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Fiscal Year 2009 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
UNITED STATES HOUSE OF REPRESENTATIVES
REGARDING FISCAL YEAR 2009 APPROPRIATIONS
March 31, 2008
On behalf of the more than 68,000 clinically practicing physician assistants in the United States, the American Academy of Physician Assistants is pleased to submit comments on FY 2009 appropriations for Physician Assistant (PA) educational 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 2009, 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.
Title VII safety net programs are essential to the development and training of primary health care professionals and, in turn, provide increased access to care by promoting health care delivery in medically underserved communities. Title VII funding is especially important for PA programs as it is the only federal funding available on a competitive application basis to these programs.
The Academy is extremely concerned with the Administration’s proposal to eliminate funding for most Title VII programs, including training programs 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 5,500 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. The increased funding for these CHCs will provide medical care to approximately 6 million people in the U.S. However, these centers must have an adequate supply of primary care clinicians to serve these facilities and communities. And across the country today, Title VII is fulfilling that role by providing funding for the pipeline of health professionals that serve CHCs now and in the future.
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 to restore funding to these important programs in FY 2009 to the FY 2005 funding level.
Overview of Physician Assistant Education
Physician assistant programs train students to practice medicine with physician supervision. PA programs are located within 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 26 months of instruction, and the typical student has a bachelor’s degree and about four years of prior health care experience. The first phase of the program consists of intensive classroom and laboratory study. More than 400 hours in classroom and laboratory instruction are devoted to the basic sciences, with over 75 hours in pharmacology, approximately 175 hours in behavioral sciences, and almost 580 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 – family medicine, internal medicine, pediatrics, and obstetrics and gynecology – and various specialties, including 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 hours every two years, and they 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 allowed by law and are within the physician’s scope of practice and the PA’s training and experience. All 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 medical and surgical specialties. Fifteen 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 37 percent of PAs are in primary care. In 2007, an estimated 245 million patient visits were made to PAs and approximately 303 million medications were prescribed or recommended by PAs.
Critical Role of Title VII Public Health Service Act Programs
Title VII programs promote access to health care in rural and urban underserved communities by supporting educational programs that train health professionals in fields experiencing shortages, improve the geographic distribution of health professionals, increase access to care in underserved communities, and increase minority representation in the health care workforce.
Title VII programs are the only federal educational 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, nurse training, 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 – the purpose of Title VII.
Furthermore, Title VII programs seek to recruit students who are from underserved minority and disadvantaged populations, which is a critical step towards reducing persistent health disparities among certain racial and ethnic U.S. populations. Studies have found that health professionals 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 Educational Programs
Targeted federal support for PA educational 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 educational 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, 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. In New York, a PA program with a 90% ethnic minority student population 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 needs of medically underserved areas or disadvantaged students. The need is very real, and Title VII is critical in meeting that need.
Need for Increased Title VII Support for PA Educational 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 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 2004 and 2014. Title VII funding has provided a crucial pipeline of trained PAs to underserved areas. One way to assure an adequate supply of physician assistants practicing in underserved areas is to continue offering financial incentives to PA programs that emphasize recruitment and placement of PAs interested in primary care in medically underserved communities.
Despite the increased demand for PAs, funding has not proportionately increased for Title VII programs that 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 2004 indicates an average annual increase of seven percent, a total increase of 256 percent over the past 20 years, as federal support has decreased.
Recommendations on FY 2009 Funding
The American Academy of Physician Assistants urges members of the Appropriations Committee to consider the inter-dependency of all public health agencies and programs when determining funding for FY 2009. 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 and Prevention (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 results of cutting edge research at NIH to 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 Academy respectfully requests that Title VII health professions programs receive $300 million in funding for FY 2009, 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 2009 appropriations.
Last Revised: 3/31/08
