By Matthew Rudberg, MMS, PA-C
I started my career with MinuteClinic more than five years ago after working in family medicine, colorectal surgery, and thoracic surgery. It was an excellent decision: I’ve been able to provide high-quality care in the retail setting, and it has afforded me opportunities to work in a variety of clinical leadership roles. When I joined MinuteClinic we hired PAs in only four states (Minnesota, Texas, Nevada, and North Carolina), and we have subsequently added New Mexico, Rhode Island, Nebraska, South Carolina, and Maryland. We are continually looking to add states to increase our interdisciplinary workforce.
A couple of years ago, I attended an AAPA conference as an exhibitor and was profoundly struck by interactions I had with many of my colleagues. I believe I inspired some to work with their state PA organizations to get legislation modernized. Some PAs were hostile toward the retail concept. But many felt that PAs were getting left out of this innovative approach to medicine; their perception was that many retail clinics hire only nurse practitioners (NPs). The NP/PA rivalry was palpable during some of these conversations. I found myself in a position to remind them: The main issue is not NPs versus PAs but outdated state regulations for PAs. Outdated regulations are the primary reason that hiring of PAs in certain states is cost-prohibitive in a retail setting.
When I returned from the conference, I talked with Angela Patterson, MS, FNP-BC, chief nurse practitioner officer (CNPO) with MinuteClinic. We discussed some of the challenges she sees for PAs in retail medicine from her vantage point as an executive in the largest company in this setting, with more than 1,100 clinics run by PAs and NPs, in 33 states and the District of Columbia. Nationally, the company has served more than 20 million patients, with a 95 percent customer satisfaction rating.
Matthew Rudberg (MR): Angela, how long have you worked for MinuteClinic and in retail medicine?
Angela Patterson (AP): I have worked with MinuteClinic for 11 years.
I have been a nurse practitioner since 1988—for 29 years. Prior to MinuteClinic I worked in primary care.
MR: What drew you to retail medicine?
AP: As a primary care clinician in family practice, it was very apparent to me for at least 10 years before joining MinuteClinic that the structure of primary care at the time was not sustainable. In my mind, it was important that I start to do work that was about strengthening primary care in our communities because I always understood and embraced the fact that comprehensive, holistic primary care that focuses on health and well-being, health promotion, disease prevention, condition assessment, and management was really foundational to achieving the country’s agenda for health and healthcare reform. When I was contacted by MinuteClinic, I did my due diligence to research what the company was trying to do with healthcare. I was really moved by the commitment that the leadership of the organization had with regard to wanting to fulfill a purpose of increasing access to quality, affordable healthcare in the communities they served. So I left my practice to be part of a company that was trying to do something different in healthcare for what I considered all the right reasons.
MR: How have you seen the landscape change for PAs in your tenure with this company compared with how the landscape has changed for NPs?
AP: In the very first few years, working across many different states, I was seeing more organized and targeted activity through NP organizations to modernize practice. In the past five years, PAs have increased their organized activity to become strong, really start to move current practice laws and pick up speed in a way that NPs have been trying to do. The amount of activity I have seen by the PAs has come to the level I have seen previously with NPs, and I really appreciate that. There are unfounded regulations or restrictions that are not based on evidence—for PAs and NPs. I am excited to see how these laws have modernized to increase access to quality care. It’s really what our patients ultimately need. MinuteClinic’s collaboration with AAPA has also increased to help advance the practice of PAs. As the landscape has changed in healthcare, the PA profession has evolved, and more resources were moved from hospitals or specialists to primary care, PAs have really stepped up to say: “We can fill that void.”
MR: I am very excited we have been able to hire PAs in nine states now. What regulations do you typically see that prevent us from hiring PAs in different states?
AP: The biggest issues in our setting as a retail clinic are physician ratios and on-site requirements for supervision. MinuteClinic is not a traditional model—we have clinics across the entire country (which is novel in and of itself). The biggest issues are around scope of practice regulations, regulations that require on-site supervision, and tight PA-to-physician ratios. These regulations add expense for our practice setting and are unnecessary given that the services provided at MinuteClinic are well within the scope and training of PAs. These regulations require additional work hours from physicians that are not required for the type of patients we see and thereby limit access to care. There is no evidence that demonstrates these tight ratios or geographic restrictions improve quality, safety, or outcomes.
The other piece that is important is on the payer side. Payers can choose to supersede state regulations and refuse to credential PAs. Hawaii, for example, has good regulations for PAs, but the PAs can’t independently enroll in Medicaid and have to bill under physicians. Payers need to modernize and credential PAs independently.
MR: How is MinuteClinic collaborating with AAPA to advance the PA profession?
AP: We believe, as does AAPA, that PAs positively impact patient outcomes in the ambulatory care setting. We believe PAs are educated and trained to deliver quality, safe care in our setting, and we want to continue to be able to hire PAs. Also, being an organization that hires a large number of PAs, we recognize it is important to our workforce to be a good partner with their national professional organization.
MR: What do you see as the most significant challenge facing retail clinicians (excluding NP/PA differences)?
AP: The biggest challenge is to support clinicians over the long term in our organization; that’s purely because of two things. First, primary care that is at the heart of the community is hard work. The other thing that makes it really tough is we commit to care for the majority of our patients on off-hours, weekends, and holidays. As the CNPO, my key role is to make a satisfying job experience for our NPs and PAs as well as support their professional and talent development. The biggest challenge is keeping folks engaged when the work is really tough. Our professionals need to know how to assess every patient and determine the next step for the patient—doing that when your friends and family are not working is tough work.
MR: What are some barriers PAs, as a profession, should be focusing on in regard to retail medicine?
AP: There is a lack of knowledge regarding what we are doing in retail health. Better education across the profession in general is needed to focus on the fact that retail health is a legitimate part of PA practice. Part of the reason we haven’t been doing PA preceptorship is because schools didn’t want their students to rotate with us because they believed we were limited—which is untrue. This has limited the perception of PAs regarding what retail health is.
MR: Tell me where you see PAs and NPs collaborating to help fix the admittedly broken healthcare system.
AP: The most powerful thing we can do is work together to demonstrate how we impact access and patient outcomes. PAs and NPs are caring for probably the majority of patients in ambulatory and primary care settings. What’s needed is data that shows we positively impact access and patient outcomes. That’s how we are going to fix it: showing what you are doing and exceeding benchmarks. Those that are lobbying and working on legislation need the data to move the laws.
MR: In states where MinuteClinic doesn’t currently employ PAs, what action would you recommend PAs take?
AP: Support AAPA and your state PA association. You don’t have to be out there lobbying because they are out there supporting you. You have an amazing group of professionals that are supporting you. They need to be funded. As clinicians, we have a responsibility to be aware of what’s going on nationally in healthcare and how we can make a difference. We need to remember that our patients are at the center of everything we do.