Saturday, March 23, 2019

What PAs entering the market want to know

Someone asked me what questions physician assistants (PAs) have when searching for a first job. As someone who recently accepted my first job working as a PA—I graduated from the PA program at Oklahoma City University in May 2018—I have spent some time thinking about this. I polled some former classmates to get their opinions. The consensus: We are enthusiastic and ready to jump in, yet we are cautious in our job search. Here are the six questions we ask ourselves, and our potential employers, as we interview and accept our first position.



What will the relationship with the supervising physician be like?



This was the single greatest concern among everyone I polled. As newly graduated PAs, we are excited about practicing, but we also know we need guidance, support, and mentorship to optimize our value to the practices where we will work. We want, and need, physicians who are willing to share their insights and time to make us the best providers we can be.


What is the salary and benefits package?



Salary and benefits represent another area of concern among recent PA graduates. Most PA students have significant education debt upon graduating and want to repay student loans as quickly as possible. According to the 2016 Statistical Profile of Recently Certified PAs, the average salary of a new PA is more than $92,000 and 77 percent have multiple job offers. We recognize there are differences in salary based on demographics and practice needs, but competitive benefit packages are important, including personal time off and reimbursement for continuing medical education, certifications, and license maintenance.


How would you describe the work environment and culture?



Many PAs chose the profession because they want to make a valuable contribution to a team and provide patient care. Team dynamics and work environment are therefore significant factors when looking for a job. As new grads, it is important for us to be in an environment that supports continued learning. Many PAs enjoy working with other PAs, which can affect which positions we apply for and consider in a job search. As with any other profession, work is much more enjoyable when there is a good staff dynamic.


Can you define the scope of practice?



We have many questions that revolve around scope of practice. What are our typical tasks and responsibilities? Will we assess and manage new patients, or will we be providing follow-up care? What role will we play in patient assessments and performing procedures? We understand that our practice patterns will be closely monitored as we onboard, and we are eager to learn and demonstrate our abilities. But it is equally as important for us to understand the degree of supervision when first beginning work and the degree of autonomy expected after gaining more experience.


Where is the practice located?



The location of practice can be very important. A job search can look dramatically different for someone who wants to work in a rural community compared to an urban community. Some new grads hope to work in a clinic, others would prefer to work in a hospital, and still others would like to have a mix of both. Furthermore, PA practice laws and receptivity to the PA profession by the public and medical community can make a big difference in one’s work life and practice—and can greatly vary depending on geography.


How would you describe the work-life balance?



A common concern among new grads is finding a job that provides a good balance between work and our personal lives. We want to know what is expected in terms of being on call, whether we will have unpredictable hours, and how long is a given shift. The ideal work-life balance looks different for everyone: Some newly graduated PAs want to maximize their time at work in order to cement knowledge gained while at school while others prefer predictable hours and a lighter load while starting out. Addressing this question up-front can outline the expectations of both the physician and PA to help find a great match for the practice.


The practice of medicine is an exciting and dynamic field, and we are eager to get started.


Physicians have an opportunity to find PA colleagues who are fully committed to helping the practice meet its goals. We are capable and dedicated to providing optimal care for patients. We look forward to finding jobs where we can continue to learn and grow.

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Friday, March 15, 2019

Caring for patients as they enter adulthood


Guest Post
Ericka L. Adler


When my children became teenagers, I allowed them to see their orthodontist and pediatrician by themselves for minor issues. Nothing disastrous ever happened, and the providers never had any issues or complaints. That was great for me as a working mom.


Previously, I wrote about how providers can care for unaccompanied minors without risk to their minor patients, or their practice, as long as they meet certain legal requirements.

Another not-so-minor matter I have advised clients on is how medical practices should care for patients seen as minors who continue to be in their care after they turn 18. Many practices, especially those with long-term relationships for chronic medical conditions, often forget the legal formalities when their patients become adults.

Here are some issues for medical practices to consider:
Make sure the practice has a way of monitoring when patients turn 18 so that it can be sure to comply with HIPAA. Violations can be avoided by having a formal process in place.

HIPAA dictates that once patients turn18, parents or legal guardians can no longer have access to their child’s medical records or information. While parents are likely to still call, make appointments, and accompany their child to appointments, medical information can no longer freely be shared.

Patients over 18 who wish to share health information with their parents must complete a HIPAA authorization form and such other documentation that state law and the provider may require, depending on the information to be shared. The authorization may restrict what information can be shared, so parents will not necessarily have access to all information.

Since parents may cover their child well past age 18 on their health insurance, this can often lead to the incorrect belief that HIPAA does not apply. Practices need to be careful not to disclose protected health information improperly when answering insurance questions.

I generally advise my clients to share information in advance with patients and parents about what happens at age 18. In the event of a medical emergency, parents will not easily be able to make decisions or receive information about their child’s condition without having appropriate documentation in place. Failure to have documentation in place can create significant distress for all parties involved.

In addition to a HIPAA authorization, a medical power of attorney allows a child to appoint his/her parents as a medical decision-maker. A lawyer can provide both parties a form that complies with state laws. If patients will be attending college out of state, it’s wise to advise them to review that state’s legal requirements as well.

For medical practices that provide services to both minor and adult patients, it’s important to be prepared when patients turn 18. Education of parents and patients, as well as completing proper documentation, will protect all parties involved and ensure continuity of care in a legally-compliant way.

Ericka L. Adler has practiced in the area of regulatory and transactional healthcare law for more than 20 years. She represents physicians and other healthcare providers across the country in their day-to-day legal needs, including contract negotiations, sale transactions, and complex joint ventures. She also works with providers on a wide variety of compliance issues such as Stark Law, Anti-Kickback Statute, and HIPAA.


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Tuesday, March 12, 2019

Physician assistants improve healthcare in rural areas

I have been concerned with the maldistribution of rural health provider assets for decades. The situation is dire. The sad reality is that the number of physicians practicing in rural and medically underserved areas has been declining for decades. The reasons for this are complex. Practice in these areas is challenging from financial and quality of life perspectives. Many clinicians I know choose to work in metropolitan areas to find a “better life,” more opportunities, and more professional support.


The PAs I know who practice in rural and medically underserved areas tell me how much they love their work and their patients. They also express concerns about the isolation and the fatigue that comes with being the only provider in a small community with little professional support. It takes a special kind of clinician to work in this environment.


In a recent policy brief, the National Rural Health Association (NRHA) recognized the substantial resource that PAs represent in solving the crisis of rural healthcare and outlined steps to better utilize PAs to do so.


Approximately 15 percent of PAs practicing in 2017 (17,280 out of 115,200 total) practiced in rural or frontier counties, as opposed to 11 percent of practicing physicians. The NRHA also found that at least in Iowa, Texas, California, and Washington state, PAs practiced in rural areas in higher percentages than other providers.


PAs are uniquely qualified to fill an expanded healthcare role in rural and medically underserved areas due to their broad generalist education and a 50-year track record demonstrating competence and skill. One issue that stands in the way of PAs practicing at the top of their experience and training is overly restrictive state laws and regulations governing PA practice. The NRHA recommends, in addition to changing state laws, that scope of practice for PAs be determined at the practice level by the teams they work with.

The NRHA policy brief supports the tenets found in the American Academy of PAs’ Optimal Team Practice (OTP) policy, which are:


Emphasize PAs’ commitment to team practice;

Authorize PAs to practice without an agreement with a specific physician—enabling practice-level decisions about collaboration;

Create separate majority-PA boards to regulate PAs, or give that authority to healing arts or medical boards that have as members both PAs and physicians who practice with PAs; and

Authorize PAs to be paid directly by all public and private insurers.

The simple fact of the matter is that physicians who work in rural areas need PAs to practice to the full extent of their training and experience. It is a quality of life issue, and PAs have shown over their long history to be competent, safe, and efficient providers in rural and all other areas of medicine and surgery. PAs have also shown since the inception of the PA profession to be part of solution and not part of the problem when it comes to healthcare delivery.

I have lived in a lot of rural areas in my life, and I have practiced in medically underserved areas. Some of the reasons that physicians and PAs choose rural practice are obvious—the outdoors, clean air, simple living, low crime, low traffic, and other characteristics of rural areas appeal to folks looking for a better, simpler life. The reasons that some folks choose not to live in more isolated areas are a lack of professional support, a lack of resources, fewer opportunities for relationships, and fewer cultural amenities, among other barriers.

I have thought a lot about this problem from a policy standpoint. If we want clinicians to consider rural practice, we have to reduce some of the barriers and incentivize people to work there. It would also be helpful to remove some of rules and regulations that get in the way of team practice of medicine and the practice of medicine in general.I’ve already mentioned OTP, which would help PAs in rural practice, but things like easier implementation of telemedicine would make rural practice much more appealing by increasing providers access to specialty care in remote areas. Tax credits and loan forgiveness for physicians and PAs who commit to rural practice are other possible incentives.

This is a massive problem that will only get worse as the rural population ages and the ratio of rural patients to physicians and PAs gets more upside down. Reversing this trend will require a comprehensive policy solution that includes PAs front and center in ensuring that rural Americans have access to quality, affordable healthcare.

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Thursday, March 7, 2019

The legal risks of an MSO agreement

Medicine is big business. For this reason, everyone wants a piece of it, including those who are not physicians or involved in healthcare in any way. As a result, it is not uncommon to find businesspeople, venture capital firms, and those looking to profit from medicine opening medical businesses. This is easily done in some states as laypeople can hire physicians, own medical practices, and profit from the practice of medicine. In other states, this process is more complicated because of laws limiting the involvement of nonphysicians in the practice of medicine, such as the corporate practice of medicine doctrine, as well as limitations on sharing physician fees and similar restrictions.


In those states where it’s more difficult for businesses to engage in the practice of medicine, a popular approach is to use a management service organization (MSO) model. Under this model, a management company is formed to “operate” a medical/professional entity. The MSO may provide the space, equipment, supplies, nonprofessional staff, and other needs of a practice. For the practice itself, however, a professional entity must be formed and, most importantly, a physician must be found to own the professional entity. This approach is especially popular for medical spas and urgent care centers.


Physicians who are invited to own a professional entity under the MSO model are often referred to as “friendly physicians.” They are usually paid a small monthly fee for medical director services, though they may actually render clinical services as well. These types of arrangements can be risky for physicians who may not consider the legality along with the associated financial and legal risks when they accept the position.


Before accepting a position, here are some questions for “friendly physicians” to consider.


What type of insurance will physicians need to maintain? In addition to malpractice, directors and officers liability (D&O) insurance may also be required.


Does owning the professional entity or providing services on behalf of such entity impact the physicians’ full-time position or existing medical practice, if applicable? It’s always important to check any employment agreements for noncompete provisions and other restrictions. Many MSOs will also require physicians to enter into a noncompete provision, which need to be carefully considered.


Is the financial arrangement legal? Certain arrangements may not comply with state fee-splitting laws. Furthermore, these arrangements may not be written in a compliant manner if the MSO involves patients who are covered by a government program. Any medical director or other agreement should be reviewed to comply with applicable federal and state laws.


What is the financial risk for the physicians who agree to these arrangements? Typically, the MSO—through a management agreement—arranges all the vendors, the space lease, the billing and collections, and the taxes. Even if the MSO is overseeing these tasks, the contracts and expenses can be in the name of the entity, for which the physicians are listed as owner. If the MSO goes out of business or defaults on these obligations, what protection do physicians have from creditors? What information is shared with physicians about the financials, so they can be protected? Indemnification provisions are extremely important in this type of arrangement and, depending on the structure of the deal, additional precautions may be appropriate.


How will physicians’ name, Tax Identification Number (TIN), and the professional entity’s provider number be used, especially if the MSO is handling the billing and collection activities?What liability might she face for fraudulent or wrongful billing in which the MSO engages in her (or the entity’s) name? I recommend purchasing an insurance policy to cover this possible event as well as indemnification provisions. Physicians should also fully understand how their information will be used when billing payers.


Are physicians required to file and review certain supervision agreement/prescriptive authority documents with the state? MSOs may or may not be familiar with these requirements. Additionally, state laws may limit physicians to supervising only those professional activities that they are experienced in. These are important considerations for the physician since it implicates their license.


These are just a few of the concerns that arise in “friendly physician” deals with an MSO. Physicians must consider the legal and financial risk they may be taking in such deals, especially if the role is merely side work and not their primary job. Government investigation, bankruptcy, unpaid taxes, and other possible repercussions can have a serious impact on physicians’ licenses and their reputation in the community. While these types of transactions are certainly doable, it’s important to have legal counsel review all documents before they are executed.

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