Fiscal Year 2007 Appropriations

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TESTIMONY OF THE

AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS

SUBMITTED TO THE

SUBCOMMITTEE ON LABOR,

HEALTH AND HUMAN SERVICES,

EDUCATION AND RELATED AGENCIES

COMMITTEE ON APPROPRIATIONS

UNITED STATES HOUSE OF REPRESENTATIVES

REGARDING FISCAL YEAR 2007 APPROPRIATIONS

 

March 31, 2006

 

On behalf of the more than 58,000 clinically practicing physician assistants in the United States, the American Academy of Physician Assistants is pleased to submit comments on FY 2007 appropriations for Physician Assistant (PA) education programs that are authorized through Title VII of the Public Health Service Act.

A member of the Health Professions and Nursing Education Coalition (HPNEC), the Academy supports the HPNEC recommendation to provide at least $300 million for Title VII programs in FY 2007, including a minimum of $7 million to support PA educational programs. This would fund the programs at the 2005 funding level, not accounting for inflation.

The Academy believes that the recommended restoration in funding for Title VII health professions programs is well justified.

A review of PA graduates from 1990-2004 reveals that PAs who graduated from PA programs that received Title VII funding in the year of or year prior to graduation were 67% more likely to be underrepresented minorities, relative to those who attended PA programs that did not receive Title VII funding. Additionally, PAs who graduated from programs that received these monies were 43% more likely to work in a Rural Health Clinic.

Title VII safety net programs are essential to the development and training of primary health care professionals and contribute to the nation's overall efforts to increase access to care by promoting health care delivery in medically underserved communities.

The Academy continues to be very concerned with the Administration's proposal to eliminate funding for most Title VII programs, including zero funding for training in primary care medicine and dentistry. As Members of the Subcommittee are aware, these programs are designed to help meet the health care delivery needs of the nation's Health Professional Shortage Areas (HPSAs). By definition, the nation's more than 4,742 HPSAs experience shortages in the primary care workforce that the market alone can't address.  In addition, the Health Resources and Services Administration (HRSA) predicts that there will be a need for over 11,000 health care professionals to implement the President's Community Health Center (CHC) Initiative.Title VII serves as crucial funding for the pipeline of health professionals that serve CHCs today. We wish to thank the members of this subcommittee for your historical role in supporting funding for the health professions programs, and we hope that we can count on your support for restored funding to these important programs in FY 2007.

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.

The typical PA program consists of 111 weeks of instruction. 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, women's health, 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, physician assistants 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 every two years. Also to maintain certification, PAs must take a recertification exam every six years.

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-nine states, the District of Columbia, and the majority of U.S. territories authorize physicians to delegate prescriptive privileges to the PAs they supervise.

PAs are located in almost all health care settings and medical and surgical specialties. 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 2005, an estimated 221 million patient visits were made to PAs and approximately 278 million medications were prescribed or recommended by PAs.

Critical Role of Title VII, Public Health Service Act, Programs

A growing number of Americans lack access to primary care; either because they are uninsured, underinsured, or they live in a community with an inadequate supply or distribution of providers. The growth in the uninsured U.S. population increased from approximately 32 million in the early 1990s to nearly 45 million today. Simultaneously, the number of medically underserved communities continues to rise, from 1,949 in 1986 to more than 4,742 today.

The role of the Title VII programs is to alleviate these problems by supporting access to quality, affordable, and cost-effective care in areas of our country that are most in need of health care services, specifically rural and urban underserved communities. This is accomplished through the support of educational programs that train more health professionals in fields experiencing shortages, improve the geographic distribution of health professionals, and increase access to care in underserved communities.

Title VII programs are the only federal education programs that are designed to address the supply and distribution imbalances in the health professions. Since the establishment of Medicare, the costs of physician residencies, nurses, and some allied health professions training have been paid through Graduate Medical Education (GME) funding. However, GME has never been available to support PA education. More importantly, GME was not intended to generate a supply of providers who are willing to work in the nation's medically underserved communities. That is the purpose of the Title VII Public Health Service Act programs, which support such initiatives as loans and scholarships for disadvantaged students, scholarships for students with exceptional financial need, centers of excellence to recruit and train minority and disadvantaged students, and interdisciplinary initiatives in geriatric care and rural health care.

Furthermore, with compelling evidence that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations, it is essential to increase the diversity of health care professionals. Title VII programs are unique in that they seek to recruit students in the health professions who are from underserved minority and disadvantaged populations. This is particularly important, as studies have found that those from disadvantaged regions of the country are three to five times more likely to return to underserved areas to provide care.

Title VII Support of PA Education Programs

Targeted federal support for PA education programs is authorized through section 747 of the Public Health Service Act. The program was reauthorized in the 105th Congress through the Health Professions Education Partnerships Act of 1998, P.L. 105-392, which streamlined and consolidated the federal health professions education programs. Support for PA education is now considered within the broader context of training in primary care medicine and dentistry.

P.L. 105-392 reauthorized awards and grants to schools of medicine and osteopathic medicine, as well as colleges and universities, to plan, develop, and operate accredited programs for the education of physician assistants with priority given to training individuals from disadvantaged communities. The funds ensure that PA students from all backgrounds have continued access to an affordable education and encourage PAs, upon graduation, to practice in underserved communities. These goals are accomplished by funding PA education programs that have a demonstrated track record of: 1) placing PA students in health professional shortage areas; 2) exposing PA students to medically underserved communities during the clinical rotation portion of their training; and 3) recruiting and retaining students who are indigenous to communities with unmet health care needs.

The PA programs' success in recruiting and retaining underrepresented minority and disadvantaged students is linked to their ability to creatively use Title VII funds to enhance existing educational programs. For example, a PA educational program in Iowa uses Title VII funds to target recruitment efforts to disadvantaged students, providing shadowing and mentoring opportunities for prospective students, increasing training in cultural competency, and identifying new family medicine preceptors in underserved areas. PA programs in Texas use Title VII funds to create new clinical rotation sites in rural and underserved areas, including new sites in border communities, and to establish non-clinical rural rotations to help students understand the challenges faced by rural communities. One Texas program uses Title VII funds for the development of Web based and distant learning technology and methodologies so students can remain at clinical practice sites. A PA program in New York, where over 90 percent of the students are ethnic minorities, uses Title VII funding to focus on primary care training for underserved urban populations by linking with community health centers, which expands the pool of qualified minority role models that engage in clinical teaching, mentoring, and preceptorship for PA students. Several other PA programs have been able to use Title VII grants to leverage additional resources to assist students with the added costs of housing and travel that occur during relocation to rural areas for clinical training.

Without Title VII funding, many of these special PA training initiatives would not be possible. Institutional budgets and student tuition fees simply do not provide sufficient funding to meet the special, unmet needs of medically underserved areas or disadvantaged students. The need is very real, and Title VII is critical in meeting it.

Need for Increased Title VII Support for PA Education Programs

Increased Title VII support for educating PAs to practice in underserved communities is particularly important given the market demand for physician assistants. Without Title VII funding to expose students to underserved sites during their training, PA students are far more likely to practice in the communities where they were raised or the communities in which they attended school. Title VII funding is a critical link in addressing the natural geographic maldistribution of health care providers by exposing students to underserved sites during their training, where they frequently choose to practice following graduation. Currently, 36 percent of PAs met their first clinical employer through their clinical rotations.

Changes in the health care marketplace reflect a growing reliance on PAs as part of the health care team. Currently, the supply of physician assistants is inadequate to meet the needs of society, and the demand for PAs is expected to increase. A 2006 article in the Journal of the American Medical Association (JAMA) concluded that the federal government should augment the use of physician assistants as physician substitutes, particularly in urban CHCs where the proportional use of physicians is higher. The article suggested that this could be accomplished by adequately funding Title VII programs. Additionally, the Bureau of Labor Statistics projects that the number of available PA jobs will increase 49 percent between 2002 and 2012. Title VII funding has provided, and continues to provide, a crucial pipeline of trained PAs to underserved areas. One way to assure an adequate supply of physician assistants, especially PAs likely to practice in underserved areas, is to continue offering financial incentives, such as funding preferences, to PA programs that emphasize recruitment and placement of people interested in primary health care in medically underserved communities.

Despite the increased demand for PAs, funding has not proportionately increased for Title VII programs that are designed to educate and place physician assistants in underserved communities. Nor has Title VII support for PA education kept pace with increases in the cost of educating PAs. A review of PA program budgets from 1984 through 2003 indicates an average annual increase of seven percent, a total increase of 245 percent over the past 19 years, yet federal support has remained relatively static.   

Recommendations on FY 2007 Funding

The American Academy of Physician Assistants urges members of the Appropriations Committee to consider the inter-dependency of all the public health agencies and programs when determining funding for FY 2007. For instance, while it is important to fund clinical research at the National Institutes of Health (NIH) and to have an infrastructure at the Centers for Disease Control (CDC) that ensures a prompt response to an infectious disease outbreak or bioterrorist attack, the good work of both of these agencies will go unrealized if the Health Resources and Services Administration is inadequately funded. HRSA administers the "people" programs, such as Title VII, that bring the cutting edge research discovered at NIH to the patients - through providers such as PAs who have been educated in Title VII-funded programs. Likewise, CDC is heavily dependent upon an adequate supply of health care providers to be sure that disease outbreaks are reported, tracked, and contained.

The critically important programs administered by NIH, HRSA, and CDC are integral components within the nation's public health continuum. One component is not more important than another, and no one component can succeed without adequate support from each of the other elements.

Furthermore, while the Academy applauds the Administration's proposal to strengthen national security by increasing support for health emergency preparedness initiatives, it should not do so at the expense of Title VII programs. Training is the key to preparedness, and Title VII, section 747, is an ideal mechanism for educating primary care providers in public health competencies, facilitating population-based and community-based skills and training, and increasing the alliance between public health and primary care providers. This is particularly important for our nation's most disadvantaged and underserved populations, because they are the most vulnerable during medical emergencies due to a lack of resources and access to care.

The Academy respectfully requests that Title VII health professions programs receive $300 million in funding for FY 2007, including a minimum of $7 million to support PA educational programs.

Thank you for the opportunity to present the American Academy of Physician Assistants ' views on FY 2007 appropriations.