Michigan Medicine Physician assistant Eryn Smith examines patient Brad Cook during an electrophysiology appointment in this photo taken before the COVID-19 pandemic at the University of Michigan Health Frankel Cardiovascular Center.
As physician assistants are being accepted more as part of multidisciplinary care teams at hospitals and as trusted providers in medical office settings, they also are opening independent offices, creating more access points for patients and taking on clinical leadership roles within healthcare organizations.
PAs — who are considered advance practice providers like nurse practitioners, certified registered nurse anesthetists, certified nurse midwives and certified nurse specialists — diagnose illnesses, write prescriptions and counsel patients on preventive care.
Thadd Gormas
In 2017, Michigan’s Public Act 379 granted more autonomy to PAs, eliminating the state’s strict ratio requirements that limited the number of PAs who could provide care under a single physician’s oversight. Nearly 30 states have expanded PA scope of practice in recent years, including New Jersey, Minnesota, North Dakota, Vermont and Massachusetts.
Under collaborative practice agreements with physicians, Michigan PAs are now defined as independent “prescribers” with full prescriptive authority. They can be licensed individually to write prescriptions for various controlled substances.
PAs also make house calls in private homes or go on rounds in many types of healthcare facilities.
“Over the last 10 to 15 years, what we have seen is providers and patients have become much more aware of what PAs do. They have really emerged into leadership roles, including owning practices, and at the executive level in hospitals as part of the team-based care approach,” said Thadd Gormas, executive director of the Michigan Academy of Physician Assistants.
“Patients really respond well to us, whether it’s because they’re taking more time to speak with patients, or that a PA is much more willing to consult other folks about the care of a patient,” Gormas said.
Michelle Petropoulos, president of the Michigan Academy of Physician Assistants, said many things have changed in her 24 years as a PA.
The Portrait Place Michelle Petropoulos
“We’re a bigger organization than when we started out. While we generally work within a physician group, over the years physicians have sold their practices and we became employed by these larger groups” such as hospitals, Petropoulos said.
Because PAs are trained as generalists, Petropoulos said they are flexible practitioners who can practice in multiple specialties, depending on their interest and job availability.
“What we are trying to do in Michigan is create an environment where we’re independent within the work that we do,” she said.
Marc Moote, chief physician assistant with Michigan Medicine in Ann Arbor, said the 2017 law gave PAs greater freedom to practice up to their licenses within the patient-centered, team-based care team.
“The changes in the law in 2017 really didn’t change our independence. It mostly eliminated administrative barriers to team-based practice,” Moote said. “Before, PAs could prescribe controlled substances. The issue was that they had to have a written delegation agreement (with a physician) and didn’t receive a license to prescribe (on their own).”
Sarang Patel
Moote said PAs will be granted increased responsibilities and autonomy over time.
“PAs are diagnosing, treating, prescribing, and yet, that will vary (between PAs and specialties),” he said. “How much independence will vary based on time and specialty training.”
Because of critical community needs, worsened by the pandemic, Gormas said the fastest growing specialty for PAs is behavioral health.
In June 2019, Canton-born PA Sarang Patel acquired one physician practice in Adrian specializing in mental health services and then in April opened another clinic in Wayne. He employs seven PAs, five NPs, several therapists and support staff.
Patel bought Adrian Counseling from Dr. Theethaye Ittiara when he retired and earlier this year opened Pure Psychiatry of Michigan in Wayne. Under state law, PAs must have collaborative relationships with physicians to operate clinics. Doctors also must own a minimum of 1 percent of clinics.
Patel, a PA since 2016, decided to specialize in psychiatric issues while training at Beaumont Hospital Wayne’s emergency department.
“We wanted to continue servicing the community of Adrian for mental health. Like many rural areas, people drive far for access to care and we wanted to make sure when they come in they feel like they are at home,” Patel said.
Patel said he plans to add other clinics when opportunities arise. “My family is business oriented and I wanted to get into a entrepreneurial role,” he said. “If something comes up in a community, and we can help, I would love to grow.”
Spectrum Health Keith Hustak
Keith Hustak, a PA for 17 years who is vice president of advanced practice provider services and operations with Spectrum Health in Grand Rapids, said PAs historically were designed to take on some of the roles that physicians couldn’t do because of time constraints.
“What’s evolved though over the past 10 years is that PAs have moved from primary care into more specialty care,” said Hustak, who also is vice president of operations for urgent care and occupational health. He oversees the system’s 700 advanced practice providers, including PAs and nurse practitioners.
“We are trying to get increasing access to care and PAs are helping do that,” he said. “In the old days, you might wait two or three weeks to see your physician and then you’d wait two hours in the office. Now it is ‘who can I see the fastest,’ and that’s where PAs are kind of being thrust into the forefront of healthcare because they have excellent medical training.”
Michigan has eight accredited PA programs, including Wayne State University and Grand Valley State University, and others are seeking accreditation at Michigan State University, Oakland University and Lawrence Technological University.
What are physician assistants? Physician assistants got their start during the mid-1960s to address a shortage of primary care physicians when the first training program was created at Duke University Medical Center. But PAs’ roots trace back to World War II, when the need for medical doctors created the fast-track training program. Unlike nurse practitioners, who are trained in the nursing care model, PAs are trained in the medical model with half their 4,000 hours spent in classrooms and half in actual patient care. NPs, who have similar licensing requirements and service limitations as PAs, must complete about 1 1/2 years of post-baccalaureate studies and some 500 hours of clinical training. With more than 268 PA schools nationally, the PA profession is listed by U.S. News & World Report as No. 1 on its 2021 “Best Healthcare Jobs” list with a projected 31 percent growth rate over the next seven years. Nationally, there were more than 130,000 practicing PAs with an average annual pay of $115,390, or $55.48 per hour in 2019, according to the U.S. Bureau of Labor Statistics. In Michigan, 48.2 percent of the 6,759 licensed PAs practice in a physician office or clinic setting, 39.3 percent in hospitals, 7.2 percent in urgent care centers and 4.5 percent in other settings, according to 2019 data, Gormas said. Overall, 43.6 percent of Michigan PAs are employed by physicians and 56.4 percent by hospitals, a number that has been growing as doctors become hospital employees. Some 21.5 percent specialize in primary care. By specialty, 22.1 percent of the state’s PAs specialize in surgery, 17.6 percent in family medicine, 14.5 percent in internal medicine, 8.2 percent emergency medicine, 7 percent urgent care and 3.9 percent in general pediatrics or general internal medicine. Another 23.4 percent are in other specialties.
— Jay Greene
John McGinnity, director of PA Medicine at Michigan State University’s College of Osteopathic Medicine, said there has been rapid growth of PA programs because of the state’s regional healthcare needs. MSU is seeking provisional accreditation and hopes to start its first class of 38 students in May 2022.
“The biggest issue is clinical rotations. PAs have now twice as many programs as a few years ago, but it is a challenge to find (training spots) for them” at hospitals, said McGinnity, who taught PA medicine at Wayne State University for 25 years.
“We’re seeing the same growth as medical schools and everyone is looking for training spots for their students,” said McGinnity. “And if you are in a smaller institution, it’s tough. (Hospitals and outpatient providers) want some reimbursement for (training).”
McGinnity said more PAs in Michigan will help address primary care shortages and also lack of providers in rural settings.
Moote with Michigan Medicine oversees more than 350 PAs. More than 70 percent of its PAs specialize, a higher percentage than most community hospitals, he said. Another 400 nurse practitioners are in the university health system, but unlike Spectrum, which operates a blended model, nurse practitioners have separate management.
“The majority of our positions are posted as APPs (advanced practice providers), where either a PA or an NP could apply. Hiring really depends on specialty and department needs. PA and nursing are fully supportive of best qualified applicants. We really want at the end of the day the best practitioners for our patients,” Moote said.
UM-Flint Physician assistant Stanley Mukundi examines a Michigan Medicine patient in 2018.
When COVID-19 struck in March 2020, some PAs switched specialties to support other providers in intensive care units and emergency departments.
A small number, estimated at about 12 percent, mostly working at physician offices, were laid off or furloughed when states ordered shutdowns that closed some health facilities, according to a report last summer by the National Commission on Certification of Physician Assistants.
“Patient volume was impacted by the pandemic, with 45 percent of PAs reporting a decrease,” the NCCPA report said. The study included responses of 21,000 certified PAs.
In April 2020, Petropoulos began working at home doing telemedicine after Preferred Medical Group in Madison Heights, where she practiced, downsized because of reduced patient visits.
“I wasn’t feeling very useful sitting at home doing a few visits every day,” she said. “I started to submit applications to (hospitals) in Detroit. They were opening up (COVID emergency centers), but I only got one response.”
Petropoulos decided to go where she was needed and left Michigan to work at Bellevue Hospital in Manhattan from April to July 2020. Then she took a job at HBO as a COVID-19 compliance officer. But she went back to Bellevue in February, during another surge, and stayed until last month.
“COVID-19 brought New York City to its knees. I have never seen such devastation,” Petropoulos said. “The unity I witnessed, the cheers of support in the streets when I walked out of that hospital, after seeing what I hope to never see again, brings me to tears to this day.”
Petropoulos, who hopes to return to Detroit, is still working for HBO on multiple shows. She said her safety protocols have resulted in zero outbreaks. At Michigan Medicine, Moote said PAs, NPs and doctors all contributed to a variety of patient care duties during the worst of the pandemic.
“Our PAs viewed COVID, especially the initial surge, as a call to action and volunteered at a tremendous level,” Moote said.
But Moote said COVID-19 has taken a toll on all providers.
“Make no mistake, for those who did not redeploy — PAs, NPs and physicians — they were bearing the brunt of extra workload under austere and extreme circumstances,” Moote said. “Everyone is back to where we were before. I’m really proud of the work they did.”
Samantha Danek, a neurosurgery PA who worked through the surges at Henry Ford Allegiance Hospital in Jackson, said the COVID-19 crisis challenged everyone differently.
“We had no furloughs at Allegiance. They incorporated staff back into different positions for a time. I went to care for patients in specialized units,” she said. “It’s almost back to normal now. It’s a relief not having to go back into a unit with all the garb on — the spacesuits.”
Danek said families can now communicate directly with their loved ones.
“It’s like a regular day now,” she said. “We’re not seeing those desperate calls for beds, those code reds, 50 patients down in the emergency room waiting. It’s a very welcome change.”
Most people treated at hospitals now are the young unvaccinated. “They don’t get as sick,” Danek said.
In late July, Danek took a job in the mental health unit at Trinity’s St. Joseph Mercy Chelsea hospital, where she will be working with a new team of doctors and nurses.
“I decided to switch to psychiatry. I’m trying to line up a little more with my vision,” said Danek, adding that a close friend recently lost her son to suicide at age 16. “This COVID pandemic gave me a broader outlook of what I want to do with my life” and career, she said.
Like many hospitals that have transitioned to multidisciplinary team-based care, Danek said St. Joe’s Chelsea is just beginning to incorporate advanced practice providers in mental health services.
“They understand what APPs can really bring to their service. They know they can’t maintain this volume without adding APPs,” Danek said.
When Danek first started as a PA in 2009, Allegiance only employed five PAs. Now it has more than 200 PAs and NPs. “It’s been an amazing expansion and worked out very well for Henry Ford,” she said. Over the past 18 months, Allegiance has begun using PAs in its psychiatric units.
When Spectrum integrated its now 700 advanced practice providers with doctors several years ago in orthopedics and other service lines, Hustak said it was done to improve team-based care, but also to reduce physician burnout.
“We are now working at the top of our competency, helping doctors and other administrators, providing help in a way that is cost effective,” Hustak said.
“We really have a great culture with our PAs and APPs. We don’t have to divide where NPs or midwives and PA do things differently. They work side by side,” Hustak said. “If you stand 10 feet back, they don’t seem much different.”
Moote said the 2017 law also is helping Michigan Medicine and other hospitals with the challenging transition from fee-for-service payments to “value-based reimbursements.” Fee-for-service payments are based on individual services while value-based payments are based on the services, but also the quality of care provided and patient outcomes.
Within a team-based practice approach, Moote said everyone is striving to find the right balance between quality, price and patient satisfaction, known as the triple aim.
But right now it is difficult to attribute costs and revenue to individual providers because of antiquated reimbursement policies, Moote said.
“If you look at inpatient care, very few inpatient providers, physicians, PAs, NPs, cover their costs exclusively, through direct fee for service reimbursement,” Moote said. “That requires a subsidy by health system to cover a portion of our costs.”
Moote said PAs can provide lower costs and delivery high-value care. Michigan Medicine’s goal is “to figure out what is the optimal number of physicians, PAs and NPs so we can provide lower cost healthcare at all times,” he said.
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