The Need for PAs and NPs in Orthopedic Practice Jason Szpak PA-C

Disclosure I am a PA

Objectives Understand the team based approach and the role of mid-level providers on the orthopedic team Understand the requirements of a supervising/collaborative physician Be aware of the future of direction of mid-level professions

The Orthopedic Team Patient Physician PA/NP PT/OT Nursing Anesthesia Radiology Athletic Trainer Social Worker

The Physician/Mid-level Team

What is a Mid-Level Provider? The Wingman

What is a Mid-Level Provider? 50 year old professions Trusted health care providers 2014 Harris Poll found extremely high satisfaction rates among Americans who have seen a PA or have a family member who has seen a PA. 93 percent regard PAs as trusted healthcare providers and 91 percent believe that PAs improve the quality of healthcare Growing profession PA – Ranked #2 Best Healthcare Job 2018 (US News and World Report) Nurse Practitioner - #4 in demand job of 2018 (Forbes) A potential solution for musculoskeletal care supply shortage Relatively constant number of orthopedic residencies with a rapidly increasing demand for care by an aging population

A Mid-level provider is NOT…. A replacement for physicians Likely going to become an MD A Physician’s Assistant Settling because we couldn’t get into medical school “Lenny who just came out of community college” – Bill O’Rielly 2014

History of Mid-Level Providers PA NP Established in 1967 – in response to shortage of primary care MDs First PA Program at Duke Currently 123,000 PAs in practice, 13000 in ortho Nursing roles grew in 40’s and 50’s Established in 1965 – in response to shortage of primary care MDs University of Colorado Estimated 248,000 NPs in practice

Mid-Level Role in Ortho (Team Approach) Clinic New patient evaluation and management Ordering imaging, labs, prescribing, documentation Performing H&Ps Casting/splinting Patient education Office based procedures Ultrasound guided injections, use of biologics, veinipuncture Phone calls Hospital Rounds Taking Call – Patient calls, ER/Hospital Sports Event Coverage

Mid-Level Role (Cont) OR 1st assist. Second set of hands, eyes Patient positioning Wound closure Splinting Equipment troubleshooting

Mid-Level Role (Cont)

Orthopedic Urgent Care/Ortho After Hours Growing role for Mid-Level Providers Identify patients that need more emergent care/referral to subspecialist Increase access Streamline patient visits Decrease cost Patients see a provider with extensive experience in musculoskeletal injury

Advantages of Utilizing Mid-Level Higher levels of patient satisfaction, higher quality care, increased access, decreased wait times Better patient education = better outcomes Same surgical assistant, increase OR efficiency Less disruption of practice when MD not present

Requirements of MD PA NP Supervising Physician – must be identifiable at any given time Availability by phone (within 15 minutes by telecommunication or other means) No requirement for co-signature on charts or prescriptions in WI **Annual prescriptive review** 4 PAs per 1 MD Collaborating Physician – relationship must be documented

How should the provider be utilized Single vs multiple surgeons Independent vs collaborative vs hybrid Level of experience Same schedule vs separate schedules Which patients?

What do patients think mid-level providers should do? Patient Perspectives of Midlevel Providers in Orthopedic Sports Medicine – 2018 Orthopedic Journal of Sports Medicine Room for improvement – requires MD support

Billing/Reimbursement Clinic billing – May see new or established patients Medicare pays 85% of physician fee when billed under mid level name “Incident to” – Physician must be in the facility Must document that patient was seen under supervision of MD Co-signatures generally not helpful for billing Surgical Assist Fees Document in operative note the medical necessity of assistant Value is difficult to assess Post op appointments – global fees Value of efficiency (OR time) Lifestyle of physician

Education NP – nursing model PA – medical model Multiple pathways 2 ½ yr program after undergrad Often experienced in other health care roles (athletic trainers) 1st year didactic, 2nd year clinical rotations Generalist Training Currently Master’s Degree 5 programs in WI Marquette, UW Madison, UW Lacrosse, Concordia, Carroll NP – nursing model Multiple pathways Typically 2 years of experience as RN 2-3 year program Mix of classroom and clinical experience population focus – family practice, geriatric, neonatal, women’s health, psych Master’s or Doctorate degree 10 programs in WI

Education – cont Orthopedic specific training (on the job)- usually takes 6-12 months to fully function, depending on experience Ultimately, roles are very similar between PA and NP Consider being a preceptor – PA Programs need surgical rotations Possible employment Educate the mid-levels that will be staffing ER/Urgent care, family practice that will be referring

CME – advanced orthopedic training PAOS – Physician Assistants in Orthopedic Surgery National Organization – offers ortho specific CME conferences JBJS/JOPA – Journal of Orthopedics for Physician Assistants ($130/year) JOPA and JBJS reviews 50 CME credits annually Salary reports Fluoroscopic Injection guide AAOS – Resident rates for conferences, JAAOS subscription ($175) PA’s Guide to the Musculoskeletal Galaxy Lecture based and hands on (injection techniques, splinting/casting) Opportunities for surgeons and PAs to learn new procedures together WOS – Advance Practice Provider Membership Practicing with active member, member discounts/conferences

Recertification PA NP CME – 50 hours category 1, 50 hours category 2 (every 2 years) Recertify every 10 years (was previously every 7) Proctored exam New - computerized exam of 25 questions every quarter X 2 years assessing core medical knowledge CME – 100 hours of CME, 1000 clinical hours (every 5 years) No recertification test Multiple certifying bodies

Post Graduate Education Orthopedic Residency Programs 1 year of additional musculoskeletal training PA- 6 programs nationally NP – 2 programs nationally No additional boards Graduates awarded certificate

Orthopedic Specific Certifications PA NP Certificate of Added Qualification (CAQ) 2 yrs experience in ortho 150 hours of ortho specific CME Letter from attending physician 120 question test Valid for 10 yrs Orthopedic Nurse Practitioner Certification (ONP-C) 3 yrs experience as RN or NP 2 yrs work experience as NP Currently work as NP caring for patients with musculoskeletal conditions

3 ONP-C in WI ONP-C® – Orthopaedic Nurse Practitioner Certified  0 certificants 1 – 5 certificants > 6 certificants 3 ONP-C in WI

PA – Ortho CAQ 2 in WI 154 in US

Why obtain additional credentials? 62% Patient Perspectives of Midlevel Providers in Orthopedic Sports Medicine – Orthopedic Journal Of Sports Medicine 2018

Future of Professions PA NP Legislative changes in WI Optimal Team Practice Collaborative instead of supervisory Scope of practice determined by individual experience and education Eliminate ratio requirements (currently 4:1) Authorize to participate in disaster/volunteer activities without supervising MD, but within scope of practice Update relationship with WI examining board NP All programs converting to Doctorate in 2025 Seeking independent practice in WI

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