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Federal Employees Compensation Act
TESTIMONY OF THE
AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS
BEFORE THE
SUBCOMMITTEE ON WORKFORCE PROTECTIONS
COMMITTEE ON EDUCATION AND THE WORKFORCE
UNITED STATES HOUSE OF REPRESENTATIVES
REGARDING THE FEDERAL EMPLOYEES COMPENSATION ACT
May 26, 2005
Good Morning. Thank you, Chairman Norwood and Representative Owens, for the opportunity to present testimony this morning before the Subcommittee on Workforce Protections. On behalf of the American Academy of Physician Assistants (AAPA), I also wish to thank you for your interest and leadership in updating the Federal Employees Compensation Act (FECA) to allow PAs to diagnose and treat federal workers who are injured on the job.
My name is Bill Kohlhepp. I am a graduate of the University of Medicine and Dentistry of New Jersey's PA Program, and I have been a physician assistant for the past 25 years. I hold a master's degree in health administration and am currently enrolled in a doctoral program in health science.
I am the Associate Director of the Quinnipiac University Physician Assistant Program, where I am also a professor. For the past 15 years, I have practiced clinically on a part-time basis for Saint Raphael's Occupational Health Plus, which is an occupational medicine practice affiliated with Saint Raphael's Hospital in New Haven, Connecticut. I was the founding Administrative Director of the practice. I am also a co-author of an article on the role of PAs in occupational medicine that was published in the Journal of the American Academy of Physician Assistants.
I am a member of the AAPA and the American Academy of Physician Assistants in Occupational Medicine (AAPA-OM). I am a former president of AAPA, as well as a former Speaker of the AAPA's House of Delegates. I am the current Chair of the National Commission on Certification of Physician Assistants (NCCPA), which is the certifying organization for PAs in the United States.
On behalf of the more than 55,000 clinically practicing physician assistants in the United States who are represented by the American Academy of Physician Assistants, I am pleased to submit comments on the need to update the Federal Employees Compensation Act (FECA) to allow PAs to diagnose and treat federal workers who are injured on the job.
Overview of Physician Assistant Education
Physician assistant programs provide students with a primary care education that prepares them to practice medicine with physician supervision. PA programs are located at schools of medicine or health sciences, universities, teaching hospitals, and the Armed Services. All PA educational programs are accredited by the Accreditation Review Commission on Education for the Physician Assistant, an organization composed of representatives from national physician groups and PAs.
The average PA program is 26 months and is characterized by a rigorous, competency-based curriculum with both didactic and clinical components. The first phase of the program consists of intensive classroom and laboratory study, providing students with an in-depth understanding of the medical sciences. More than 400 hours in classroom and laboratory instruction are devoted to the basic sciences, with over 70 hours in
pharmacology, more than 149 hours in behavioral sciences, and more than 535 hours of clinical medicine.
The second year of PA education consists of clinical rotations. On average, students devote more than 2,000 hours or 50-55 weeks to clinical education, divided between primary care medicine and various specialties, including family medicine, internal medicine, pediatrics, obstetrics and gynecology, surgery and surgical specialties, internal medicine subspecialties, emergency medicine, and psychiatry. During clinical rotations, PA students work directly under the supervision of physician preceptors, participating in the full range of patient care activities, including patient assessment and diagnosis, development of treatment plans, patient education, and counseling.
After graduation from an accredited PA program, the physician assistant must pass a national certifying examination jointly developed by the National Board of Medical Examiners and the independent National Commission on Certification of Physician Assistants. To maintain certification, PAs must log 100 continuing medical education credits over a two-year cycle and reregister every two years. Also to maintain certification, PAs must take a recertification exam every six years.
A growing number of PAs possess master's degrees, and the majority of PA educational programs now offer master's degrees. According to data collected by the AAPA, 61.7 percent of PAs graduating from a PA educational program in 2004 received a master's degree. Approximately 80 percent of the 137 PA educational programs currently offer master's degrees.
Physician Assistant Practice
Physician assistants are licensed health care professionals educated to practice medicine as delegated by and with the supervision of a physician. In all states, physicians may delegate to PAs those medical duties that are within the physician's scope of practice and the PA's training and experience, and are allowed by law. Forty-eight states, the District of Columbia, and Guam authorize physicians to delegate prescriptive privileges to the PAs they supervise.
PAs always work with physicians. However, this does not mean that the physician is necessarily on site, nor does it suggest that PAs do not make autonomous medical decisions. PAs employed by the State Department, for example, may work with a physician who is a continent away and available for consultation by telecommunication.
PAs are located in almost all health care settings and in every medical and surgical specialty. Nineteen percent of all PAs practice in non-metropolitan areas where they may be the only full-time providers of care (state laws stipulate the conditions for remote supervision by a physician). Approximately 41 percent of PAs work in urban and inner city areas. Approximately 44 percent of PAs are in primary care. Nearly one-quarter practice in surgical specialties. Roughly 80 percent of PAs practice in outpatient settings. In 2004, an estimated 206 million patient visits were made to PAs and approximately 250 million medications were prescribed or recommended by PAs.
PAs are covered providers within Medicare, Medicaid, Tri-Care, and most private insurance plans. Additionally, PAs are employed by the federal government to provide medical care, including the Department of Defense, the Department of Veterans Affairs, the Public and Indian Health Services, the State Department, and the Peace Corps. PAs are designated as covered providers in the overwhelming majority of State workers' compensation programs. (A chart is attached to the testimony, summarizing coverage of medical services provided by PAs in the State workers' compensation programs.)
Physician Assistants in Occupational Medicine
Physician assistant versatility and interpersonal skills are well suited to the demands of occupational medicine. Working as part of a medical team, physician assistants participate in the promotion of employee health, including the treatment of occupational injuries and illnesses, preventive and pre-placement examinations, health maintenance activities, immunization programs, Department of Transportation exams, workers' compensation case management follow-up, and health and safety education.
PAs deliver employee health services in diverse settings - corporate medical offices, occupational medicine clinics, private physician offices, hospital employee health departments, clinics for production plants or mines, remote pipeline locations, aboard ship, on military bases, and on the White House medical staff.
The US Department of Transportation allows PAs to perform and sign truck driver physicals. The regulations identify the responsibilities of the medical examiner in performing and recording the physical examination (49 CFR, Part 391.43) and define physician assistants as medical examiners. PAs are employed in occupational medicine roles by numerous federal agencies, including the Department of Veterans Affairs and the Department of Defense. OSHA recognizes PAs as qualified occupational medicine providers able to "perform physical examinations, identify health problems, and plan therapeutic interventions."
Following are a few examples of PAs who practice in occupational medicine.
PA Fills Diverse Role with Occupational Med Company
A PA working for Mercy Occupational Health - a clinic providing occupational medicine services to a diverse range of employers including General Motors, Wal-Mart, Lear Jet, local school districts, and service industry employers - treats patients with a wide range of work-related injuries, including strains, lacerations, and repetitive stress ailments. After diagnosis, she equips employees with detailed written instructions concerning all aspects of their recovery, including the use of prescribed medications and how to best protect injured areas against further damage. She consults with managers about lighter duty assignments during employee recovery. Follow-up visits help to ensure a full and well-coordinated recovery.
The PA administers a range of pre-placement physicals for employers, including fitness tests and drug screenings tailored to reflect the physical demands of the work to be performed. In addition, she performs DOT physicals for employers including the local school district and Federal Express.
This physician-PA team effectively increases patient access to care by sending the PA off-site to provide care at a laboratory equipment factory four hours a week. The physician is available for consultation by phone if necessary while the PA sees the workers, many of whom have no other medical provider. By answering their medical questions and providing general health education, the PA helps keep the factory workers well and able to work in a physically demanding setting.
PA Care at Los Alamos
The workers and researchers of Los Alamos Nuclear Laboratory receive their occupational health services from a physician assistant. This PA specializes in the prevention, diagnosis, and referral of radiation-related conditions. To help Los Alamos fulfill strict Occupational Safety and Health Administration (OSHA) regulations concerning radiation exposure, he conducts rigorous medical exams for employees on a yearly basis. The PA also treats the researchers employed by the facility who travel to remote locations and return with ailments related not only to radiation exposure but also more mundane problems such as stomach ailments. A physician is always on-site at the facility and coordinates care with the PA.
PA Versatility Shows at New York Presbyterian Hospital
A PA employed by New York Presbyterian Hospital treats a diverse population of hospital employees and Cornell University researchers. Her versatility is impressive, ranging from pre-placement exams to developing preventive worker safety measures. In conducting pre-placement examinations for candidates offered employment by the hospital, she tests for TB, illegal substances, and HIV, and gauges applicants' physical fitness to perform job duties. This PA also serves as a main contact person for impaired employees, making referrals to drug and alcohol treatment centers.
As a certified New York state HIV educator, the PA at New York Presbyterian Hospital conducts employee safety training for hospital employees at risk for HIV exposure through blood or body fluid exposure. This PA also oversees a program addressing the special health needs of Cornell researchers working in a Biosafety Level 3 Lab. Here researchers are exposed to a variety of health risks through their contact with lab animals, including rare viruses. To protect against these hazards, the PA has devised and implemented lab safety measures in cooperation with the New York State Department of Health and laboratory and hospital officials.
CDC Employs Occupational Medicine PAsAt the federal Centers for Disease Control and Prevention (CDC), a PA cares for researchers who typically spend a month at a time in "hot spots" or disease outbreak areas around the world. His practice combines travel medicine with infectious disease medicine. Researchers generally return with at least one ailment, ranging in seriousness from digestive problems to malaria. One of the PA's specialty areas is the testing of researchers' fitness for the use of physically demanding protective gear. Cardiopulmonary tests gauge employees' fitness for use of protective gear used in highly toxic environments. Working closely with his supervising physician, he coordinates the annual bioterrorism fitness exams required of CDC researchers.
His other large patient base consists of CDC office workers who typically suffer from carpal-tunnel syndrome and similar repetitive stress injuries. In these cases, the PA collaborates with the CDC's industrial hygienist to restructure employees' workstations along ergonomic standards and trains employees in preventive measures against repetitive stress.
State Department Counts on Versatility
The U.S. Department of State employs occupational medicine PAs to provide medical care to State Department employees and their families overseas. For example, a PA working for the State Department manages family medicine as well as emergency medical crises. In addition, he serves as the medical liaison between employees and host country medical personnel and facilities, inspecting local hospitals to determine their quality of care. In countries where acceptable inpatient care is not available, he has developed alternative sites where patients can be stabilized prior to airlift to hospital. This PA's work epitomizes the clinical range and organizational versatility of PAs in occupational medicine.
PA Practice at Saint Raphael's Occupational Health Plus
The hospital-based occupational medicine practice where I work has 300 clients. For our federal clients, like the FBI and the Post Office, we perform pre-employment physicals and treat injuries that are covered by FECA. With respect to the workers on the merchant ships arriving in New Haven Harbor , virtually all illnesses and injuries are covered under workers' compensation. We do a lot of work with employees who have back, shoulder, and knee injuries. In order to be most effective as a clinician, it is important for me to be familiar with the workplace and know about the workers' compensation system so that informed decisions can be made about returning employees to work.
My day at Saint Raphael's Occupational Health Plus is typically divided between seeing employees with work-related injuries and doing examinations on individuals who are being hired or employees who need periodic screening. Injuries are generally musculoskeletal sprains and strains, but may also involve lacerations, burns, fractures, or eye injuries. Evaluating and treating employee exposures to infectious agents like tuberculosis or bloodborne pathogens (i.e., Hepatitis B or HIV) may also be involved. Pre-placement examinations are performed immediately before the employee is hired. Periodic examinations are performed to evaluate potential health effects of exposures to chemicals or other things in the worker's environment. They are also completed to evaluate the worker's continuing ability to safely perform their jobs, such as DOT physicals for truck drivers or respirator examinations for firefighters.
What does it mean for my practice that I can not sign FECA claims forms as a PA? The bottom line is that unless the physician signs the form, the DOL's Office of Workers' Compensation will not honor the FECA claim. At a minimum, this means that the physician can not make the maximum use of my skills and must sign every workers' compensation form. Quite frankly, this is not the best use of the physician's time and expertise. The problem is exacerbated when I'm performing on-call services for the practice or if I'm providing after-hours care at the practice. Physicians hire PAs to extend their reach and to extend access to care. Many physicians also hire PAs to make life a little easier for them - to share on-call duties and to provide after-hour care.
The Problem with the Federal Employees Compensation Act
In letters responding to congressional inquiries on PAs and FECA, the Office of Workers' Compensation has taken the position that claims or reports are not acceptable if they have been signed by a PA, because PAs are not included in FECA's definition of "physician" (section 8101 (2)).
In a December 2001 letter to Senator Gramm, the Director of the Office of Workers' Compensation Program wrote:
OWCP is responsible for the administration of the Federal Employees' Compensation Act (FECA). In Section 8101(2) of this Act, physicians are defined as surgeons, podiatrists, dentists, clinical psychologists, optometrists,chiropractors, and osteopathic practitioners within the scope
of their practice as defined by State law.
Since Physician's [sic] Assistants are not included in this definition, we are unable to accept their clinical reports as medical evidence unless these reports are countersigned by a physician.
Why It Makes Good Sense and Good Public Policy to Update FECA to Allow PAs to Diagnose and Treat Federal Employees who are Injured on the Job
Simply put, the current restriction limiting PAs ability to provide care to federal workers who are injured on the job results in added costs to the system, unnecessarily limits federal workers' access to quality medical care, restricts federal workers' choice of preferred health care professional, and may result in problems related to continuity of care.
PAs currently jump through hoops to ensure that physicians sign the workers' compensation claim in order to make the system work for the injured employee and the practice. However, physicians aren't always available - particularly in rural and urban medically underserved communities where PAs may be the only health care professional serving the community or in clinics staffed by PAs that provide care during evenings and weekends. Following are a few of the personal examples that we've heard from PAs regarding the FECA problem.
- A PA in Georgia informed us that federal workers were advised to use hospital emergency rooms for non-emergency care, rather than receiving care after-hours at local clinics where PAs were the only health care professional on-site. Ironically, the care provided in the emergency room could be provided by a PA - at 4-5 times the cost.
- A federal worker in Massachusetts recently asked a PA in a surgical practice where he had undergone surgery to suture a laceration on his leg that occurred while on the job. The physician was not in the office that day, and the PA had two choices - to send her patient to the emergency room or to provide the care, knowing that the practice wouldn't be reimbursed. She chose continuity of care and sutured his leg.
- Every rural community in the nation has at least one employee of the U.S. Postal Service. A PA from Iowa commented that it made no sense that she could provide medical care to this employee on an ongoing basis, but not be able to collect reimbursement for attending to a dog bite or other injury that occurred on the job.
We also understand that the FECA issue is particularly troublesome in the Peace Corps and State Department where many injuries and illnesses are covered under the Federal Workers' Compensation Program.
As federal employees, Subcommittee Members and staff have the option of seeing a PA through your Federal Employee Health Benefit Plan. But, you may not be able to see the PA if you're injured during working hours.
There is also another very good reason to update FECA to allow PAs the ability to diagnose and treat injured workers - the shortage of physicians in occupational medicine. According to the American Board of Preventive Medicine, only 3,332 physicians have been certified in occupational medicine since 1955, and only 1,500 -1,800 of these physicians are actually in practice today. This number falls far below the Bureau of Health Professions' estimated need of 4,830 physicians certified in occupation medicine or the Institute of Medicine's need estimate of 3,100 -5,500 occupational medicine physicians.
We believe that expanded access to care and continuity of care for federal workers are compelling reasons to update FECA to recognize PAs, as are potential cost savings and meeting the need that is created by the physician workforce shortage in occupational medicine. After all, that's why the physician-PA team concept was created - to expand the physician's ability to provide care.
Thank you for the opportunity to present testimony before the Subcommittee. I look forward to responding to your questions.
STATE WORKERS' COMPENSATION PROGRAMS
State
PA Covered Provider
Services Covered
ALABAMA
Yes
Determined in pre-authorization. PA limited to 99201, 99211 evaluation and management codes; 12.5% reimbursement for first assisting
ALASKA
Yes
All medical services cited in PA law
except assisting at surgery
ARIZONA
Yes
Same as PA law, first assist 10%
ARKANSAS
*
CALIFORNIA
Yes
Insurer authorizes PA services, first assist 10%
COLORADO
Yes
Insurer authorizes PA services, first assist 10%
CONNECTICUT
Yes
Same as PA law
D. C.
No
DELAWARE
*
FLORIDA
Yes
75% of physician allowable
GEORGIA
Yes
Same as PA law
HAWAII
Yes
Maximum 15% for first assisting
IDAHO
*
Same as PA law
ILLINOIS
*
INDIANA
*
Check with individual company
IOWA
*
KANSAS
Yes
All practitioners limited to $500 unless pre-authorized by employer
KENTUCKY
Yes
20% reimbursement rate for first assisting
LOUISIANA
Yes
Same as PA law
MAINE
Yes
50% for first assisting
MARYLAND
Yes
All services cited in PA law except
first assisting at surgery
MASSACHUSETTS
Yes
All medical services cited in PA law except administration of anesthesia and ionizing radiation
MICHIGAN
Yes
13% reimbursement rate for first assisting
MINNESOTA
Yes
Same as PA law. Reimbursement for assisting in surgery depends on facility type.
MISSISSIPPI
No
MISSOURI
*
MONTANA
Yes
Same as PA law
NEBRASKA
Yes
Same as PA law
NEVADA
Yes
Rural PA contacts physician daily when treating workers comp patient, 14% for first assisting
NEW HAMPSHIRE
Yes
Same as PA law
NEW JERSEY
*
NEW MEXICO
Yes
First assisting determined by insurance carrier
NEW YORK
Yes
Same as PA law
NORTH CAROLINA
Yes
All medical services cited in PA law except
first assisting at surgery
NORTH DAKOTA
Yes
10% reimbursement for first assisting
OHIO
Yes
Same as PA law
OKLAHOMA
Yes
10 % reimbursement rate for first assisting
OREGON
Yes
PENNSYLVANIA
Yes
Same as PA law
RHODE ISLAND
Yes
16% reimbursement rate for first assisting
SOUTH CAROLINA
Yes
Same as PA law
SOUTH DAKOTA
Yes
10% reimbursement rate for first assisting
TENNESSEE
Yes
TEXAS
Yes
Same as PA law, 10% for first assisting
UTAH
Yes
PA cannot take anyone off work
VERMONT
Yes
Same as PA law
VIRGINIA
Yes
Same as PA law
WASHINGTON
Yes
Same as PA law
WEST VIRGINIA
Yes
Same as PA law, 15% for first assisting
WISCONSIN
Yes
WYOMING
Yes
Same as PA law, 15% for first assisting
*Individual workers' compensation insurance carriers determine coverage policy. The state has no specific policy regarding medical services provided by PAs.
This chart is based on information gathered from phone calls made to workers' compensation offices throughout the country. Blank spaces indicate incomplete information provided by state agencies. It is best to call the state workers' compensation offices for specific information about their policies regarding coverage of medical services provided by physician assistants. In most cases (except when the reimbursement rate is less than 100%) services provided by PAs are billed under the physician's name and provider number. 5/9/03
Last Revised: 5/26/05
