Office of Personnel Management: Draft Classification Standard

     for PAs

September 30, 2003

 

U.S. Office of Personnel Management

Strategic Human Resources Policy

Center for Talent and Capacity Policy

Standards, Competencies, and Assessment Development Group

1900 E Street, NW, Room 6H31

Washington , DC   20415-8330

 

RE:          Draft Job Family Position Classification Standard for Professional and Administrative Work in the Medical Sciences Group, GS-0600

              GS-0603:   Physician Assistant

 

 

Dear Sir or Madam:

 

On behalf of the more than 46,000 clinically practicing physician assistants in the United States , the American Academy of Physician Assistants (AAPA) is pleased to submit comments on the draft GS-0600 job family standard (JFS). The AAPA is encouraged by the OPM's initiative to develop new qualification and classification standards for PAs and looks forward to working with the OPM to correct errors in the draft standards. The AAPA's comments are specific to the draft GS-0600 JFS as it relates to the physician assistant profession.

 

The PA profession was very young in 1970 when the Office of Personnel Management (OPM) first developed standards to establish minimum employment criteria for physician assistants (PAs) employed by the federal government. Unfortunately, for over thirty years, the Office of Personnel Management has used an inappropriate classification standard, the GS-610 nursing series, to determine the general service ratings for PAs. The absence of a classification standard that accurately reflects the educational preparation and role of the PA profession has resulted in significant recruitment and retention problems for PAs within the federal agencies. PAs have been hired at unusually low entry salary levels and grades, and senior level salary levels and grades have been capped.

 

Federal agencies have attempted to respond to the recruitment and retention problems in varied ways.

 

One of the most egregious problems with the current system is that the qualification standard improperly allows any individual with three years of medical school or any individual who has completed medical training, but lacks licensure to practice as a physician, to be employed as a PA. Until the Bureau of Prisons (BOP) adopted a policy in 2002 to require that all newly hired PAs be certified by the National Commission on Certification of PAs, which is possible only for graduates of accredited PA programs, many of the "PAs" employed by the BOP were actually foreign medical graduates who were unable to obtain state licenses to practice as doctors.

 

For 30 years, PAs employed in federal service have been classified according to inaccurate and unfavorable standards. As a result, PAs have been employed at a lower grade and salary than other comparable health care professionals. Federally employed PAs have also been subject to lower grade and salary caps than colleagues of other health care professions. The physician assistant profession is now a well-established profession, and it is time to institute federal qualification and classification standards that accurately reflect PAs' educational preparation and fairly evaluate PAs' contributions as health care professionals employed by the federal government. Accordingly, the AAPA strongly urges OPM to devote the time now to create good qualification and classification standards for federally employed PAs.

 

The AAPA is appreciative of the work undertaken by OPM to draft updated qualification and classification standards for PAs. However, the AAPA has serious concerns with the draft standards regarding --

 

We believe that the above problems reflect a continued misunderstanding on the part of OPM of the physician assistant profession. Accordingly, the AAPA's comments include information on PA education, the qualifications for individuals to practice as a PA, PA practice, the role of supervision in physician-PA practice, and the inadvisability of attempting to impose a state licensure requirement for federally employed PAs.

American Academy of Physician Assistants (AAPA)

 

The American Academy of Physician Assistants was founded in 1968 and is the only national organization representing physician assistants (PAs) in all medical specialties. The Academy educates the general public about the PA profession, assures competency of PAs through active involvement in the development of educational curricula and accreditation of PA programs, provides continuing medical education, and conducts PA-related research. The mission of the Academy is to promote quality, cost-effective health care, and the professional and personal growth of physician assistants.

 

Following years of frustration in unsuccessfully urging the OPM to develop new qualification and classification standards for PAs, the AAPA worked with members of the U.S. House of Representatives and the U.S. Senate during the 106 th Congress to introduce the PA Equity Act (HR 1697/S 909), legislation to require the OPM to develop a new classification standard for physician assistants based on the educational and practice qualifications required for PAs, including national accreditation standards.

 

Physician Assistants (PAs)   

 

Physician assistants are licensed health professionals, or in the case of those employed by the federal government, credentialed health professionals, who -

Physician assistants practice medicine as delegated by and with the supervision of a physician. 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. A physician assistant provides health care services that were traditionally only performed by a physician. Forty-seven states, the District of Columbia , and Guam currently authorize physicians to delegate prescriptive privileges to the PAs they supervise. An estimated 183 million patient visits were made to PAs and approximately 223 million medications were prescribed or recommended by PAs in 2002.

PAs work in virtually every area of medicine and surgery and are widely acknowledged as essential health care professionals.

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. Approximately forty 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. Ninety percent of PAs practice in outpatient settings.

 

According to the AAPA's 2002 Census Report, an estimated 3,204 PAs are employed by the federal government to provide medical care, including the Department of Veterans Affairs, the Department of Defense, and the Public and Indian Health Services.

 

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.

 

Quality of PA Services

 

Studies conducted by the Rand Corporation have found that PAs save as much as 20 percent of the costs of medical care, can perform at least 80 percent of the functions in an ambulatory care practice, and are widely accepted by patients. The congressional Office of Technology Assessment studied health care services provided by PAs and determined that "within their scope of practice, physician assistants provide health care that is indistinguishable in quality from care provided by physicians."

 

Professional liability insurance premiums are low, because PAs have been involved in very few lawsuits.

 

Supervision in Physician-PA Team Practice

 

A PA's scope of practice is determined by state law or federal standard, the supervising physician's delegation of responsibilities, the PA's education and experience, and the specialty and setting in which the PA works. Direction of the medical practice of the physician assistant is assured by the supervising physician, but this does not necessarily require the physical presence of a supervising physician at the place where services are rendered. Nor does this suggest that the PA does not exercise autonomous medical decision-making. Accountability for physician supervision of PAs may be determined prospectively, by scheduling, or retrospectively, by review of the charts - as determined by the physician-PA team. It is the obligation of each team to ensure that the PA's scope of practice is identified; that delegation of medical tasks is appropriate to the PA's level of competence; that the relationship of, and access to, the supervising physician is defined; and that a process for evaluation of the physician assistant's performance is established.

 

All health care is subject to supervision - whether it is medical care provided by a physician or physician assistant or nursing care provided by a nurse practitioner. For the physician-PA team, supervision is, by design, more defined. The fact that the supervisory role is part of the physician-PA team practice - whether it be a physician visit every two weeks for a PA practicing in a federally certified rural health clinic in the US or by telephone communication on an as-needed basis for a PA working in Liberia as a foreign service health practitioner through the State Department - should not be construed to suggest that PAs possess a lesser degree of competency or exercise a lesser degree of autonomy in the provision of medical care.

 

Eugene Schneller, PhD, trained as an occupational sociologist and a professor of Health Administration and Policy in the College of Business at Arizona State University , was an assistant professor at Duke University when the PA profession was born. He studied physician-PA team practice and understood the role of "negotiated performance autonomy," as well as its difficulty for obvious classification. In a 1994 article published in the Journal of the American Academy of Physician Assistants, Dr. Schneller wrote:

Two years of observing PAs in the Duke clinics, carrying out interviews with scores of PAs, conducting numerous discussions with PA educators and employers, and analyzing surveys led to a specification of the unique design features for the PA occupation - an occupation characterized by "negotiated performance autonomy." In short the occupation's design side-stepped the pitfall of the new medical technology occupations' susceptibility to narrow task definition.  

 

State Licensure and Federal Employment

 

State licensure laws regulate the physician-PA team practice for non-federal employees. All states require that a physician assistant's supervising physician(s) be licensed in the same state as the PA. In many cases, the states require that the supervising physician(s) be in active practice in the state as well.

For this and other reasons, the AAPA opposes any requirement that federally-employed PAs obtain a state license. The issue is not that the PAs employed by the federal government do not have the same (or in some cases, superior) qualifications as the thousands of PAs across the country who hold state licenses; rather, the state laws simply aren't practical for federal employees.

 

During 2002, the Department of Veterans Affairs, the Department of Defense, and the US Public Health Service all re-evaluated and reaffirmed their policy that it is not practical to require federally employed PAs to obtain a state license.

Individual Occupational Requirements for GS-603:   Physician Assistant Series

Although the qualification standards and functional classification code correctly identify the name of the profession, the draft individual occupational requirements for GS-603 continues to incorrectly name the profession as "Physician's Assistant." This must be corrected.

 

Two basic requirements must be met for any individual to practice as a PA in federal service.

  1. The applicant must be a graduate of a physician assistant educational program accredited by the Accreditation Review commission for Physician Assistants (ARC-PA), or by one of its predecessor agenciese [Committee on Allied Health Education and Accreditation (CAHEA), or the Commission on Accreditation of Allied Health Education Programs (CAAHEP)].
  2. The applicant must be certified by the National Commission on Certification for Physician Assistants (NCCPA) and maintain NCCPA certification throughout employment. (Maintenance of NCCPA certification requires the PA to log 100 continuing medical education requirements over a two-year cycle; reregister every two years; and sit for the recertification exam every six years).

Under no circumstances should the GS-603 physician assistant series be used to employ individuals who have completed or partially completed medical school or any other training as a health professional, but who do not meet the applicable qualification standards to practice in that profession.

 

Although the majority of applicants to PA programs have a bachelor's degree and experience in a health-related occupation, we caution the OPM not to use this criteria as a prerequisite for employment of PAs in the federal government. It more accurately describes the successful applicant to a PA program rather than a graduate PA. We have been informed that the current language has been used to deny eligibility to PA students and clinicians for National Health Service Corps scholarship and loan repayment programs, because they do not possess a bachelor's degree in a health-related occupation. Graduation from an accredited PA educational program and NCCPA certification allow an individual to practice as a PA, not a degree that was obtained prior to enrollment in the PA program.

 

The entry level for a PA in federal employment should be at a GS-11, with the ability to qualify for PA positions through the GS-15 level. Unless the federal system remunerates PAs at levels equivalent to the private sector, federal agencies will not be able to compete for PAs. Results of the 2002 AAPA Physician Assistant Census Survey indicate that the mean total income from primary employers for PAs who are not self-employed and who work at least 32 hours per week for their primary employer is $72,241; the median is $69,567. The comparable mean for PAs who have been in clinical practice for less than one year is $63,168; the median is $61,363.

 

The AAPA encourages the OPM to work with the Chief PAs in the Armed Services, Department of Veterans Affairs, and the Indian and Public Health Services to develop the criteria, including experience and knowledge, to be used as additional requirements for Grades GS-12 and above.

 

Physician Assistant, GS-603, Qualification Standards

 

The first sentence of the definition of physician assistant is correct; the second sentence is incorrect. It underestimates the role of the PA in medical decision-making. The second sentence states, "The work may include prescribing medications but does not include full responsibility for interpretation of medical findings requiring the professional knowledge and skills of the licensed profession." The statement suggests limits on PAs' ability to prescribe controlled and non-controlled medications that don't exist.

 

The AAPA is pleased that this statement uses the correct occupational title, "Physician Assistant."

 

As previously stated, studies have indicated that PAs, along with nurse practitioners (NPs), can perform at least 80% of the functions in an ambulatory care practice. Yet, the general occupational information for PAs, NPs, and physicians in the GS -0600 Medical Sciences do not reflect this. Although the general occupational information for PAs is good, there is no consistency in the presentation of the occupational information for PAs, NPs, and MDs.

 

Factor Level Descriptions

The AAPA is pleased with the inclusion of PAs at all levels of Factor 1, Knowledge Required by the Profession; Factor 2, Supervisory Controls; Factor 3, Guidelines; Factor 6, Personal Contacts; Factor 7, Purpose of Contacts; Factor 8, Physical Demands; and Factor 9, Work Environment.

 

The AAPA believes that PAs must also be added to

Inclusion of PAs in Level 4-6 is necessary to capture the role of experienced PAs as clinicians in the Armed Services, VA, Pentagon, NIH, and Public and Indian Health Services. Inclusion of PAs in Level 5-6 is necessary to capture the role of PAs who serve as PA Advisors and Chief PAs to Surgeon Generals and Under Secretaries for Health of the Armed Services and federal agencies.

 

Appendix F, Factor Illustrations

 

Appendix F's factor illustrations for PAs requires much more work. Again, there is no overall consistency in describing the functions that PAs, NPs, and physicians share. The factor illustrations for PAs are truly a mixed bag. Some are good; some are inaccurate; and some apply to PAs with certain jobs or specialties, while overlooking other PA functions.

 

Some incorrect statements in the appendices imply that PAs refer all patients and that there are separate medical protocols for PAs. There is no recognition that the PA may order, perform, and interpret diagnostic tests; make medical diagnoses; select and modify therapies; serve as the leader of a multidisciplinary team of health care professionals; develop protocol for the facility; manage and supervise clinic staff and resources, etc.

 

The job functions of a PA in a medical setting are broad and complex, and they should be reflected throughout the appendices in a way that captures the breadth of the profession and the increasing difficulty of the functions performed by an experienced PA.

 

The AAPA believes that the factor illustrations require greater attention and time. At a minimum, the AAPA recommends that OPM extend the deadline on comments for the draft qualification and classification standards to enable the AAPA and other parties to provide detailed comments on the factor level illustrations. The AAPA also recommends that the OPM consider convening a working group of PA representatives from the federal agencies that utilize PAs, PA educational programs, and the AAPA to refine the factor level illustrations for PAs. After 30 years of poor standards, we believe that it's essential to devote the time and attention to craft quality qualification and classification standards for federally employed PAs.

AAPA's Annual Census Reports of the PA Profession from 1991 to 2003 document a progressive decline in the number of PAs who report federal government employment. In 1991, nearly 13.4% of total profession was employed by the federal government. The percentage dropped to 6.8% in 2003.With the increasing demand for PAs in the private

market place, the federal government will not be able to compete for PA employees unless it develops qualification and classification standards that accurately reflect the profession's worth.

 

The AAPA is eager to work with the OPM to develop qualification and classification standards that truly reflect the educational preparation and value of the PA profession. Should you have any questions or require additional information, please do not hesitate to contact Sandy Harding, AAPA's Director of Federal Affairs, at (703) 836-2272, extension 3205.

 

We look forward to working with you.

 

Sincerely,

 

Stephen C. Crane, PhD, MPH

Executive Vice President, Chief Executive Officer

 

Last Revised: 10/1/03