Fiscal Year 2002 Appropriations

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

U.S. HOUSE OF REPRESENTATIVES

March 29, 2001

 

On behalf of the 41,000 clinically practicing physician assistants in the United States, the American Academy of Physician Assistants is pleased to submit comments on FY 2002 appropriations for Physician Assistant (PA) education programs that are authorized through Title VII of the Public Health Service Act.

 

A member of the Coalition for Health Funding (CHF), the American Academy of Physician Assistants supports the CHF recommendation to appropriate $44.285 billion for the Public Health Service in FY 2002. The Academy is also a member of the Health Professions and Nursing Coalition (HPNEC) and supports the HPNEC recommendation to provide at least $440 million to support the Titles VII and VIII programs in FY 2002. The Academy believes that the recommended increase in funding for the Title VII health professions programs is well justified. The 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 is very concerned with the Administration's proposal to reduce FY 2002 funding for the Titles VII and VIII programs. 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 2,800 HPSAs experience shortages in the primary care workforce that the market alone can't address. 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 these important programs in FY 2002.

 

Overview of Physician Assistant (PA) Education

 

PA programs provide students with a primary care education that prepares them to practice medicine with physician supervision. Physician assistant programs are located at schools of medicine or health sciences, universities, teaching hospitals, and the Armed Services. All PA educational programs are intensive education programs that 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, 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.

 

Physician assistant education is competency based. 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.

 

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-seven states, the District of Columbia, and Guam authorize physicians to delegate prescriptive privileges to the PAs they supervise.

 

PAs are located in almost all health care settings and in every medical and surgical specialty. Fourteen percent of all PAs practice in rural areas where they may be the only full-time providers of care (state laws stipulate the conditions for remote supervision by a physician). Approximately twenty percent of PAs work in urban and inner city areas. The majority of PAs are in primary care. Nearly one-quarter practice in surgical specialties. Seventy percent of PAs practice in outpatient settings. In 2000, an estimated 161 million patient visits were made to PAs and approximately 202 million medications were prescribed or recommended by PAs.

 

Critical Role of the 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 US population increased from approximately 32 million in the early 1990s to over 42 million today. Simultaneously, the number of medically underserved communities continues to rise, from 1,949 in 1986 to 2,800 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.

 

The 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 has 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.

Title VII Support of PA Education Programs

Targeted federal support for PA education programs is currently 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 and faculty, 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 program works. A review of PA graduates from 1991-1999 reveals that 16.5% of students graduating from PA programs supported by Title VII are from underrepresented minorities, compared to 7.7% of graduates from programs that did not receive Title VII support. Similarly, 13.5% of the graduates who attended PA programs receiving Title VII support during the eight-year period practice in underserved communities, compared to 10.1% of graduates of programs not receiving such support during the same period.

 

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 undersered areas, including new sites in border communities, and to establish non-clinical rural rotations to help students understand the challenges faced by rural communities. A PA program in Kansas has used Title VII funds to provide a significant portion of the training for 500 PA students in remote, medically underserved communities in the state. 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. Nevertheless, 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 the 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.

 

The supply of physician assistants is inadequate to meet the needs of society, and the demand for PAs is expected to increase. A 1994 report of a workgroup of the Council on Graduate Medical Education (COGME), "Physician Assistants in the Health Workforce," estimated that the anticipated medical market demand and the estimated workforce requirements for PAs would exceed demand. Additionally, the Bureau of Labor Statistics projects that the number of available PA jobs will increase 48% between 1998 and 2008.

 

Despite the increased demand for PAs, funding has not proportionately increased for the Title VII programs that are designed to educate and place physician assistants in underserved communities. Nor has the 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 1999 indicates an average annual increase of 7.2%, a total increase of 173% over the past sixteen years; yet, federal support has remained relatively static. The FY 2001 increase in appropriations for Title VII's Cluster on Training in Primary Care Medicine and Dentistry, which includes funding for PA education, represented the first real increase in funding in nearly a decade.

 

Recommendations on FY 2002 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 2002. 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, the good work of both of these agencies will go unrealized if the Health Resources and Services Administration (HRSA) 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. The Academy is particularly concerned that any increase for the NIH not be made at the expense of the health professions education program or other public health programs, as recommended this year by the Senate Budget Committee.

 

The American Academy of Physician Assistants is particularly appreciative of the increase in funding for PA education programs that was appropriated for FY 2001. Yet, the increase is not sufficient to meet the increasing demand for PA graduates in the growing number of medically underserved communities. Accordingly, the Academy respectfully requests that the Title VII health professions programs receive a 15% funding increase in FY 2002, including $10 million to support PA educational programs.

 

Thank you for the opportunity to present the American Academy of Physician Assistants' views on FY 2002 appropriations.

 

 

Last Revised: 10/10/03