Preserving Rural Seniors' Access to Health Care

                              

TESTIMONY OF THE

AMERICAN ACADEMY OF PHYSICIAN ASSISTANTS

SUBMITTED TO THE

SPECIAL COMMITTEE ON AGING

 

UNITED STATES SENATE

REGARDING PRESERVING RURAL SENIORS’

ACCESS TO HEALTH CARE

 

August 8, 2008

 

On behalf of the nearly 70,000 clinically practicing physician assistants in the United States, the American Academy of Physician Assistants appreciates the opportunity to submit comments for the record on the role of physician assistants in providing and preserving health care for seniors in rural America.

Physician Assistant Practice

Physician assistants (PAs) are licensed health care professionals educated to practice medicine with the supervision of physicians. 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. In 2007, an estimated 245 million patient visits were made to PAs and approximately 303 million medications were prescribed or recommended by PAs.   

PAs in Rural Communities

PAs extend the ability of physicians to provide medical services and provide quality, cost effective medical care in communities across the country, delivering needed health care services in settings such as rural health clinics, community health centers, private practices, and public hospitals. Many PAs practice in areas with large Medicare populations, where they have been credited with improving access to quality, cost-effective health care for vulnerable Medicare patients. Fifteen 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).

Physician assistants have a long history of serving the underserved. Since the rise of the profession in the early 1970s, physician assistants have played a key role in providing needed health care services for medically underserved populations, such as frontier and border communities, small rural towns, and at-risk groups such as the elderly. The 1977 Rural Health Clinic Services Act increased and improved the delivery of health care to rural physician shortage areas by assuring Medicare (and Medicaid) reimbursement to certified clinics staffed by physician assistants working with physician supervision. In rural communities across the country, PAs are often the only health care professionals for some distance; as a result, PAs form a special connection with their communities and with the patients they serve – patients who utilize and rely upon their PA as their medical home.

Access and Continuity of Care Challenges for Rural Seniors

The Centers for Medicare and Medicaid Services holds that the 1997 Balanced Budget Act’s Medicare provisions regarding coverage of services provided by PAs does not apply to home health care, hospice care, or skilled nursing facility (SNF) care. As a result, Medicare beneficiaries who use a PA as their medical home and who have critical, chronic, or end-of-life care needs, are not able to have these important medical needs met. The problem affects Medicare beneficiaries throughout the United States, but it is especially acute in rural and other medically underserved communities where a PA is often the only primary care provider and has established relationships with Medicare patients that span a decade or more.

By definition, PAs work as part of a physician-PA team; that is the hallmark of the profession. Because direct on-site supervision is not generally required by state law, PAs are able to extend their supervising physician’s reach beyond the immediate community. Currently under Medicare, PAs must obtain the supervising physician’s signature on orders for hospice, home health, or SNF care. However, physicians aren’t always available to sign the forms, especially in remote communities if the physician is a great distance away or on travel, or in clinics staffed by PAs who by themselves provide the night and weekend care. Therefore, PAs who are otherwise able to provide full-spectrum care to patients as delegated by their supervising physician must ask patients to wait – sometimes days or weeks – because of paperwork requirements. For these Medicare patients, these delays can often mean decreased time at home with loved ones when little time remains, and places an unconscionable burden on patients and families to find alternative care outside of their medical home at a time when they are the most vulnerable.

The inability of PAs to certify and provide hospice, home health, or SNF care disrupts continuity of care and decreases the availability of care, especially in medically underserved communities, at a time when the Medicare patient most needs efficient and timely attention.

PAs have shared with us many examples of delays in health care for Medicare patients caused by the inability of PAs to order home health, hospice and SNF, or to provide the hospice benefit. In one such example, a Georgia grandmother was turned away from a skilled nursing facility when it was discovered that a PA had signed the form. The grandmother was sent home where she suffered a fall and was subsequently hospitalized.

 

In yet another, PAs at critical access hospitals in Nebraska and other states report difficulty with discharge planning. By law, critical access hospitals must have a PA or nurse practitioner on site fifty percent of the time. However, because Medicare will not accept the hospitals’ skilled nursing facilities orders that have been signed by a PA, many Medicare patients end up spending more time than necessary in a costly hospital bed while the problem is sorted out.

 

America’s seniors who utilize a PA for their medical home, especially those in rural areas, deserve the same access to care and continuity of care that their fellow seniors in non-rural areas receive.

 

Recommendations

The American Academy of Physician Assistants and the nearly 70,000 clinically practicing physician assistants across the country take great pride in the role PAs have played in increasing access to care to some of the country’s most geographically isolated or otherwise medically underserved communities. As cost-effective, high-quality, and critically needed health care providers, America’s physician assistants appreciate the Committee’s interest in looking for ways to increase and improve medical care for seniors, and look forward to being a continued part of the health care solution in future reform efforts. Thank you.

 

 

 

 

Last Revised: 8/13/08