to their physician training, NPs and PAs in specialty care typically colleagues. receive the bulk of their specialty training from their supervising physicians on the job. One interview Level of Supervision and Independent subject suggested that NPs and PAs practicing in Practice academic centers may be more fortunate because Some PAs and NPs worked with several physicians, hospitals have formal specialty training programs for while others partnered with only one specialist. their fellows. Other practices may have less structured Supervising physicians were usually on-site or procedures for on-the-job training. According to available by phone, but most NPs and PAs reported study participants, it can take several months to that they confidently handled most outpatient needs a year of on-the-job training for NPs and PAs to without direct supervision. Physicians confirmed perform to the level of competency required by these assessments. Some clinicians practiced at employers. Observing and shadowing physicians is one site (clinic or hospital) full time while their critical, regardless of prior experience and formal supervising physicians traveled among sites or split institutional training. their time between hospital and clinic work. Other However, some training could be standard and NPs and PAs worked at multiple sites. theoretically completed prior to beginning work. Several NPs and PAs indicated they would be Training interested in formal procedure- or condition-specific Presently, postgraduate training in the specialties training courses, if they were available. Several is limited. In PA programs, students are trained specialist physicians reported interest in standard in general surgery and may participate in elective postgraduate programs to facilitate the hiring process rotations in their specialty of choice. Many PAs and streamline on-the-job orientation and training. reported that they were hired by the practices where There is an ongoing national debate regarding they had done their rotations. NPs may elect to earn the establishment of specialty certification for postgraduate certifications in areas such as women’s PAs. Given their generalist education, PAs may health or pediatrics, but certificates in the outpatient choose any medical specialty after graduation. In 8 | C alifornia H ealth C are F oundation addition, certification by the National Commission Reimbursement and Sustainability on Certification of Physician Assistants (NCCPA), Generally, third-party payers reimburse practices which is required by all states as a prerequisite for services provided by NPs and PAs but policies for licensure, is a general, non-specialty focused vary depending on the service and the level of certification. Many PAs move among specialties clinician independence. When these clinicians throughout their careers and enjoy a range of practice independently provide services to patients, Medicare settings. Stakeholders reluctant to formalize specialty typically reimburses at 85 percent of the physician training are concerned that such certification reimbursement rates. requirements could impede the professional mobility Outpatient services may alternatively be billed of PAs and NPs by pigeonholing them into certain under Medicare’s “incident to” physician care specialties, creating additional barriers to access. One provisions, which reimburse at 100 percent of the study participant cautioned that “any certification physician’s reimbursement rate if the following scheme that requires experience in the specialty prior guidelines are met: 1) the physician is physically to certification will discourage new PAs from entering on-site when the NP or PA provides care; 2) the the specialty.”20 Some postgraduate programs could physician personally treats and diagnoses patients find accreditation and recognition requirements on their first visit for a particular condition, though challenging, such as granting degrees or being NPs and PAs may provide subsequent care; and affiliated with academic institutions. On the other 3) patients with new conditions are treated and hand, the lack of standardization and individual diagnosed by the physician, though NPs and PAs focus currently required to train each clinician could may provide subsequent care. Further, the physician impede practitioner mobility among practices within must remain involved in the patient’s care.22 specialties. This, in turn, could hamper access to care Under Medi-Cal, California’s Medicaid program, by perpetuating the insufficient workforce supply and services provided by PAs and NPs may be reimbursed difficulties in recruitment. at 100 percent of the amount payable to a physician Several independent professional organizations for the same service. Medi-Cal rates are notoriously have moved to establish their own postgraduate low, however, and while any service provided by a PA programs. For example, the American Association working under a physician may be billed to Medi- for the Study of Liver Diseases has offered highly Cal, only primary care services provided by NPs selective fellowship programs for NPs and PAs may be billed.23 Despite these limitations, Medi-Cal specializing in hepatology, supported by funding may be critical to specialty services for some patient from pharmaceutical companies. The national populations. A recent analysis found that recent Gastroenterology Physician Assistants association policy changes permit Federally Qualified Health is developing a standardized core curriculum with Centers to provide preventive and screening specialty continuing medical education organizations. The services; these services are associated with enhanced NCCPA has recently decided to take the first steps Medi-Cal reimbursement, which is key to financing toward offering a voluntary PA specialty credential.21 specialty care services at safety-net clinics.24, 25 Services provided to patients enrolled in Medi- Cal managed care plans are reimbursable under varying plan policies. Similarly, while many private Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 9 third-party payers follow Medicare guidelines, and better quality care. When PAs and NPs handled individual plan policies may vary. many routine and follow-up patient visits, specialty Practices that participated in the study reported physicians were freed to focus on complex cases. being in good financial positions in large part because The better match of expertise between provider and of their integration of physician assistants and nurse patient reportedly improved the quality of care. practitioners. Many offices arranged their practice Published outcomes data on NPs and PAs in models to comply with Medicare policy, allowing specialty medical practice is limited but consistent them to bill NP and PA services at 100 percent of with the interviews and with long-established the physician rate. Even if they billed some services research that has found NP- and PA-provided at 85 percent, the increased patient volume and the primary care comparable to care provided by lower salaries of NPs and PAs contributed to solid physicians.28 In specialty practices, outcomes were financing. In many practices, the increased patient almost always positive and were measured in terms volume was divided: Routine, follow-up patients of clinical and cost effectiveness, increased physician were directed to NPs and PAs and new, more acute, time for more complex duties, increased capacity to or complex cases were seen by physicians. These accept new patients, and decreased lengths of stay acute and complex cases are often associated with and readmission rates for inpatients.29 Numerous high-level procedures, which are reimbursed at high studies compared the work of NPs and PAs to a rates. variety of other clinicians, including primary and Published studies examining how integration specialty physicians, residents, and certified nurse of PAs and NPs into specialty practices has affected specialists, and found comparable competence.30 costs are sparse but noteworthy. A 2006 article For example, a study measuring patient quality of regarding NPs and PAs in a GI practice found that life and treatment outcomes found that hepatology billing charges were two and a half to four times the NPs can be as effective as physicians.31 Several salaries of the NPs and PAs, making them extremely articles have specifically examined the dynamics of cost-effective.26 Additional research has shown that interdisciplinary practices using providers of various PAs generate revenue far greater than the cost of their professions, including NPs and PAs. Most studies compensation.27 concluded that these teams achieved positive clinical outcomes.32 Effect on Access, Quality of Care Study participants reported that in addition to Few Regulatory Hurdles the financial benefits, integrating NPs and PAs All of the study participants reported being able to contributed to positive results in terms of access and implement successful practice models integrating PAs quality. Especially notable were reduced wait times and NPs as clinicians well within their state legal and for patients to secure appointments and increases regulatory frameworks. Responses varied, however, in the overall number of patients or appointments. with regard to whether state scope-of-practice This increase in volume was directly associated with laws were appropriately broad. One GI physician PAs and NPs assuming significant patient caseloads. assistant described struggling with her state’s vague Study participants also reported improved care laws regarding authority to discharge patients. A few coordination, which leads to patient satisfaction clinicians were dissatisfied with state rules prohibiting 10 | C alifornia H ealth C are F oundation them from prescribing controlled substances, though Physician Acceptance and Perspectives most practitioners could work with the prohibition Several study participants noted that some physicians because they had access to prescribing specialists. were initially reluctant to fully accept NPs and PAs Other care providers reported that physician chart as clinicians. Some suggested that physicians who sign-off requirements were time-consuming and had not worked with NPs or PAs as colleagues before unnecessary. often were unaware of what they could do in a Most study participants were satisfied with clinical setting. Others stressed that some physicians the range of services they provided and the level were very concerned about the competence of PAs of physician oversight. Exceptions included rare and NPs. Some thought that community practice occasions when specialists were not readily available physicians, particularly those just starting their when needed, and when NPs or PAs felt rotating careers, might be uncomfortable bringing an NP or physicians didn’t trust them. Most physicians PA into the practice before the practice is financially reported satisfaction with state scope-of-practice laws well established, out of concern for competition. and regulations regarding NPs and PAs, although one Other physicians were troubled by the amount of asserted that his practice model worked as well as it time they would need to dedicate to training and did because its monitoring system was stricter than mentoring NPs and PAs, time that would need to be required by the state. Study participants who had taken from already busy schedules. overlapping inpatient and outpatient responsibilities All of the study participants reported that any noted increasing requirements to comply with hesitancy among physicians was overcome with hospital policies and credentialing rules, which can time, comprehensive practice procedures, and daily encompass matters already covered by state practice interactions with NPs and PAs. Some physicians acts, such as scope of practice, safety, privacy, probably will always want tighter control and and billing. Additionally, these requirements may supervision over PAs and NPs. But it appears vary among different sites, creating confusion for that once physicians work with competent and clinicians who practice at multiple sites or wish to appropriately trained NPs and PAs, they understand move from one site to another. and appreciate how such an arrangement can work for the benefit of everyone involved. At the same time, a few study participants cautioned that some physicians in other settings may have gone too far with their use of NPs and PAs. They thought these practitioners may be excessively or inappropriately used. They warned of consequent decreases in quality of care, especially where NPs and PAs are insufficiently trained and/or do not understand their limitations. Physicians and other clinicians said the greatest potential issue is not always PAs or NPs overstepping boundaries, but can be doctors acting irresponsibly when working with NPs and PAs. Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 11 Six Examples of Specialty Practices without direct physician oversight at all times. PAs In-depth follow-up interviews were conducted with and NPs are considered active clinical partners and representatives from two sites in each of the three professional colleagues; they not only attend but also specialties to get a detailed picture of how these deliver departmental lectures on specific conditions models work. These case studies are examples of or procedures. Jim Delaney, PA-C, sees the Kaiser specific practices that have integrated PAs and NPs practice as notable in its recognition of competence into their clinical settings. of PAs and the role they can play. Kaiser relies heavily on the nearby postgraduate Orthopedics orthopedic training offered at Arrowhead Regional Kaiser Permanente Fontana Medical Center, Medical Center, which in turn depends on Kaiser Orthopedic Department, Fontana, CA members.kaiserpermanente.org/kpweb/facilitydir/facility.do? for student rotation opportunities. Mary Hurley, id=100127&rop=SCA#anchor1 M.D., chair of the orthopedic department at Kaiser The Kaiser Fontana Medical Center Orthopedic Fontana, noted that the department only hires PAs Department relies on 13 physician assistants and who have completed an orthopedic postgraduate one nurse practitioner to provide a broad range of program at one of the few such programs in the out- and inpatient services, including “first call” country. After they are hired, the physician assistants for all orthopedic consult requests from urgent are expected to become PA IIs, a job classification care, primary care, emergency, or inpatient services. that indicates a high level of competency. The Although Kaiser’s closed financing model is unique, department continues to work on its commitment the orthopedic practice model is worth noting to adequately proctor and mentor PAs during this because of the range and quality of services PAs process. provide. Representatives from Kaiser Fontana see PAs conduct all initial evaluations and fully themselves as having been on the cutting edge of handle an estimated 80 percent to 90 percent the movement to bring PAs fully into orthopedic of patient cases, with the remainder — such as practice, a movement that could still go further fractures that are not reducible and may require throughout California and the United States. Both surgery — referred to physicians. PAs order and Dr. Hurley and Mr. Delaney indicated that the read imaging studies and other tests, apply casts, set integration of PAs had enabled the department to bones such as wrists, prescribe medications (except meet an extremely high and growing demand for schedule II drugs at discharge), and provide most orthopedic services. Indeed, Dr. Hurley said she other orthopedic treatment. Fourteen physicians did not know how the department would function supervise the PAs. A team of four rotating PAs works without PAs. She also believes quality of care has essentially as PA hospitalists to support inpatient care improved with the PAs rounding and seeing hospital and work closely with three internist physicians. The patients, in large part because of the PAs’ attention to nurse practitioner works in podiatric surgery. detail. Kaiser Fontana orthopedic PAs work fairly independently. Although supervising physicians are usually available on-site, the model is structured for PAs to see and treat patients on their own 12 | C alifornia H ealth C are F oundation St. John’s Clinic – Orthopedic Specialists, Training for PAs at St. John’s is mostly on the job Springfield, MO www.stjohns.com/healthinfo/adult/orthopaedics and through continuing medical education courses, St. John’s Clinic – Orthopedic Specialists provides a which are readily available. Fred McQueary, M.D., full range of orthopedic services within an integrated an orthopedic surgeon and St. John’s Springfield health care system owned and operated by the Sisters division president, noted that although it is not of Mercy. Approximately 13 physician assistants required of the PAs with whom he works, he sees work with 16 orthopedic physicians providing advantages to having a specialty-focused postgraduate both in- and outpatient clinical care. The clinic is training program for PAs because it would permit probably a good example of many practices across the them to practice more independently more quickly. country that have incorporated significant numbers However, there would still need to be some of PAs into clinical care due to increased demand. orientation time — six to 12 months, perhaps — for Jeff Del Vecchio, MPAS, PA-C, who has worked each PA to learn how the physician with whom at the clinic for 11 years, noted that the clinic has he or she will be working thinks, treats, and deals grown significantly — in numbers of physicians and with patients. The clinic offers orthopedic rotation PAs and volume of patients — during that time. In opportunities to students at a local physician assistant addition to hospital responsibilities such as daily program where Mr. Del Vecchio teaches, and has had patient rounds, assisting in the operating room, success hiring from the program’s graduates. and call duty, Mr. Del Vecchio provides outpatient With a large and varied patient population, care in the clinic. Outpatient services provided by reimbursement options and rates differ from patient the PAs include seeing and evaluating patients, to patient. As in other settings, reimbursement applying and removing casts, prescribing medications rates for PAs can be lower than those for physicians. (except narcotics), ordering and interpreting tests, However, even if PAs are reimbursed at a lower rate, and delivering joint injections. Physicians and PAs patient access to care can be increased with this usually work together in teams of two, though some model because PAs can see follow-up patients, freeing physicians in the group do not work with any PAs. physicians to see new consults, perform surgeries, With the one-on-one team approach, PAs always and care for patients with complex conditions. As have access to a physician and receive both direct and Dr. McQueary pointed out, though, the integration general supervision. of PAs into an orthopedic practice is not so much a The practice experimented with allowing cost-saver as a lifestyle-saver. Once a new physician experienced PAs to see some new patients but has built up enough of a patient caseload to justify modified its policy due to concerns from some the cost of a PA’s salary, it is worth bringing one into community primary care physicians. Now, all new the practice so the team can handle “on-call” and patients see a physician in addition to a PA. Patients other patient care demands. are seen exclusively by PAs for many follow-up visits, although physicians emphasize to PAs during their orientation and training that they must continuously sharpen their skills regarding patient satisfaction and assess whether a patient may want to see a physician instead of, or in addition to, the PA. Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 13 Gastroenterology a GI rotation in school is not sufficient, however. It University of Florida, Department of Medicine, is expected to take at least six months of on-the-job Division of Gastroenterology, Hepatology & Nutrition, Gainesville, FL training to grasp the basics of disease management www.medicine.ufl.edu/gastro and up to 12 months to be competent to see patients The Gastroenterology, Hepatology & Nutrition independently and draft well-reasoned treatment plan Division within the University of Florida’s (UF) letters. From Dr. Forsmark’s perspective, postgraduate Department of Medicine is a top-ranked unit in the GI programs for PAs and NPs would be a significant United States. A team of 14 medical doctors, four contribution. He also said he sees potential for PAs, and three NPs work to meet extremely high- identifying competent GI centers for training PAs volume demands for GI services ranging from basic and NPs so future employers would have confidence assessments to liver transplants. Chris Forsmark, in training quality. M.D., professor of medicine and chief of the NP and PA services covered by public insurance gastroenterology division, underscored that the unit programs can be billed at 85 percent of the could not function without PAs and NPs. physician rate, permitting physicians to focus on Physician assistants and nurse practitioners focus fully reimbursable procedures and complex clinical on outpatient needs and function similarly to medical services. Private insurance contracts with UF do not fellows or junior attending physicians. Working allow billing for independent NP and PA services, collaboratively with the physicians, the PAs and NPs which perpetuates backlogs of patients who must have broad scopes of responsibility and competence. wait to see a physician. In response, several clinics The unit stresses communication among all clinicians now see Medicare and Medicaid patients exclusively. and works to ensure that PAs and NPs have access to At some of these clinics, PAs such as Mr. Davis physicians whenever needed. Specific responsibilities practice quite independently and treat patients on vary. Rick Davis, PA-C, who has been working as a their own, checking in with physicians only as legally licensed PA in GI settings for 26 years — including and medically indicated. These clinics have been 15 years at UF — works closely with an attending successful in providing patients access to quality GI physician and the medical director to evaluate and care they otherwise would not have received. The treat patients with advanced GI and liver diseases. only other challenges UF clinicians noted related Nurse practitioner Mitzi Tucker, who focuses on to state practice laws. The co-signature rule has just hepatology, runs the hepatitis C treatment program. been deleted by Florida state laws; NPs and PAs both After an initial evaluation by a physician, patients are have prescriptive authority in the state, but not for seen and treated by Ms. Tucker throughout their six- controlled substances. to-18-month course. The integration of physician assistants and nurse Practitioners have different education and practitioners into UF’s GI unit has been invaluable. training backgrounds. Ms. Tucker worked in liver As Dr. Forsmark noted, they make the whole process disease as a registered nurse prior to her NP studies. much more efficient. He estimated that patient wait As an NP, she completed a fellowship with the times have been reduced from six months to three American Association for the Study of Liver Diseases. over a two-year period in part due to the PAs and Dr. Forsmark noted that the division seeks PAs and NPs. Without them, he said, the system would grind NPs with some experience, preferably in GI. Even to a halt. With them, the division has increased the 14 | C alifornia H ealth C are F oundation volume and number of procedures performed, which company that makes, among other products, in turn has boosted revenue streams. interferon for treatment of hepatitis C. This fellowship provided him with a good working Digestive Health Specialists, Federal Way, WA knowledge of gastroenterology. He still had close www.digestivehlth.com physician oversight for his first four to six months at Digestive Health Specialists (DHS) is a specialty DHS before taking broad responsibilities for patient group of medical doctors and non-physician clinical care. Other PAs and NPs, especially new graduates, staff working at nine gastroenterology outpatient have come to DHS with more general family practice clinics and four endoscopy centers in and around backgrounds that sometimes necessitate longer on- Tacoma, Washington. Collectively, eight physician the-job training periods. assistants and five nurse practitioners complement The staffing model at DHS ensures physicians are a team of about 20 gastroenterologist physicians always available and incorporates time for physician to provide care in outpatient settings and at several review so PA and NP services are billed as “incident affiliated local hospitals for inpatient services. DHS to” physician services, at 100 percent of the physician hired its first non-physician provider in 1987 to help reimbursement rate. An article by James Wagonfeld, meet demand that was outpacing provider supply.33 M.D., former CEO of DHS, included billing data The group has continued to expand its overall size and productivity comparisons that demonstrated and the number of NPs and PAs in the practice ever charges generally running at two and a half to four since. times the non-physician provider (NPP) salary. Although specific duties and responsibilities may Although productivity must be mitigated by the need vary, the PAs and NPs work fairly independently and for physician supervision, which can require as much provide a full range of medical care except high- as 25 percent of a physician’s time with inexperienced level diagnoses and procedures such as endoscopy practitioners, Dr. Wagonfeld noted that “the value of and colonoscopy. For example, Timothy Morton, NPPs cannot be overemphasized.” To underscore the PA-C, who focuses on liver disease, follows patients business case, he went on to state that “NPPs do an continuously from initial consult through treatment. outstanding job of handling 80 percent of the cases at With physicians always available to answer questions, a fraction of a physician salary.”34 his practice includes making decisions regarding The model at Digestive Health Specialists, which diagnosis, medication, treatment, and laboratory fully integrates PAs and NPs into the practice as tests. Mr. Morton has also developed a strong collaborative providers, has been very successful. As professional relationship with gastroenterology noted in the conclusion of Dr. Wagonfeld’s article, specialists at the local academic center and teaching “NPPs greatly enhance physician productivity, hospital, whom he can call for complex questions or revenue, and patient and physician satisfaction.” cases. Because there is no standard training pathway for PAs and NPs in gastroenterology, the backgrounds of these practitioners at Digestive Health Specialists vary. Mr. Morton took advantage of a one-year GI “fellowship” that was offered to PAs and NPs by Schering-Plough Corporation, a pharmaceutical Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 15 Dermatology seeing every patient jointly with a physician for Dermatology Clinic, P.C., Salem, OR several months. Some continuing education and www.salemdermatology.com conferences are also available. An estimated three The Dermatology Clinic is a private group practice to six months is required to train new graduates composed of four dermatology physicians and three from a PA program sufficiently to permit them to physician assistants. Each PA has his or her own see their own patients. Jon Denton, M.D., who has patient caseload, which is generally equal to the been at Dermatology Clinic since 1987, sees value in physician caseloads. Compared with physicians, PAs developing more postgraduate dermatology programs for the most part provide a similar scope of clinical for PAs. Dr. Denton said he thinks standard services. Exceptions include some complicated postgraduate programs would make it easier to hire surgeries and diagnostically complex patients, PAs in this specialty and would encourage greater whom the physicians handle. PAs see patients, write acceptance of PAs by physician dermatologists. treatment plans, prescribe medication, perform Without such formal training, some physicians in biopsies for skin cancer, make incisions, and provide this field are reluctant to accept PAs. some laser treatments. PAs work collaboratively with Most of the clinic’s patients have health physicians on-site, requiring minimal supervision insurance through Medicare or other government but under a rigorous monitoring policy. PAs do not programs. Under the monitoring and practice see patients without a physician on-site. All new guidelines outlined above, most PA services are patients are seen by a physician and a PA at their billed at 100 percent of the physician rate. The time first visit. PAs may see the patients on their own for physicians spend overseeing the PAs’ work is offset follow-up visits when there is no change in treatment by the volume of patients that can be seen, and the plans; if any questions arise, the PA consults with practice is in good financial shape. the physician to resolve the question, reevaluate the Dermatology Clinic sees itself as one of the patient, and/or re-establish a treatment plan. If any early leaders in the area to integrate PAs into a new problems arise, the patient sees the physician. All dermatology practice. Today, many local practices PAs work with all physicians and interact regularly rely on PAs to some degree, although there may be throughout the day. differences in practice protocols and monitoring The PAs in the group came from different guidelines. Despite initial reluctance among backgrounds. Amy Ullan, PA-C, for example, some physicians in the group, Dr. Denton has a worked for several years as a medical assistant in high opinion of the PAs and values their work. the Dermatology Clinic before going to PA school. As other physicians have come to trust the PAs Carolyn Greenwade, administrator at Dermatology and the monitoring system that is in place, their Clinic, stressed that the practice relies heavily on concerns — particularly around the PAs’ technical graduates from the physician assistant program at and diagnostic skills — were resolved and clinicians Oregon Health & Science University because it is are very comfortable with the model. PAs do a a good program and offers dermatology rotations great deal of work well within their training and at local settings such as the clinic. Although some competence. Although the group has not done any dermatology postgraduate programs are available formal measurements, it appears that the practice nationally, most postgraduate training for PAs at this practice is intensive on-the-job training, including 16 | C alifornia H ealth C are F oundation functions well and that they are seeing more patients independently. If the PA sees the patient “incident in less time. to” the services of the physician, the reimbursable rate is 100 percent. Central Carolina Dermatology Clinic Inc. Mr. Engstrom emphasized the importance of High Point, N.C. www.centralcarolinaderm.com PAs knowing their limitations when practicing This six-physician dermatology group employs one dermatology. Physicians working with PAs also physician assistant, Gary Engstrom, PA-C, who sees have a responsibility to train and trust their PA 25 to 40 patients per day. He does evaluations, orders colleagues, and not to misuse them in any way. laboratory tests, orders ultraviolet light treatment, While the practice has not formally collected data, and performs biopsies and excisional surgeries Mr. Engstrom said that well-trained PAs free up (though not flaps, grafts, or Mohs surgeries). He has physicians to do higher-level procedures, and he prescriptive authority but no Drug Enforcement noted that six-month wait times for appointments Agency number, by choice, so he does not prescribe are now a thing of the past at the clinic. narcotics. He has worked with this practice for five years and previously was at another dermatology practice for seven years. With this experience, he works fairly independently and occasionally consults with the physicians for second opinions or complex cases. Mr. Engstrom is aware of the two dermatology postgraduate programs currently available but, aside from his dermatology rotation during physician assistant school, most of his specialty training has been on the job. He has taken advantage of continuing education courses, distance learning programs, and national conferences devoted to dermatology. For his first six to 12 months, he only saw patients with a physician also present. By that point, he estimated, he could provide most of the dermatological services provided by a primary care physician (e.g., routine acne, warts). By his second year in dermatology practice, he had sufficient confidence and trust from his physician colleagues to see his own patients. For Central Carolina Dermatology patients covered by private insurance, PA services are usually reimbursed at the physician rate. As in other settings, the Medicare rate for PA services is 85 percent that of the physician rate if the PA sees the patient Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 17 V. Conclusion With many Californians A number of medical specialty practices across the United States rely in part on NPs and PAs to provide clinical experiencing long wait times to care, including high-demand specialties such as orthopedics, see specialists in these fields, it is gastroenterology, and dermatology. These practices have successfully improved access to care for patient populations that had been worth exploring the possibility of experiencing significant wait times to see specialists. This has been replicating these practice models accomplished with sustainable financial systems. Safety and quality of care has been maintained, if not improved. The literature, while throughout the state. limited in this area, supports the notion that such practice models can have positive impacts on access, cost, and quality of care. With many Californians experiencing long wait times to see specialists in these fields, it is worth exploring the possibility of replicating these practice models throughout the state. Particular attention could be placed on replicating these models for patients of community clinics and public hospitals, which have been reporting severe bottlenecks in referring patients to specialist practices. While these models are persuasive evidence that alternative ways to provide care can be better than historical models, some areas of further research and improvement are recommended. There is room for education and information-sharing among all types of practitioners about these models, how they work best, and their limitations. In addition, further quantitative research about their impact on access, cost, and quality could better inform all involved. Finally, the limited availability of postgraduate programs in the medical specialties for PAs and NPs could be explored and addressed to better prepare these clinicians to provide specialty patient care. The successful medical specialty practice models that have integrated PAs and NPs as clinicians have several important implications for practices in California, particularly for community clinics and public hospitals that are facing patient demand exceeding current capacity. Replication of practice models. Some community clinics and public hospitals may be able to replicate these models by hiring PAs and/or NPs to complement part- or full-time specialist 18 | C alifornia H ealth C are F oundation physicians in the specialties that are in highest Additional research. Finally, stakeholders need demand for their populations. The model clinics more outcomes studies on the deployment of discussed in the case studies are in a strong NPs and PAs in specialty care. To both encourage position to inform clinics across California adoption of these models and fine-tune their about maximizing utilization of NPs and PAs. implementation, practitioners, administrators, Investment money from the federal government 35 and consumers need to see more research on might stimulate adoption of these models but how they work. Although there is compelling current reimbursement policies, if applied to a anecdotal information indicating NPs and PAs well-administered practice, should be sufficient improve access to care by reducing wait times to to support the models. There does not appear see specialists, hard data are needed. In particular, to be any legal or regulatory prohibition to stakeholders need facts and analyses regarding implementing these models in California. impacts on clinical patient outcomes, patient and practitioner satisfaction, access to care, and cost Collaboration with specialty practices. Some of care. clinics and hospitals would be well served to understand and collaborate with practices that employ NPs or PAs. For example, physicians might feel more confident about referring patients to these practices if they understood when patients would be seen by a physician specialist, when they would be seen by a PA or NP, and what practice guidelines and protocols were in place to ensure safe, high-quality care. Sharing more information through in-person meetings, Web site posts, or other communications could go far in helping these arrangements work well. Expansion of postgraduate opportunities. One of the biggest challenges identified by study participants was the amount of on-the- job training required to bring an NP or PA, particularly a recent graduate, up to the level of competence necessary to see patients in a busy specialty practice. Although some on-the- job training will always be necessary, standard postgraduate opportunities could be explored in some specialties. A starting point would be to compare current NP and PA programmatic elements to the needs of specialty practices, with attention to both procedural and cognitive skills. Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 19 Endnotes 1. Kaiser Permanente, et. al., January 14, 2008. “Specialty 11. Larson, E.H., and L.G. Hart. 2007. “Growth and Care Access Survey: Preliminary Findings.” Change in the Physician Assistant Workforce in the United States, 1967 – 2000.” Journal of Allied Health 2. American Academy of Physician Assistants. 2008. 2008 36(3): 121 – 30 (cited in Dill, J., and E. Salsberg. 2008. AAPA Physician Assistant Census Report (www.aapa.org/ “The Complexities of Physician Supply and Demand: images/stories/2008aapacensusnationalreport.pdf); Projections Through 2025.” Association of American see also McCann. October 1, 2005. “Graham Center Medical Colleges Center for Workforce Studies, pp. One-Pager: Physician Assistant and Nurse Practitioner 65 – 7). Workforce Trends.” American Family Physician. 12. Association of Postgraduate Physician Assistant Programs. 3. Health Resources Services Administration. 2004. The “AAPAP Programs by Specialty” (www.appap.org/prog_ Registered Nurse Population: National Sample Survey of specialty.html). Registered Nurses March 2004: Preliminary Findings. 13. Christian, S., C. Dower, and E. O’Neil. 2007. Chart 4. Hall K., et al. 2005. “American Gastroenterological Overview of Nurse Practitioner Scopes of Practice in the Association Future Trends Committee Report: Effects of United States. University of California San Francisco, Aging of the Population on Gastroenterology Practice, Center for the Health Professions; Christian, S., C. Education and Research.” Gastroenterology 129: 1305 –38. Dower, and E. O’Neil. 2007. Overview of Nurse 5. Resnick, J., and A. Kimball. February 2008. “Who Else Practitioner Scopes of Practice in the United States: Is Providing Care in Dermatology Practices? Trends in the Discussion; Dower, C., S. Christian, and E. O’Neil. Use of Nonphysician Clinicians.” Journal of the American 2007. Promising Scope of Practice Models for the Health Academy of Dermatology 58(2): 211– 6. Professions. UCSF Center for the Health Professions. 6. Kimball, A.B., and J.S. Resneck Jr. 2008. “The 14. AAPA. October 6, 2007. 2007 AAPA Physician Assistant U.S. Dermatology Workforce: A Specialty Remains Census Report. in Shortage.” Journal of the American Academy of 15. Solomon, Neil, M.D. January 9, 2009. Personal Dermatology 59(5): 741– 5. communication to the authors. 7. Jacobson, C., et al. December 2004. “Generational 16. AAPA. Physician Assistants in Gastroenterology and Differences in Practice Patterns of Dermatologists in the Hepatology (www.aapa.org/images/stories/gastro.pdf). United States: Implications for Workforce Planning.” Archives of Dermatology 140: 1477 – 82. 17. Solomon, personal communication. 8. 16 California Code of Regulations §§1480(a), 1485; 18. AAPA. February 2009. Physician Assistants in Dermatology California Business & Professions Code §§2725, 2725.1, (www.aapa.org/images/stories/derm.pdf). §2836.1. 19. Ullan, Amy, PA-C. February 13, 2009. 9. B&PC §3502(c) (2008); 16 CCR §§1399.540-1399.546 20. Carpenter, D. August 2006. “Perspectives on (2008); B&PC §3502.1 (2008) (www.pac.ca.gov/about_ the Physician Assistant Specialty Credentialing us/lawsregs/law-booklet.pdf). DebateEducation, Not Certification.” Journal of the 10. Cooper, R.A. 2007. “New Directions for Nurse American Academy of Physician Assistants 19(8). Practitioners and Physician Assistants in the Era of 21. National Commission on Certification of Physician Physician Shortages.” Academic Medicine 82(9): 827– 8. Assistants. 2009. Public Statement Regarding NCCPA’s Commitment to Offer a Voluntary Credential for PAs Practicing in Specialties (www.nccpa.net/news_a_ specialtycredential.aspx). 20 | C alifornia H ealth C are F oundation 22. Balanced Budget Act of 1997, Public Law 105 – 217 30. Ahern, M., J. Imperial, et al. 2004. “Impact of a §4512 (1997); AAPA. February 2009. Third-Party Designated Hepatology Nurse on the Clinical Course and Reimbursement for Physician Assistants Quality of Life of Patients Treated with Rebetron Therapy (www.aapa.org/images/stories/3rdparty.pdf). for Chronic Hepatitis C.” Gastroenterology Nursing 27(4): 149 – 55; Hillier, A. 2001. “The Advanced Practice Nurse 23. California Department of Health Care Services. in Gastroenterology: Identifying and Comparing Care Medi-Cal Provider Manual. Part 2. Non-Physician Medical Interactions of Nurse Practitioners and Clinical Nurse Practitioners. Specialists.” Gastroenterology Nursing 24(5): 239 – 45; 24. Wunsch, Bobbie. January 2009. A Slippery Slope: Oliveria, S.A., K.S. Nehal, et al. 2001. “Using Nurse Financing Specialty Services in California’s Safety Net. Practitioners for Skin Cancer Screening: A Pilot Study.” Pacific Health Consulting Group. American Journal of Preventive Medicine 21(3): 214 – 7. 25. Health Resources and Services Administration. “Specialty The minority of studies that yielded negative or mixed Services and Health Centers’ Scope of Project.” Policy results addressed specialties that were not the focus of Information Notice (PIN) 2009 – 02 (bphc.hrsa.gov/ this report: Krein, S.L., M.L. Klamerus, et al. 2004. policy/pin0902/default.htm); HRSA. “Defining Scope “Case Management for Patients with Poorly Controlled of Project and Policy for Requesting Changes.” PIN Diabetes: A Randomized Trial.” American Journal of 2008-01 (bphc.hrsa.gov/policy/pin0801). Medicine 116(11): 732 – 9; PriceWaterhouse Coopers. February 1999. “The Use of Therapeutic Pharmaceutical 26. Wagonfeld, James B. October 2006. “The Nonphysician Agents by Optometrists in California: A Study of Provider in the Gastroenterology Practice.” Competence and Cost-Effectiveness.” Gastroenterology Endoscopy Clinics of North America 16(4): 719 – 25. 31. Ahern, “Impact of a Designated Hepatology Nurse.” 27. Medical Group Management Association. 2008. 32. Salvana, J., et al. 2005. “Chronic Osteomyelitis: “Physician Compensation and Production Survey” (cited Results Obtained by an Integrated Team Approach to by American Academy of Physician Assistants. February Management” Connecticut Medicine 69(4): 195 – 202; 2009. “Physician Assistants in Dermatology.”). Conger, M., and C. Craig. 1998. “Advanced Nurse Practice: A Model for Collaboration.” Nursing Case 28. Mundinger, M. O., R. L. Kane, et al. 2000. “Primary Management 3(3): 120 – 7; Lieberman, D. A., and Care Outcomes in Patients Treated by Nurse Practitioners J.M. Ghormley. 1992. “Physician Assistants in or Physicians: A Randomized Trial.” Journal of the Gastroenterology: Should They Perform Endoscopy?” American Medical Association 283(1): 59 – 68. American Journal of Gastroenterology 87(8): 940 – 3; 29. Kirkwood, B.J., et al. 2006. “Ophthalmic Nurse Walter, F.L., N. Bass, et al. 2007. “Success of Clinical Practitioner Led Diabetic Retinopathy Screening: Results Pathways for Total Joint Arthroplasty in a Community of a 3-Month Trial.” Eye 20(2): 173-7; Riportella-Muller, Hospital.” Clinical Orthopaedics and Related Research 457: R., et al. 1995. “The Substitution of Physician Assistants 133 – 7. and Nurse Practitioners for Physician Residents in 33. Wagonfeld, “The Nonphysician Provider.” Teaching Hospitals.” Health Affairs (Millwood) 14(2): 181 – 91; Baker, K.E. 2000. “Will a Physician Assistant 34. Ibid. Improve Your Dermatology Practice?” Seminars in 35. The federal government intends to spend $2 billion over Cutaneous Medicine and Surgery 19(3): 201– 3. the next two years to support innovation, health IT and other improvements in community clinics nationwide. Rauber, C. March 3, 2009. “Pleasanton Clinic Wins $1.3M in Federal Stimulus Funding.” San Francisco Business Times. Physician Assistants and Nurse Practitioners in Specialty Care: Six Practices Make It Work | 21 C A L I FOR N I A H EALTH C ARE F OU NDATION 1438 Webster Street, Suite 400 Oakland, CA 94612 tel: 510.238.1040 fax: 510.238.1388 www.chcf.org