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Positioning Medical Assistants for a Greater Role in the Era of Health Reform

Chapman, Susan A. PhD, RN; Marks, Angela MSEd; Dower, Catherine JD

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doi: 10.1097/ACM.0000000000000775
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Abstract

One of the fastest-growing health care occupations is widely misunderstood and often underused by health providers. When employed appropriately, medical assistants (MAs) are critical members of the health care team and key contributors to better patient care. Over the past several years, the role of the MA has evolved and expanded with innovations in practice redesign, and in delivery model changes driven by cost pressures and health care reform. MAs have become more active members of interdisciplinary health care teams and are recognized for the important role they play in care coordination, chronic care management, and health promotion.1–11 The MA role is poised to continue to expand with the greater adoption of electronic health records, increased implementation of patient-centered medical homes, and accountable care organizations (ACOs). Innovations in the use of MAs have been documented across practice settings in a variety of expanded roles including health coach, chronic disease panel manager, diabetes educator, and scribe. The cultural and linguistic concordance between MAs and the patient population is often greater than that found with other health professions, a factor that is found to contribute to the success of many of these expanded roles.12

Despite this increased attention and enhanced use of MAs, the medical assisting occupation is little understood by many health care providers, employers, and policy makers. Many questions about the training, competency, and regulation of MAs arise as the field continues to evolve. Our purpose is thus twofold. First, we describe the medical assisting occupation, including demographic characteristics, practice environment, training and education, certification, and regulation. Second, we explore how traditional MA roles have expanded or may expand and discuss the challenges in preparing both MAs and health care provider teams for these expanded MA roles.

Background: Who Are MAs?

The MA is the most common nonphysician staff member found in medical practices.13–15 Figure 1 displays information on growth of the MA occupation from 1998 to 2014. According to the Bureau of Labor Statistics, the number of MAs employed in the United States grew from about 280,000 in 1998 to over 585,000 in 2014, outpacing the growth of most other health professions.16,17 The field is one of the 30 largest growth occupations, with a projected increase of 29% between 2012 and 2022.16 According to the 2010 American Community Survey, the vast majority of MAs are female (93%) and racially and ethnically diverse: 53.5% white, 26.2% Latino, and 12.9% black.18 The average age of MAs is 36 (median age 34), with about one-third in the 25–34 age group. Median hourly wages for MAs in 2014 were $15.01 per hour.17 Figure 2 illustrates median MA wages from 1998 to 2014. These data show that although mean wages for MAs have increased during those years, when adjusted for inflation, their real wages have not increased during that time.

Figure 1
Figure 1:
Growth in the number of medical assistants in the United States, 1998–2014. Sources: Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2014–2015 Edition, Medical Assistants16; and Bureau of Labor Statistics, U.S. Department of Labor, Occupational employment statistics survey.17
Figure 2
Figure 2:
Median hourly wage increase for medical assistants in the United States, actual versus adjusted for consumer price index (CPI) increase, 1998–2014. One line shows the actual median wage each year, and the other shows what the median wage was each year if adjusted for yearly CPIs. Source: Bureau of Labor Statistics, U.S. Department of Labor, Occupational employment statistics survey.17

The Traditional MA Role in Practice Settings

The majority (over 60%) of MAs are employed in physician offices. Other settings employing MAs are outpatient care settings, including clinics, and offices of other health care practitioners.16

The traditional role of the MA involves a limited clinical scope: escorting a patient to an exam room, taking vital signs, noting the chief complaint in the record, and then leaving the exam room unless the physician or other health care practitioner requires assistance with a procedure. After the patient visit, the MA duties include taking care of needed prescriptions and referrals. The traditional MA role also includes patient reception, making appointments, and completing the diagnostic and coding information required for billing and reimbursement.

How Are MAs Trained?

There is much variability in the length and type of MA training programs as well as with the curriculum. MA educational programs can range from six months to a two-year associate degree. It is difficult to count the overall number of medical assisting educational programs because they are offered in both the private and public sector, may be accredited or not, and may or may not report statistical data to the U.S. Department of Education. The 2013 U.S. Department of Education’s Integrated Postsecondary Education Data System (IPEDS) reported 105,061 MA program completions from 1,469 unique institutions.19 Because of the short nature of the training, MA training programs may be offered periodically in response to market demand and closed when demand ebbs. Reliable and publicly available data on open programs, enrollment, and the number of MAs entering the workforce are likely incomplete because of these factors.

Accredited associate-degree-granting programs in medical assisting are primarily found in community colleges. These programs take about two years to complete and usually require additional general education courses required for an associate degree. The Commission on Accreditation of Allied Health Education Programs (CAAHEP)20 and the Accrediting Bureau of Health Education Schools (ABHES) are the two primary accrediting bodies for MA programs and schools offering MA programs.21

The majority of MA graduates complete nondegree certificate programs lasting less than one academic year.19 Program type and whether students earn college credits, a degree, or a certificate of completion have implications for MAs who want further training and careers in health care.

Many MA students attend private, for-profit schools19 that are relatively expensive compared with the cost of not-for-profit private schools and community colleges. Table 1 displays 2013 data from IPEDS on the number of MA-completed awards by type of institution. According to these data, 82% of MA awards in 2013 were from private for-profit schools.19 Education in private for-profit schools is costly for MA students. With relatively low wages, MA students may have difficulty paying loans they received to attend these programs.

Table 1
Table 1:
Number of Medical Assistants Completing Training Programs, by Type of Institution, 2013a

Licensure and Certification

No states currently require MAs to be licensed or hold a national professional certification.22 However, a few states have certification requirements related to particular practice settings, on-the-job training requirements, particular procedures, scope of responsibilities, or requirements for the practice to receive payment for services provided.22,23

Several national MA professional organizations and certification organizations offer certification for MAs, all with varying education and training requirements. There are also smaller, state-based certification organizations. The American Association of Medical Assistants (AAMA) and the American Medical Technologists (AMT) are two primary professional organizations offering a national certification. The number of MAs certified by national organizations is small relative to the size of the MA workforce. In 2014, the AMT reported 39,943 MAs actively certified as registered medical assistants,24 and the AAMA reported 75,022 MAs certified as certified medical assistants.25 The educational requirement for certification varies significantly among the certification organizations. Among the two largest national certification agencies, the AAMA is the only certification that requires MAs be graduates of an MA program with programmatic accreditation from CAAHEP or ABHES.

Scope of Practice Regulation for MAs

In most states, MAs may perform basic clinical procedures under the direct supervision of a licensed medical practitioner.22 States have adopted various approaches to regulate MAs, which can be categorized in three areas: delegation, regulation of specific tasks, and no specific regulation.

In 2003 and again in 2012, the AMT published detailed information about the scope-of-practice regulations for MAs in the United States. The most recent AMT report identifies 11 states that have enacted laws explicitly addressing specific duties that “medical assistants” are legally able to perform, as well as requirements around delegation and supervision.22

The 2012 report notes that 10 states have laws that explicitly allow delegation of clinical tasks under specified conditions to “unlicensed personnel,” and an additional 14 states also allow for delegation to unlicensed personnel but do so through exemptions from licensing requirements in state laws.22

In the remaining handful of states, no laws or regulations directly address MA practice or delegation by physicians. In most of those states it is presumed that MAs can perform all duties for which they were educated and/or trained if the duties are not prohibited by medical, nursing, or other practice laws and are performed under the supervision of a licensed physician.22 However, in a few states this presumption is not followed, and delegation to MAs for certain procedures is restricted.22

The Changing Role of MAs

The importance of primary care and challenges in providing high-quality, accessible care have been widely reported in the literature.7,26–28 Projections of workforce shortages in primary care,29 pressure to reduce costs, and the opportunity for innovation in practice models provided by payment reform have increased the focus on primary care teams. However, these practice innovations could benefit from more discussion and consensus building over who is on the team and what tasks and roles are appropriate and cost-effective for each team member. This includes rethinking the role of the MA as a critical team member.

Using MAs in Expanded Roles

Several care models describing the involvement of MAs have been published, the most well-documented being Bodenheimer’s “teamlet model.”4 Several studies have demonstrated the association of expanded MA roles with positive patient outcomes in a variety of settings including academic primary care practices,30–32 community health centers,33 rural family care practices,34 large urban health centers,6 and large managed care organizations.35 In a randomized controlled trial conducted in a practice-based research setting, MAs were briefly trained to make referrals to treatment programs for patients with health risk behaviors. MAs in the intervention group made significantly more patient referrals, although there were no significant differences in patient behavioral outcomes.8 In another randomized controlled trial, MA health coaches were trained to provide diabetes education and support to low-income racial and ethnic minority populations in a large network of federally qualified health centers. Although the authors did not find an intervention effect specific to MA training, there was an improvement in diabetes measures across all groups.12 A study conducted at an academic health center’s community clinics assessed the impact of training MAs to recommend needed colorectal cancer screening to patients and enter preliminary orders for screening tests. The MA intervention resulted in a sustained increase in colorectal cancer screening referral rate.36 Another study conducted in an academic primary care practice used MAs as health coaches to implement the teamlet approach4 to improve care for patients with diabetes and/or hypertension. Patients in the teamlet model showed significant improvement in several measures.30 In a large urban health center for union members, MAs participated in an intensive health coach training program. They subsequently worked individually with patients to coordinate care and manage chronic conditions, resulting in increased control among diabetic patients.6 In case studies highlighting MA role innovation and career development, examples of expanded MA roles included using MAs to conduct home visits with seniors37; using MAs to identify gaps in preventive screening using a system-wide electronic health record35; training MAs to provide feedback to the health care team on quality improvement performance measures38; and training bilingual MAs to be health coaches.39 Most of the case study sites included MAs in daily care team “huddles” used to prepare the team for patient visits and provide opportunities for physicians and nurse practitioners to teach MAs. Practices employing MAs in expanded roles also offered improved career opportunities for the MAs as well as improved financial sustainability and efficiency for the organizations. A multiyear project to promote high-performing primary care practices, Learning From Effective Ambulatory Practices (LEAP), also identified a number of expanded roles for MAs in 25 high-performing ambulatory care practices in a variety of settings.40

Considerations in Expanding the MA Workforce

Efforts to adopt innovative practice models and provide cost-effective care will drive the expansion of the MA role. The short pipeline to train MAs, the abundance of private schools available to respond readily to market demand, and the regulatory structure of MA practice all make MAs a flexible component of the workforce. In addition, using MAs more effectively may improve clinician satisfaction by freeing up time to allow physicians and other health care providers to practice to the highest level of their training and expertise.11 However, educators, employers, regulators, and policy makers should address several issues as MA practice continues to evolve. There is a lack of consensus among the provider community about which tasks are appropriate in an expanded role, whether MAs are prepared for such roles, and whether the regulations in each state allow for expanded MA roles such as those just described. The provider and policy community need to address these issues so that MAs can be used effectively in transforming health care delivery.

Lack of standardized educational standards

There is a great deal of variability in the quality and degree of job preparedness of MAs, and clinical competence cannot be ensured even for basic procedures.41 Education programs vary by length and overall quality of curriculum. More important, most training programs do not prepare MAs for expanded roles. In focus group research, both physicians and MAs agreed that the traditional MA curricula are focused on clinical procedures and administrative tasks and do not prepare MAs for new and expanded roles such as chronic care management or health coaching.42 In case studies of successful MA innovations, most key informants stated that training MAs for expanded roles required a considerable investment.39,43 More rigorous accreditation may help standardize programs and spur the development of curricula to address new practice models.

Professional certification for MAs

Certification is often the norm in health professions practice as a way to establish and standardize competencies across geographic boundaries and practice settings. But, it is a confusing picture in medical assisting. There are several routes and different types of certification. The rigor of certification criteria differ substantially, especially between national and state certifying organizations. For example, some certifying agencies require MAs to have graduated from a medical assisting program with CAAHEP or ABHES programmatic accreditation, while other certifying agencies do not have the accreditation requirement and may allow MAs to substitute completion of a formal educational program with on-the-job experience. Employers and policy makers need better information about certification. Some employers may embrace certification and may even pay higher wages to a certified MA, yet there is little research that demonstrates how certification benefits MAs or contributes to patient outcomes. One of the benefits of certification may be in the more widespread adoption of standardized competencies for training and professional development.

Cost of MA education and lack of a career ladder

From a workforce development perspective, MA career development may be limited because of the prevailing education model that leaves MAs without academic credit and considerable debt after training. Within the traditional MA role, there is limited opportunity for increased responsibility or wage gain. MAs represent a diverse sector of the health care workforce and are often the team members most culturally aligned with the patient population, yet they are usually the lowest-paid team members. With more than 80% of MAs being educated in private for-profit programs, educational debt may be a barrier to seeking further education. Employers, educators, and policy makers who value the contributions MAs make to the health care system need to develop and provide meaningful opportunities for advancement within the MA role (e.g., health coach) as well as create opportunities to advance the career path into other health professions.

Regulatory concerns

With the expansion of MA roles and with practice innovations, providers and educators need clarity on the legal scope of practice for MAs and how the role can be expanded while still meeting state regulations. Unfortunately, the available information is not easily interpreted. There is variation from state to state in the delegation of duties that MAs may perform that ranges from vague descriptions to specific lists of procedures.22–23 There may be resistance from employers to more specific regulation of MAs’ practice with concern that further regulation would stifle innovation in the expansion of roles. However, clarification of regulations within states may also benefit the process of innovation.

How to pay for expanded MA services

A key challenge in developing expanded roles for MAs is determining how practices bill and are reimbursed for the services MAs provide, such as patient education, care coordination, and outreach. An additional challenge is determining how to pay for the training needed to prepare MAs for these expanded roles. The fee-for-service practice model does not easily support expanded MA roles. Global billing, capitated models, and case management payments are more promising mechanisms to support expanded MA roles. More research is needed on the cost-effectiveness of using MAs in expanded roles in ACOs and other global payment environments.

Need for studies of cost-effectiveness and patient outcomes related to expanded MA roles

Additional research on the impact of expanded MA roles on patient care outcomes and costs is needed. More studies are needed that demonstrate in which settings MAs can make the most impact and for what patient populations. Much of the research on expanded MA roles has been case studies of individual sites with a limited set of outcomes. The LEAP study and other multisite evaluation studies underway may provide the data needed by policy makers and employers for widespread adoption of care models with expanded roles for MAs.

Concluding Remarks

Medical assisting is a rapidly growing occupation, and the demand for MAs is expected to continue to rise. Despite the significant role that MAs play in patient care, there is little standardization around their practice, education, and training. Misconceptions about these issues may limit the development of role enhancement or create confusion in the process of transforming care models. MAs are a critical component of primary care practice. However, they may be underprepared, or prepared yet underused, for the roles most valued by those practices—providing a satisfactory and high-quality experience for the patient and maximizing the efficiency and effectiveness of medical care.

To realize the potential that MAs have as members of the health care team, several objectives should be pursued. Those include training for MAs that is accessible, affordable, and easily delivered; clear and consistent policies regarding the legal scope of practice; and mechanisms to pay for the services MAs provide. Finally, robust research and evaluation of cost-effectiveness and patient care outcomes in the various practice settings in which MAs work would assist employers and clinicians in making optimal use of these valuable workers.

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© 2015 by the Association of American Medical Colleges