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Monday, November 24, 2014
Kim Zuber, PA-C, DFAAPA
Since 2010, payment for dialysis treatments has been a bundled charge. The Centers for Medicare and Medicaid Services (CMS) has paid one set fee to dialysis providers for each treatment provided to a Medicare patient; 90% of all dialysis patients in the United States are covered by Medicare. This bundled payment includes laboratory fees, oral and IV medications, staff charges, machine rentals, dialyzers, and any incidentals needed to provide hemodialysis or peritoneal dialysis to a patient. Each year, CMS recalculates the fee and either raises (or lowers) the bundled payment depending on the average cost nationwide. This process lets CMS manage costs and budget for dialysis patients from year to year.
The most divisive issue each year is the cost of medications. Medicare has defined seven categories of medications as being dialysis-related and thus part of the bundle payment: antiemetics, anti-infectives, antipruritics, anxiolytics, drugs for managing excess fluid, drugs for fluid and electrolyte management, and analgesics. Because the categories are so large, many medications are included, such as naloxone for drug overdose or diphenhydramine for allergies. Neither of these medications is routinely considered dialysis-related by most practitioners.
Thus practitioners, patients and dialysis providers often are confused about whether a medication is dialysis-related or not . From 2010 to 2013, Medicare encouraged a “pay and chase” method for medications that may or may not be dialysis-related. In other words, pharmacies would issue the medication when a patient presented the prescription. If Medicare later determined that the medication was actually dialysis-related, Medicare would refuse to pay the pharmacy and the pharmacy had to turn to the dialysis provider for payment. This put the burden on the pharmacy and Medicare, with Medicare either paying for the medication twice (once to the dialysis provider in the bundle and once to the pharmacy) or the pharmacy having to chase down the payment.
As of January 2014, Medicare allowed pharmacies to ask for proof before filling a prescription to determine if a medication was dialysis-related or not. And as one can imagine, everything hit the fan.
As scut work rolls downhill, many PAs and NPs were doing preauthorizations for every medication their patient consumed: antihistamines for allergic rhinitis, Tylenol #3 for chronic back pain (remember…no NSAIDS for kidney patients!), hypertension medications, and every antibiotic patients took. A preauthorization was needed for antibiotic coverage for a dental procedure, for a preparation for any surgical procedure, or for any infection that the patient developed. Because patients on dialysis typically are immune-compromised and have diabetes, preauthorizations for antibiotics were taking on a life of their own…and most practitioners were spending 2 to 3 hours a week on them. The National Kidney Foundation (NKF) listserv was burning up with stories of denied medications or hours of phone and computer work to obtain a preauthorization for a $4 amoxicillin prescription.
The Renal Physician Association (RPA), NKF, American Society of Nephrology (ASN), and patients’ representatives were all on the same page—this was an untenable situation. E-mails were sent to Medicare, which asked for examples of patients having problems due to preauthorizations.
Wayne was a typical dialysis patient—he had diabetes, hypertension, coronary artery disease, peripheral vascular disease, a below-the-knee amputation of one leg, and a chronic open ulcer on the remaining foot. He also had a cheery disposition that belied his medical issues. Wayne presented to the wound center on Friday for his weekly evaluation and it was decided he was to continue his hyperbaric oxygen therapy, oral antibiotics, and whirlpool therapy. His infectious disease physician wrote the antibiotic prescription and sent Wayne on his way. Wayne took the prescription to the pharmacy and was promptly denied because of the need for preauthorization. The physician was notified, could not understand why a preauthorization was needed, and asked the pharmacy to call the nephrology provider for the paperwork. Thus the 5 p.m. call on a Friday night to me.
No one is at the other end of a preauthorization phone line after hours on Friday night. I was directed by the phone message to use the website, which promised a result in 1 business day. Useless to me on a Friday night. I sent a blistering e-mail to NKF and RPA, who forwarded it to the right person at Medicare. I pointed out that because a $20 prescription needed a preauthorization, Medicare was going to be out more than $20,000 for unnecessary surgery and rehabilitation, my patient would have a second amputation, and this whole system was not saving any money and was hurting fragile patients. Wayne did not get his antibiotics until Monday night.
Medicare was overwhelmed with the volume of complaints. They sent out a letter of explanation about preauthorizations stating that any prescription not written by the nephrologist should be filled without preauthorization. This did not help. As Tricia Marriott of the AAPA will tell you, when Medicare tries to explain something, it only goes from bad to worse.
As winter turned to spring, the system continued to founder. The large nephrology societies (RPA, NKF, and ASN) asked for a meeting with the medical director of Medicare. This meeting was set for July 1, and “real providers” were asked to attend in order to ascertain how the system was working in the field. I was invited to share Wayne’s story.
Jeffery Kelman, MMSc, MD, chief medical officer for CMS, collected staff involved in the bundled payment system and sat down with us to discuss the issues. The first thing he asked me was how Wayne was doing. I had to admit Wayne had needed a revision surgery on his remaining foot, 30 more days of hyperbaric oxygen therapy, and his chronic foot ulcer was still unhealed. This could have been the outcome even if he had not had a disruption in antibiotic therapy, but the disruption increased his chances of a bad outcome. Dr. Kelman shook his head in agreement.
We spent the next hour outlining the issues, explaining our views. Dr. Kelman explained his rulings and detailed how the whole system had developed. I was incredibly impressed by Dr. Kelman’s belief that all Medicare patients were his responsibility to care for using best practices. Yet Dr. Kelman also felt that he answered to the American taxpayer and was responsible to make sure that our tax dollars were not wasted. According to him, every member of his staff felt personally responsible for my patients. They truly wanted my patients to obtain the best care out there. The dialysis preauthorization system denied care and Dr. Kelman was unhappy with that outcome. He agreed with us that something had to change.
On July 3, just as most of us were leaving for a holiday weekend, Medicare released new rules for comment that removed antibiotics from the list of medications that need a preauthorization for dialysis patients. Medicare would rather accidently pay for an antibiotic twice than take the chance of a lost leg by another dialysis patient. Wayne’s Rule will save other’s lives and limbs, although Wayne lost most of his second leg. On November 12, Medicare released their final rule removing all seven categories of drugs from the preauthorization schedule.
Wayne's Rule was a bigger win that we had dreamed of—no one will be denied antibiotics, pain medications, or fluid medications just because they are on dialysis. Wayne has never been one to complain. He is thrilled that his namesake rule will make a difference to others even though it was too late for him. Wayne feels lucky that someone took the time to write a letter and go talk to CMS. Patients place their trust in their providers and expect the provider to be an advocate. PAs bring more to their practice than just knowledge; they also bring a commitment to patient care and a promise to honor the trust patients have in them.  And sometimes, just sometimes, you can actually make a difference in the lives of those who entrust us with their hopes and dreams.  
Kim Zuber practices at Metropolitan Nephrology in Alexandria, Va., and is AAPA Outstanding PA of the Year. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, November 17, 2014
Wanda C. Gonsalves, MD
A few weeks ago, at our class reunion, I celebrated 30 years since my medical school graduation from the University of Kentucky. I looked forward to seeing old friends, but especially to seeing the three women who, along with me, my classmates called “the Medicare Maidens” because we had turned 30 years old before our graduation. We had studied together for 4 years, helping to keep each other in school.
There were the usual questions: “What are you doing now?” “When do you plan on retiring?” “Is that his second wife?” “Did you hear he/she passed away?”
Many of us reflected on how medicine had changed. Physician extenders were now an important part of our practices. Most of us had hired either physician assistants (PAs) or nurse practitioners. And of course, I commented how PAs were better-prepared to practice with physicians. We all felt we were working harder for less reimbursement. I complained that primary care physicians at the University of Kentucky were expected to see patients every 20 minutes, whether the patients were new or established. Some of my colleagues from other institutions had even shorter appointment visits. And everyone complained that the electronic medical record required more documentation than paper charts and consumed way too much of our time. Most of us were doing our documentation after work, because running from room to room left little time to complete our records. All but a few of us worked for a company, university, or medical specialty group.
Drs. Wanda and Gerald Gonsalves
A few days later things had settled down from the parties. I was visiting with friends and lunched at Keeneland to see the horse races, I began to reflect more about my own future and the changes in medicine. What would I do if I did retire? I knew that I would always want to make a difference in the lives that I touched. I thought about the students and the residents I precept in my clinic. I thought about the patients and the bond that I have with them
I firmly believe that physicians and other healthcare professionals have a social responsibility toward those whom they serve. Each time I’m with a learner, I try to emphasize our responsibility as medical professionals. That goal definitely becomes much harder when we’re running around “like chickens with our heads cut off” between each patient room, but the goal is still something we should keep in mind as role models to our learners. I can’t retire. I still have much to offer and to much more I’d like to accomplish.
Wanda C. Gonsalves is vice chair of the Department of Family and Community Medicine at the University of Kentucky in Lexington. She also is a steering committee member of Smiles for Life, a national oral health curriculum. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Tuesday, November 11, 2014

Jennifer M. Coombs, PhD, PA-C

I was recently asked to give a webinar with my colleague Christine Everett, PhD, PA-C, called “Filling the Primary Care Gap: Opportunities and Challenges Facing Rural Physician Assistants.”  The webinar was part of a rural workforce webinar series put on by Vanderbilt University’s Center for Interdisciplinary Health Workforce StudiesI spoke about the history of PAs in rural areas, distribution, scope, and retention challenges. Dr. Everett described some of her latest research on clinical roles and the effect on cost, quality, and access in the rural setting. You can see our talks here

Much can be said about rural healthcare providers now that PAs and NPs together outnumber family medicine physicians.1,2 Promises made because of changes as a result of the Affordable Care Act (ACA) may increase the number of insured Americans, especially in rural areas. The New York Times recently reported that 10 million more people have insurance coverage this year than last as a direct result of the ACA. According to the paper, some of the biggest gains were in rural areas.

Michael Powe from the American Academy of Physician Assistants (AAPA) reported in May that the Centers for Medicare and Medicaid Services (CMS) eliminated the requirement for physicians to be physically on site once every 2 weeks at a certified rural health clinic, federally qualified health center, or critical access hospitals.

PAs will still need to follow their state laws, which contain a considerable amount of variation in terms of adopting the AAPA's “6 key elements of a modern PA practice act” (PDF). The issue is this: only 9% of US physicians practice in rural areas, and among the 2,050 rural counties in this country, 77% are designated health professional shortage areas. 62 million Americans, or 20% of the population, live in rural areas.  Are PAs are ready willing and able to fill those gaps in underserved areas?

I decided to call my friend Amy M. Klingler, MS, PA-C, who lives in a rural and remote area of the country—Stanley, Idaho—and ask what changes she has noticed as a result of the ACA. According the New York Times, Custer County, the central Idaho county where Stanley is located, has gone from 14% uninsured in 2013 to 9% uninsured in 2014. Ms. Klingler is 60 miles from the nearest critical assess hospital and a 45-minute life flight to the nearest major level 2 trauma center. Idaho has no level 1 trauma centers. Her supervising physician visits her clinic once a month. This is a mutually agreed upon supervisory arrangement, and before the latest ruling from the CMS, Ms. Klingler and her supervising physician were able to obtain a waiver allowing for the once monthly visit rather than every 2 weeks.

According to the AAPA, Idaho has only four of the six elements of a modern state practice act. Importantly for a rural state, the delegation of service agreement lets the PA or physician decide the appropriate scope of practice for each PA.  The ratio of physicians to PAs is 1:3; a waiver can be obtained to allow a ratio of 1:6. Most state practice laws allow the flexibility for physicians and PAs together to determine the delegated medical tasks and the method of supervision. Some states require physicians to review a certain percentage of charts; the percentage may depend on how long the PA has been in practice. Being able to decide together how and when Ms. Klingler’s supervising physician was able to visit her is certainly important and critical to her ability to practice so remotely. Her supervising physician or alternate physician are always available by phone. According to the AAPA, 25 states impose some type of travel time or distance limits to their supervision requirements for PAs.

Another important feature to be able to practice remotely is the ability to prescribe controlled substances in categories 2 through 5. All states allow PAs to prescribe medications, but 14 place some limitations on the types of medications PAs can prescribe, a limitation that can hamper PAs practicing in remote areas.

One of Ms. Klingler’s biggest challenges is durable medical equipment and obtaining hospice care for the terminally ill residents in her county.  Older adults make up 13% of the US population, but account for as much as 45% of the population in some rural areas. Hospice and palliative care, Medicare, and rural long-term care facilities are issues facing those aging in remote places.

For Ms. Klingler, living and working in a small town was the reason she went to PA school in the first place. Becoming an MD would not have allowed her to practice in her chosen rural area, where physicians work in the clinics 1 to 2 days per week.  Although most PAs practice in urban areas, PAs and NPs are more prevalent in rural and underserved areas than physicians.3-5 Many rural counties in the United States face serious challenges to provide sufficient healthcare services. The ability of PAs to practice in rural and remote areas is highly variable and depends on many factors, both economic and political. Shortages of PAs and the inefficient use of PAs are the two next great issues in our profession.  As we consider the many changes on the horizon for PAs, aligning our laws and regulations to the needs of rural PAs is paramount. Only then can the maldistribution of providers and shortages of PAs in all areas of medicine be solved.

Jennifer M. Coombs is an assistant professor in the Division of Physician Assistant Studies, Department of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


1. Stange K. How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. J Health Econ. 2014;33:1-27.

2. Auerbach DI. Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Med Care. 2012;50(7):606-610.

3. Hooker RS, Muchow AN. Supply of physician assistants: 2013-2026. JAAPA. 2014;27(3):39-45.

4. Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. 2012;20(1):20-31.

5. Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advance practice nurses, and physician assistants. J Amer Coll Surgeons. 2011;212(6):991-999.

Monday, November 03, 2014
Richard W. Dehn, MPA, PA-C, DFAAPA
It has become quite obvious recently that PAs are in short supply. New graduates in my neck of the woods have many employment options, and starting salaries appear to be very good. In the world of PAs, life is good.
However, whenever the PA job market gets really hot, recruiting and retaining PA educators gets even more challenging than usual. In my opinion, the reason for this is that clinical salaries typically are more responsive to supply and demand forces than salaries in academic institutions, so when demand increases, clinical salaries rise faster than academic salaries. Those rapidly increasing salaries offered by easy-to-find clinical positions will attract many PA faculty back to full-time clinical practice, leaving many faculty positions vacant. The PA faculty shortage cuts across the entire academic landscape, which needs more qualified program directors, didactic coordinators, clinical coordinators, as well as core PA faculty. The faculty shortage was hard to ignore at the recent PAEA education forum in Philadelphia; an entire display board was dedicated to posting academic vacancies, the conference materials included a whole book of available faculty jobs, and deans and program directors in active recruitment mode were everywhere. From my vantage point, we have definitely reached a PA faculty shortage crisis.
This shortage of PA program directors and faculty couldn’t happen at a worse time. In response to the increasing demand for clinical PAs, many new PA programs are being developed. These programs need competent program directors and faculty. The baby boom generation of faculty, many who have been in their positions for decades, is beginning to retire. Additionally, many program directors are being promoted to higher administrative positions in educational institutions, leaving fewer experienced program directors. Two of these factors, the retiring of an older generation of faculty and the promotion of PA program directors to higher positions, would normally be considered a good thing illustrating the longevity and increasing acceptance of the profession in academia. However, in the current environment, these factors substantially contribute to the faculty shortage.  Although one might think that the PA program director and faculty shortage is a problem mostly affecting newly developing PA programs, the shortage has even affected legacy programs. Faculty are attracted away from these programs by opportunities in developing programs or the higher salaries of clinical practice.
PAs typically enter PA education after 3 to 5 years in clinical practice, usually after having served as a clinical preceptor or lecturer for a PA program. In most cases, they trade a salary decrease for a somewhat more flexible work schedule and the opportunity to teach students rather than treat patients. Most programs consider that an entry-level new faculty member will need about 2 years of training and mentoring to get up to speed. Most program directors would prefer that most of their faculty have program experience, such that at any given time the number of new faculty recently having entered education from clinical practice in a program do not constitute more than the program can comfortably afford to mentor. The current faculty shortage has resulted in some programs containing a majority of inexperience faculty.
How can PA education attract enough qualified and competent faculty to educate the number of PAs needed to meet healthcare’s current needs? Many processes have been proposed, such as educator rotations and teaching fellowships designed to attract early-career PA to an academic career. However, all of these also require the participants to accept less pay than clinical PA positions would offer. The unfortunate irony of the PA profession’s current success, as measured by the high demand for PAs, is that there simply may not be enough qualified PA educators to train all of the PAs that the market demands.
Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the university's Department of Physician Assistant Studies. The views expressed in this blog post are those of the author and may not reflect AAPA policies.

Monday, October 27, 2014
Kim Zuber, PA-C, DFAAPA; Jane Davis, DNP
A hush falls over the OR. Every day we do our jobs but today is an unreal day for us. We are losing a family member but know that his death will give life to many others. Two days earlier, the husband of one of our OR nurses was riding his bicycle when he was hit by a car. We had passed him riding his bike on the way to work and 3 hours later he was in our ED. We gathered with our colleague in the ED, drawn by a need to do something. We held her hand while the burr hole was placed in his skull to try to stop the swelling of the closed head injury. After 24 hours in the ICU, when we had tried everything, he was declared brain dead. We all knew what it meant when representatives from the local transplant center came to talk to her. We knew what her answer would be “of course his death must help others,” but that did not make today any easier. A young and ardent bicycle rider, he was in excellent physical shape. She asked that we help with the donation and we said, “of course.” So here we are, in a lounge in the OR, holding her hand and watching as groups of surgeons come in and out.
After thanking the ICU staff, she walked with her husband’s bed and nurse anesthetist to the OR. She said goodbye in the darkened, quiet OR (quite unlike the usual scene), thanked the anesthesia providers, and was walked to the OR lounge by the head nurse. Magically, the first group of surgeons appeared, coming in the door opposite the one she had left. The anesthetist stayed and monitored the ventilator.
The transplant teams had been notified by Donor Net, a computerized alert system that contacts all local transplant programs as soon as a donor has been found. Information regarding age, race, BMI, laboratory results, medical history, and cause of death along with results of testing (CT, MRI, and other specialized testing) is sent via a beeper system to either transplant coordinators or surgeons at each local program. The local transplant programs have 1 hour to respond or the organs are offered nationally. Due to cold ischemic time, priority is always given to the local area to increase the survival of the donated organs.
As the teams set up to do the donation, the lung team does a quick bronchoscopy to check lung condition and a sample is sent for arterial blood gas analysis. The heart will be the first organ removed, but each surgeon preps his or her particular organ before the heart is cross-clamped. After each organ is prepared, the cardiac surgeons stand on either side of the OR table. The procurement teams know each other well and work in a manner of a choreographed ballet. The chest is opened quickly from the sternal notch to the pubic bone and the skin and fat are retracted. The heart surgeons work with expert, experienced hands and quickly isolate the heart. They cross-clamp the aorta, lift the heart out of the body, free it from the attached structures and flush it with cold preservation solution. The clock starts at this moment. They have 6 hours to get this heart into the recipient or all will be lost. They race out the door, heart in ice, and into the evening traffic on their way to the heart hospital, where the rest of their team has the recipient in the OR already prepared for his new heart.
Ice is packed into the donor body cavity and the next team steps up. The lungs have been determined to be excellent and they are the next organs to be taken. Again the cold preservation solution is used for flushing and the lungs are on their way to another lucky patient. The abdomen teams are next. The liver and/or lungs can be taken with the heart but today each of the organs is designated for a different recipient. The abdominal surgeons work quickly and take the liver and pancreas, flush them with the cold preservation solution and pack them in ice for the trip to another transplant center. The liver will be split between two recipients but the dissection of the liver will be done at the transplant hospital. The cold ischemic time for livers should be less than 5 hours; although livers can survive up to 12 hours, travel to the more distant transplant center can be slow, so the team quickly gets on the road.
The small bowel is now sent to the same transplant center as the heart. The kidneys are taken and flushed with the cold preservation solution. Because kidneys have the longest cold ischemic survival time, they always are the last of the abdominal organs to be taken. One of the kidneys will be traveling quite a distance, so it is placed on a pump and continually flushed with the preservation solution. The local kidney is packed up in ice and transported to a waiting patient.
At this point the local organ procurement office (OPO) steps in. The OR, bustling with noise and surgeons just 10 minutes ago, is now quiet. The donor’s corneas, skin, and bone are taken by the OPO staff. The PAs who have stayed behind to stitch the donor listen while the OPO shares stories of each of the recipients. A 20-year-old with cystic fibrosis will receive one lung and a longtime government worker whose kidneys have been ravaged by diabetes will be free from dialysis. A blind man in Baltimore will see with the corneas. A grandmother waits for the liver. A young mother with postpartum cardiomyopathy will get the heart.
We finish our stitching, and he looks so peaceful. His wife walks back in and says a final goodbye, while the OPO staff thank her for her gift.
(For more on transplantation, see the authors' article in the current issue of JAAPA.)
Kim Zuber practices at Metropolitan Nephrology in Alexandria, Va., and is AAPA Outstanding PA of the Year. Jane S. Davis is a nurse practitioner at the University of Alabama at Birmingham and a member of the National Kidney Foundation’s board of directors and the American Society of Nephrology’s CME committee. The views expressed in this blog post are those of the author and may not reflect AAPA policies.
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