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

2. Disclosure
I am a PA

3. 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

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

5. The Physician/Mid-level Team

6. What is a Mid-Level Provider?
The Wingman

7. 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

8. 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

9. History of Mid-Level ProvidersPA NP
Established in 1967 – in response to shortage of primary care MDs
First PA Program at Duke
Currently 123,000 PAs in practice, 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

10. 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

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

12. Mid-Level Role (Cont)

13. 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

14. 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

15. 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

16. 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?

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

18. 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

19. 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

20. 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

21. 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

22. 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, clinical hours (every 5 years)
No recertification test
Multiple certifying bodies

23. 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

24. Orthopedic Specific CertificationsPA 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

25. 3 ONP-C in WI ONP-C® – Orthopaedic Nurse Practitioner Certified
 0 certificants
1 – 5 certificants
> 6 certificants
3 ONP-C in WI

26. PA – Ortho CAQ
2 in WI
154 in US

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

28. 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

29. THANK YOU!