Uncovering the “hidden value” of PAs

If a PA performs a procedure but no one knows about it, did it really happen? If a PA treats a patient but the service is billed under a physician’s NPI number, or performs pre-op services that are covered under a global surgery payment, did the PA contribute any revenue to the practice?

These kinds of questions are becoming increasingly relevant as health-care systems and public and private payers look to become more data-driven in their approach to determining the productivity and value of health professionals, and as healthcare transitions to fee-for-value reimbursement and rewarding quality.

Uncovering the “hidden value” of PA practice is a major element of AAPA’s 2016-2020 Strategic Plan, approved by the AAPA Board of Directors last year. “Documenting PA value through recognition and billing” was identified in the plan as one of the six key issues facing the profession, and the issue is also top of the list of concerns under one of AAPA’s four “strategic commitments to the profession”: Advance the PA Identity. (This story is the sixth in a continuing series of strategic plan–related articles.)

“This is one of the most important issues that AAPA will tackle in the coming months and years,” says then AAPA President Jeffrey A. Katz, PA-C, DFAAPA. “As we move toward a system that will reimburse us based on the quality of our care, we must make sure that PAs are represented in the data that is collected on that care.”

In fact, AAPA is already working hard on this issue. AAPA’s reimbursement team undertook an intensive research project to identify which of the major private third-party payers allow medical and surgical services delivered by PAs to be billed under the PA’s name and provider number, making them trackable through the claims process. Policies regarding PA billing can vary both by plan type (basic fee-for-service, Medicare Advantage, Medicare supplement, PPO models, etc.) and by state. Reimbursement staff is meeting with and lobbying identified payers to change those policies that do not authorize PA-provided services to be billed under the PA’s name.

As well, an AAPA task force is at work on a white paper, “Unmasking the Hidden Value of PAs,” that examines the issues surrounding the need to document the value of PA practice. The paper is scheduled to be published this year.

“Our goal is to provide some tools that PAs and organizations can use to quantify the value of the care PAs provide,” says task force chair Folusho Ogunfiditimi, DM, MPH, PA-C, who over-sees PAs and NPs at Detroit Medical Center.

 The hidden value of PAs

No definitive data are yet available, but the percentage of care that is provided by PAs but not billed for under the PA’s name is likely between 40 to 60 percent of all PA care, according to Michael Powe, AAPA vice president, reimbursement and professional advocacy.

PAs in administrative and leadership roles around the country agree that the issue is difficult to quantify, but of crucial importance.

“We do not have good data yet; we are just scratching the surface—but this issue is very real every day for me,” says Tim Pysell, DrHA, MMSc, PA-C, DFAAPA, who oversees more than 100 PAs as director of PAs at OrthoCarolina in Charlotte, N.C. “Our PAs do a lot of work that is not directly revenue generating — often not quantified or even quantifiable. It’s going to take some different thought processes to get to the real costs and value of healthcare. As a patient goes through the clinic, how much does each person cost and how much do they contribute? How much time does the PA spend and what is the cost of the PA’s time? We need very granular data to get to the real costs of healthcare as opposed to the historical way of doing it.”

“It’s all about data, data, data,” agrees Todd Pickard, MMSc, PA-C, director of PA practice at MD Anderson Cancer Center in Houston, one of the largest employers of PAs in the country. “There is now so much pressure in the regulatory, reimbursement and accreditation arenas to generate the data to demonstrate how what we are doing is different from the fee-for-service model.”

“Real value,” Pickard adds, “is not determined by how many bills you dropped. It’s about whether you got results for your patients in a timely fashion, and reporting such metrics as, “How many patients got urinary tract infections in the hospital from indwelling catheters? Much of what PAs and NPs do is about quality and safety.”

But at present, much of this type of care, important as it is, is not credited to the PAs who provide it. At MD Anderson, a survey found that about 60 percent of the patients seen by PAs were comanaged, due to the complexity of cancer treatment. This comanaged care is nearly always billed under physicians.

The role of electronic health records

One reason that the value of PAs and NPs is so often hidden is that electronic health records (EHR) systems are often designed primarily to capture the contributions of physicians. This is in part an issue with the inherent design of the systems and in part to do with the institutional rules of health systems and hospitals, PAs say “Whenever I see a patient in the hospital, the note has  to be cosigned,” says Lisa Shock, MHS, PA-C, senior director of clinical operations for WakeMed Key Accountable Care Organization in Raleigh, N.C. “If the EHR system changes the clinical care note and lists it under the physician’s name then it does not reflect the care that I personally delivered. We are working on this issue but it is hard to undo a process that has been programmed into the EHR system.”

Some institutions are trying to change how PA care is captured in their systems. Last year,  MD Anderson transitioned to a new system, the widely used EPIC, that should allow them to capture much more granular data about PA practice, Pickard believes.

“We will be able to more efficiently document the processes of care,” he says. “First generation electronic systems were very clunky, but newer versions allow us to get that data. We can better understand the demand for services, where there might be gaps or deficiencies in services. It will drive staffing models.”

But there is a lot of work to be done before EHR systems will truly be able to capture the nuances of real-world practice, says Alma Rodriguez, MD, vice president of medical affairs at MD Anderson. “One challenge has been to get [EPIC] to understand that we are multidisciplinary,” she says. “They are hung up on needing a primary care provider; in a cancer institution there are lots of different providers, all in it together. Another challenge is that in an interprofessional practice model the PA and I are tied at the hip. It is often hard to tell who should be billing for a particular service.”

“They were able to make some customizations but this has been very challenging for them,” Rodriguez added. “We will see how it goes; we should have some meaningful data in a few months.”

AAPA also has a work group of PAs and staff devoted to this specific issue. The EHR Work Group is developing educational materials aimed at both PAs and EHR vendors. The materials for PAs will be designed to help PAs understand the importance of proper EHR utilization and give them talking points for discussions with colleagues, while those for vendors will explain the value of identifying all health professionals who treat patients in order to promote transparency and accountability and to help identify quality teams.

Sharing in the savings

Making sure that PAs are present in the data will likely become even more important as healthcare systems and payers move further towards shared savings and other alternative payment models, even if the day when PAs will share in these savings is likely still some way off.

“These discussions are very nascent,” Shock says. “Even the physicians haven’t figured out yet how to share the dollars. I don’t know of any model where the PA is getting any of the shared savings.”

“Absolutely we are heading towards a place where quantifying will affect PA incomes,” Ogunfiditimi says. “But the effect of PAs being hidden in the data is probably more personal than related to payment at this point. As a professional you want to know how you are contributing to the organization. And as healthcare evolves more toward a focus on quality it will become more and more essential for PAs to be represented. It is going to be incumbent on all of us to really quantify the work of PAs and to link it to quality and patient satisfaction.”

“It is hard to tie payment to PA salary at this point,” Pysell says. “In my experience salaries will lag behind the performance. We need to look at how to identify value first and then look at compensation.”

Creating the future

Uncovering the hidden value of PAs will only become more important as reimbursement continues to move toward payment for value rather than volume, say PAs interviewed for this story. And this makes it imperative for them to be involved in laying the groundwork as health systems and practices begin to write the rules that may soon link how providers are paid to the data they are collecting.

“The shift to value-based reimbursement is driving this,” Pysell says.

“And this presents a huge opportunity for PAs to shine a spotlight on the value-added work they do that is not usually part of the process. I’m a firm believer that the best way to predict the future is to create it.”

“Get involved,” Pysell adds. “Take some time to get to know the finance people and the leadership in your institution. Make sure that when the idea of measuring the cost of healthcare starts to take hold, PAs have input into that. Approach leadership with something to add. Bring value and the money will follow.”

Article by Steven Lane, senior strategic writer for AAPA. Originally published April 2016.