Is There a Physician Assistant in Your Future?

PAs now play a key role in leading ophthalmology practices.

By Jerry Helzner, Senior Editor

If you are one of the relative handful of ophthalmology practices that already employs one or more physician assistants (PAs), it is appropriate to offer congratulations. Your practice is clearly seeking to create a more efficient and cost-effective staff structure that is in keeping with the increased regulation and reduced reimbursement rapidly becoming the hallmark of 21st century medical practice. But if you are one of the thousands of ophthalmology practices that does not currently have any PAs on your staff, perhaps it is time to look in that direction.

Why the sudden burst of interest in bringing PAs into ophthalmology practices?

Part of the reason stems from a landmark May 2009 Medicare ruling that patients who are about to undergo any surgical procedure must have a comprehensive history and physical (H&P) done within 30 days prior to surgery. This means that a cataract surgery patient who returns a month later for a simple YAG capsulotomy must have the H&P again despite the fact that the H&P was done just recently for the cataract surgery.

While this Medicare ruling is having more of an impact on higher-volume practices, a broader justification for the use of PAs in other practice settings is that they have the skillset to be trained for tasks that are medical in nature but that can free ophthalmologists to do the things that only a physician can do. Here, we will describe how some ophthalmology practices are finding value in the use of PAs.

A Ruling That Rocked ASCs

“The Medicare H&P ruling of May 2009 was the first change in 20 years,” says Cristine Boore, RN, BSN, of Progressive Surgical Solutions, a consulting firm that assists in developing and operating ambulatory surgical centers. “The ASC world was rocked by this ruling. The new H&P standard created a bigger burden and it came with increased regulatory surveillance.”

Performing physicals is a key role that a physician assistant can play in the preoperative phase of ophthalmic surgery.

One of the first eyecare providers to feel the impact of the change was Barnet Dulaney Perkins Eye Center, a large statewide practice in Arizona that operates eight ASCs. The high-volume, high-profile practice was surveyed by both Medicare and state regulators shortly after the May 2009 ruling went into effect and was told to find a way to comply with the new H&P standards.

“We do about 3,500 YAGs a year and almost 15,000 surgical procedures overall,” says Imelda Kelly, RN, surgical administrator and director of nursing. “For our surgeons to add thousands more H&Ps to their workload represented an impossible burden. For an ASC to be state-licensed in Arizona requires that the H&Ps be done by a member of the medical staff, which meant adding either physician assistants or nurse practitioners.”

A PA explains a procedure to a patient. PAs can be very effective in this role, as they can spend more time with patients.

After studying Arizona state regulations, Ms. Kelly determined that it would be easier to credential a physician assistant to the medical staff than to credential a nurse practitioner.

“It's very important that you know your state's regulations regarding the responsibilities that can be taken on by a physician assistant,” she notes. “These regulations can vary on a state-to-state basis.”

An Experiment That's Working

Given the high surgical volume that Barnet Dulaney Perkins generates, the practice hired four PAs to perform H&Ps in the clinic. The pre-surgical check of heart and lungs is still done by a physician.

“I believe we are on the leading edge of ophthalmology here with the hiring of four PAs,” says Andrew Rabinowitz, MD, a partner in the practice. “In some ways this is an experiment that may provide staffing ideas for other ophthalmology practices. So far, it is working out for us but we are exploring longer-term ideas for expanding the roles of our PAs. Any expansion of their roles will require extensive training, but each PA is closely supervised by an ophthalmologist and we regularly have to report on their progress and performance.”

Probably the most forward-looking practice in bringing PAs into ophthalmology is St. Luke's Cataract & Laser Institute in Tampa, Fla., which has employed physician assistants for more than 20 years. St. Luke's currently employs four PAs.

“Dr. (James) Gills has always been known as an innovator in ophthalmology and more than two decades ago he had the belief that, with lots of extensive training, PAs could close the eye following cataract surgery,” says Brad Houser, practice administrator. “As surgical techniques changed, Dr. Gills trained PAs to open for cataract surgery. In a surgical setting, efficiency is a driving force and using our PAs in this role has worked out extraordinarily well for us because we have three ORs, which allows us to rotate the PAs from patient to patient in front of the surgeon. Our PAs are also involved in our aesthetic practice doing Botox, filler injections and closing after oculoplastic surgery.”

PAs in a Retina Practice

Retina Associates of Cleveland is one of the few retina practices that employs PAs. The practice, which has a long history of using PAs to assist in and facilitate surgery, currently has three PAs and is delighted with their performance in the OR.

“There is extensive training involved but the PAs have been a very good fit with our surgeons,” says Warren Laurita, practice administrator. “Having someone from your own practice assisting the surgeon is, for us, preferable to using only hospital staff, who may not be familiar with retina procedures.”

Mr. Laurita says the PAs in the practice are also used to conduct H&Ps, handle postop visits and also take their regular turn “on call.”

He notes that the state of Ohio has strict guidelines for using PAs, including that they must be supervised by a physician. The PAs at Retina Associates of Cleveland “absolutely” do not do intravitreal injections.

“We are reviewing ways to expand their utilization within the practice,” concludes Mr. Laurita. “Having PAs works very well for us as they are trained in the medical model that fits well with the skills of our ophthalmologists.”

The AAPA Applauds

Ann Davis, senior director for state advocacy and outreach for the American Academy of Physician Assistants (AAPA) is happy to hear that more PAs are being employed in ophthalmology. A review of AAPA records sent to Ophthalmology Management showed only about 25 US ophthalmology practices that have thus far reported hiring PAs, though that might not be a complete list.

“PAs have been playing a key role in many medical specialties for years and with their full breadth of training in a medical model they can fit very well into ophthalmology practices,” says Ms. Davis. “Not everything requires the full skillset of the physician, and PAs are especially trained to work closely with physicians and consult with them. In addition, PAs can spend more time talking directly to patients, which is something patients really appreciate.”

Ms. Davis says some of the tasks that can be performed by a PA include preoperative and postoperative evaluations, patient education, telephone triage, changing prescriptions, assisting in surgery, plus eyecare-specific exams and procedures that can be learned after appropriate training.

“A practice must be aware of state laws in these areas, as there are differences that might preclude certain procedures (such as refractions) that might not be permitted to be performed by PAs,” Ms. Davis cautions.

Possible Settings for Adding PAs

While the experiences of Barnet Dulaney Perkins and St. Luke's makes a strong case for the use of PAs in high-volume surgical practices, smaller and even solo practices might also think about adding a PA to their staff.

For example, in a satellite or rural office where there is a single medical ophthalmologist, a PA could be hired as patient demand grows in lieu of adding a second MD. With the two practitioners working as a team, the MD can develop a plan of care and the PA can execute it. In addition, the PA will be instructed to consult with the MD if any problems or issues arise. In practice, this arrangement has led to a more efficient use of the MD's time and skills.

In a growing solo practice, adding a PA could be a cost-effective way to preclude or postpone the need for bringing in a second ophthalmologist.

One caveat: When one or more PAs comes into a practice, there is always the question of how the rest of the staff may react. Optometrists especially may be sensitive to PA hires and how the presence of lower-paid PAs may ultimately affect their roles. In some practices that provided information for this article, PAs were reported to earn about 60% to 70% of the salary that an OD is paid. Given the disparity in pay and the fact that PAs have the potential to play a much broader overall role in a practice than ODs, turf wars are to be avoided at all costs.

St. Luke's employs six ODs and four PAs and reports absolutely no friction between the two groups.

“Having clearly defined roles for all of your staff members is important,” says Brad Houser of St. Luke's. “In Florida, the state has made it very clear as to what PAs can do and cannot do. Our goal with PAs has been to optimize the skills of our ophthalmologists and delegate tasks that others can do. This makes the most sense to us.” OM