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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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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When employees walk away from the job

Guest Post
Melissa Young, MD


My practice has had a fairly stable staff for the last several years, but I’ve had my share of unpleasant employee exits.


There was one who gave notice but one day up and left without saying a word.


There was another who quit but claimed I fired her. We were on the phone with unemployment, and it was her turn to tell her side of the story. She started with, “Well, Dr. Young was in another one of her moods…” I listened in angry silence. When it was my turn, I was honestly confused and asked, “I just want to clarify, she gets to collect unemployment even if she has a new job?” I knew she did since she wrote “start new job” on her desk calendar and told another employee all about it. Needless to say, she was ineligible to collect.


And then there was the one who was technically employed for about a month but was only physically present for a week. Someone was always sick, had to go to the doctor, or the car broke down.


But even when employees don’t give you troubles like these, they can still cause headaches.


An acquaintance of mine recently had a long-time employee who just disappeared one day, along with hundreds of dollars in cash and a few items from the office. There was proof should she wish to prosecute, but it’s more than the theft. She feels betrayed and violated. Now that former employee wants her last paycheck. It is our understanding that, by law, she cannot withhold this from the employee.


Some people are telling her to send the check and let it all go. That it isn’t worth the hassle for a few hundred dollars. Then there are others who feel she should fight this on principal because the employee committed a crime and should be held accountable. That a police report should be filed. Some have suggested deducting the losses from her paycheck but as far as us non-lawyers can tell, that’s not legal.


Regardless of what is legal or what a lawyer might advise, she has still been hurt by this employee's actions. Those actions are likely to cause a ripple effect throughout the physician's exisiting and future relationships with co-workers and staff. The theft is more than a monetary loss. It's a violation of trust.


What can physicians do to protect themselves from theft in the office? A good background check and references are helpful prior to hiring. Establishing a system of checks and balances system for cash transactions at the front desk is also important. No one person should be solely responsible for all the financial transactions. Physicians may also consider investing in security cameras. If there are any valuables or controlled medications, a good inventory must be kept.


Most physicians in solo practices are so busy seeing patients and running the practice that they don’t have time to serve as human resource managers and security officers. But we must find time to take steps to prevent such events when we can. Otherwise, we will pay the price.

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How to improve interactions with special needs patients

At the age of five, my brother, Guy, ran into the street and was hit by a truck while flying a kite. He suffered a traumatic brain injury and remained at the cognitive level of a 5-year-old for the next 53 years.


Since then, I have been fortunate to work with those with special needs, volunteering locally every week and with Special Olympics. I have witnessed firsthand peoples’ struggle to communicate with those with special needs.


As a certified physician assistant (PA) specializing in neurosurgery, I work regularly with other medical providers and special needs patients. From my personal and professional experiences, I can offer five suggestions that may help clinicians provide the best quality care to those with disabilities.

Prepare for the encounter in advance by reviewing patients’ histories.

Being prepared is paramount to a successful encounter for both clinicians and patients. The complex challenges of those with special needs requires extra preparation and a thorough review of their history. For example, if the patient has a central nervous system deficit, flaccid paralysis, or spasticity is consistent with their baseline, we clinicians must understand these crucial parameters.


Also consider in advance who will chaperone the patients. Wherever patients reside, it is imperative that they be accompanied by a reliable caregiver who is familiar with their activities of daily living and physical, social, and intellectual norms versus a driver who transports patients to the clinic. In a perfect world, physicians could schedule a phone consult before a visit with a caregiver/family member to better understand how they can make the visit most comfortable for patients.

Assume patients with disabilities understand what is being said to them.

It is common for clinicians to be uncertain about how to communicate to the patients for fear they may not understand questions or comments.


In most circumstances, speak to patients with disabilities first, even if patients are nonverbal, visually impaired, and/or have a blunt affect. We do not know how patients interpret interactions. Many clinicians assume that if the patients cannot see or speak, they may not comprehend what is being said. The human mind/body is extraordinary and will elicit clues and sensory mechanisms. We should not underestimate their ability to understand. After speaking to patients, it is also vital that the caregiver/family member then share their insights and answer pertinent questions for clarification.


I speak from personal experience. When I would escort my brother to a medical appointment, physicians would ask complicated questions directly to him, aware that he could not fully understand the question. However, he greatly appreciated that he was being spoken to directly. Guy would try to answer the questions as best he could. I would wait until Guy finished commenting, and then sensitively offer additional clarification to the questions.

Remember a disability is different than an illness.

While illness and disability can coexist, it is important to separate the disability from the acute care treatment plan. Patients and the caregiver/family member do not feel the disability needs a cure. Treating the disability as an illness inappropriately perpetuates the “sick” role and is ultimately disempowering for people who struggle with challenging conditions.

Allow additional time for visits.

Patients with disabilities need more of clinicians’ time than nondisabled patients because of their physical, communication, and cognitive barriers.


Patients with disabilities may need more time to express themselves, or they might use technological aids that delay the process. They may also need extra time dressing and undressing or require more time for clinicians to position and examine them.


When the family member/caregiver attends appointments, three-way conversations are more time-consuming. Patients with a cognitive disability require more detailed or simplified instructions and explanations. Some also require written material to support verbal directives.

Consider their vulnerabilities.

Patients with disabilities are more vulnerable to secondary complications, such as unattended minor infections that progress quickly to major infections. Patients with disabilities may also be economically vulnerable, age prematurely, or be at increased risk of physical, sexual or verbal abuse. Clinicians who look for these risk factors can offer a line of defense by recommending community resources or referrals.


Patients with disabilities afford us the chance for immense professional growth if we welcome the opportunity to remain clinically teachable and emotionally compassionate to those with special needs.

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What patients wish you said

Imagine you are a patient rather than a healthcare provider at your practice. Now, complete the following sentence: “I wish my healthcare team would communicate more clearly about…” What was your response?


Patients have strong feelings about what healthcare teams are and are not getting right when it comes to communicating with them. Understanding patients’ wishes helps healthcare teams create better care interactions and support patients both during and in-between appointments. Of course, knowing what patients expect when it comes to communicating about their healthcare can be challenging. But, when healthcare providers understand what patients want and expect from healthcare interactions, they can do a better job of creating healthcare experiences that satisfy patients.


West, a patient engagement communications provider, recently surveyed 1,036 adults and 317 healthcare providers in the United States to learn more about patients’ communication preferences. Survey findings identified 10 types of communication that patients say are important to them. Their communication wish list revolves around themes of prevention, disease management, and billing transparency.

Patients prioritize routine and preventive care outreach

Patients say they want more support from their healthcare providers between appointments so they can better manage their own health at home. West’s survey showed patients think it is important for providers to make communications more prevention focused by helping track lab results (77 percent); recommending and scheduling preventive tests and screenings (71 percent); sending text messages and participating in online chat sessions (60 percent); and using automated text, voice, and email reminders to encourage prevention and promote routine health management. Here’s a closer look at the prevention-focused communications patients want:


Updates about lab tests – Routine screenings and lab tests are an integral part of preventive care. Depending on the circumstances, waiting for lab results can range from mildly annoying to downright nerve-racking. It is not uncommon for patients to experience anxiety, worry, or fear when they are waiting to get their lab results. West survey data revealed nine in 10 providers (91 percent) agree that it is very or extremely important to communicate with patients about the status of their lab results. Healthcare providers can make the wait for test results less stressful by using their patient engagement technology to send patients messages so they know how and when test results can be retrieved.


Recommendations for preventive services – Patients rarely know when they are due for preventive exams or what screenings they need. Worse, many aren’t receiving guidance from their healthcare team. More than one in three patients (36 percent) report their healthcare team does not proactively recommend preventive screenings or they do a poor job communicating which preventive services are needed. Sending automated messages to let patients know they need to make an appointment for an annual exam or preventive screening, such as a mammogram or colorectal cancer screening, is simple and creates awareness about preventive care.


Text Messages – In the past seven years, patients’ interest in texting with providers has doubled. Texting is a widely popular form of communication, so providers shouldn’t be surprised that patients want healthcare professionals to text them. However, many providers have been slow to adopt texting. Nearly one-quarter (24 percent) of patients say they do not receive text messages from their healthcare team. Using patient engagement technology, providers can easily send patients mass or one-to-one text messages about routine care and prevention.


Health management advice – Patients welcome tips and information they can follow at home to maintain their health. A reminder to get 30 minutes of physical activity daily, recipes and healthy eating tips, or an invitation to join a smoking cessation program are just a few examples of the types of automated communications providers can send patients to encourage prevention and wellness. Although patients say they want to receive automated text messages, voicemails, or emails with prevention-themed advice, 21 percent of patients don’t currently receive these communications from their providers.

Disease management support is in demand

Approximately half of adults in the United States face the daily struggle of having to manage a chronic illness, and they don’t want to do it without help from their healthcare team. More than three in four chronic patients say it is very important for providers to give them personalized disease management recommendations based on their specific needs (78 percent) and help them understand their current and target health metrics (76 percent). Sixty-four percent of patients with a chronic illness want to receive medication reminders while 53 percent want providers to administer surveys or check-ins to monitor conditions, assess health risks, and help manage their chronic conditions. Here are examples of how providers can offer patients communication to support disease management:


Personalized recommendations – Nearly all (95 percent) healthcare providers agree it is important to give patients personalized—not generic—recommendations targeted to their conditions. Fortunately, sending disease-specific communications on a mass scale is easy for providers who leverage their patient engagement technology. For example, staff can send a series of emails with tips and information on lowering blood pressure to all of their patients who have been diagnosed with high

Information about health metrics and goals – For patients with chronic diseases, tracking health metrics is the first step to improving and maintaining health. Unfortunately, more than one-third (36 percent) of chronic patients say they don’t get enough information from their providers about health metrics. Patients want more frequent communication to help them understand what their health readings are, or should, be. After discussing health metrics during appointments, providers can follow up and send patients automated messages that clearly define goals for metrics like blood sugar, weight, or blood pressure. This guidance helps ensure patients know what range they need to work toward and whether they are within their target levels for optimal health.

Medication reminders – Patients with chronic diseases often rely on medication(s) to manage their health, but many struggle with adherence. Clear communication about medication can make a big impact. For example, automated reminder messages can help encourage patients to pick up and take prescribed medications. Medication adherence surveys can be used to identify medication issues, so providers can intervene when necessary.


Monitoring surveys – Patients with chronic diseases say they would prefer for their providers to proactively monitor their health and alert them of health risks. Survey check-ins give healthcare teams a way to do that. Teams can send patients automated messages with invitations to complete online surveys on their health. Surveys can be used to identify new and worsening symptoms. When survey data shows patients are struggling, providers can escalate cases and intervene to prevent avoidable issues.

Patients want better billing transparency

In addition to health and wellness themed outreach, patients expect providers to communicate about billing. Seventy-six percent of Americans want providers to give them an easy way to understand and pay for their medical bills. And 80 percent of patients say it is very important for healthcare providers to help them understand what is covered by insurance and how much they are responsible for paying. Here is a look at how healthcare teams can grant patients’ wishes for better communication about billing:


Manage expectations for insurance vs. patient responsibility – Not knowing what to expect when it comes to medical expenses is both common and frustrating for patients. Despite wanting to help patients understand what insurance covers, 35 percent of providers give their organization a poor grade for communicating about out-of-pocket expenses. A simple action like sending an automated message prior to appointments to let patients know they need to make a copayment helps manage expectations.


Make medical bills easy to understand and pay – Patients often receive little to no information about the cost of care until they open their healthcare bills. To eliminate confusion and encourage on-time payments, healthcare teams can begin communicating with patients about billing even before bills are mailed. For example, staff can send automated messages following appointments to let patients know what services they should expect to be billed for and when. Implementing automated reminders for upcoming payments is another easy way providers can improve communication about billing.


These 10 examples are easy ways for healthcare teams to drastically improve healthcare experiences for patients. Most providers have the necessary technology in place and are already using it to deliver communications like appointment reminders. By listening to what patients want and applying existing technology in new ways, healthcare teams can deliver more of the prevention, disease management, and billing information patients expect. In the process, providers can drive better healthcare interactions.

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