1. PA Coordinates Massive Surgical
Team for Historic Surgery
the
of
Gift
Hands
T H E L E A D I N G N E W S R E S O U R C E F O R PA s
D E C E M B E R 2 0 1 5
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3. ContentsD E C E M B E R 2 0 1 5 • V O L . 7 , N O . 1 1
Departments
President’s Letter
Time to Make an Impact on the PA Foundation
Laws+Legislation
Supporting PAs in the VA
Payment Matters
Performance Measurements Take Center Stage
STAT
Groundbreaking CME Collaboration;Turning theTide
on Pediatric Obesity; Screening Adults for Diabetes;
and more
One-On-One
PA Employer Q&A—Allegheny Health Network
Professional Practice
Nailing the Job Interview
First Rounds
News by students, for students
Eating Well
Poached Pears With Marscapone Cheese
and Walnuts
Reflections
Helping Cancer Survivors Reclaim Their
Sexual Health
7
13
17
10
35
39
51
41
53
Features
C O V E R S T O R Y
The Gift of Hands
PA Coordinates Massive Surgical Team for Historic Surgery
F E AT U R E S T O R Y
Community Care Units:
Taking the Service to the Patients
PAs Reducing ER Transports Through 911
Response Home Visits
23
30
COVER PHOTO COURTESY OF CHILDREN'S
HOSPITAL OF PHILADELPHIA
AAPA’s Navigating Healthcare
Look for AAPA’s Navigating Healthcare icon to read
stories on the Affordable Care Act and the
broader changes impacting PAs in this rapidly
changing healthcare environment.
Visit us at aapa.org to see what else we
are doing for you.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 1
8. MPAS Degree Advancement Option
Division of Physician Assistant Education
Requirements
§ Graduate of accredited PA program and possess
a baccalaureate degree
§ Current or prior NCCPA certification
§ Physician/Mentor who agrees to be your preceptor
Learn more and apply at:
unmc.edu/alliedhealth/padao | 402-559-6673
Program Highlights
§ Over 30 years of proven success granting
master’s degrees to nearly 2000 practicing PAs
§ 36 semester credit hours of courses including
a clinical or education track
§ Affordable program with no required resident
time on the UNMC campus
§ Graduate in 5 semesters with up to 5 years to
complete studies
9. PRESIDENT’SLETTER
Time to Make an Impact
Help the PA Foundation Help PAs Improve Health
G
iving back is important to me. I work in a rural
community that has a lot of needs, in healthcare
but also in many other areas. One of the nonprof-
its I’m most passionate about is Head Start, which is com-
mitted to the belief that every child, regardless of circum-
stances at birth, has the ability to succeed in life.
When I think about the Head Start mission, I cannot help
but arrive at a similar belief about healthcare … that
everyone, regardless of circumstance, should be able to
access healthcare. Yet, despite the gains made under the
ACA, more than 30 million U.S. residents are currently
uninsured, severely limiting their access to care. Lack of
access means no well-baby visits and no regular monitor-
ing of chronic diseases. These people are in my commu-
nity, and I know they are in yours, too.
I’ll bet that you, like me, have compassion for those in
your community who need but do not have regular care
for themselves or their family members. As PAs we are in a
unique position to serve those who are ill. We have the
medical expertise to care for those who are underserved
and vulnerable to health crises. And yet, with so many
responsibilities vying for our time, we’re often challenged
to help.
That’s where the PA Foundation comes in. Its mission is to
empower PA engagement in philanthropic programs that
Steven Xiao, a
recent Touro
University
Nevada PA
program
graduate,
examines a
patient in the
mobile health
clinic operated
by the
program.
PHOTOCOURTESYOFTOUROUNIVERSITYNEVADA
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 7
10. PRESIDENT’S LETTER | continued
improve health. For almost 40 years, the Foundation has been known in our
profession for providing scholarships to PA students and grants to support
philanthropic programs in the cities in which AAPA convenes each year.
But did you know that in the last year the PA Foundation has expanded
its support to PAs and PA students who have a heart for helping those
most at risk for health complications? Its volunteer Board of Trustees made
a strategic decision to expand opportunities for PAs to give back to their
communities through healthcare, which led to the launch of the Founda-
tion’s IMPACT Grant Program earlier this year.
IMPACT Grants support PAs and PA students who recognize healthcare
needs in their communities and want to help address those needs through
healthcare service focused on patient education and outcomes. As a
result, patients across the nation are receiving care they would otherwise
go without. IMPACT Grants complement the Foundation’s well-established
Global Outreach Grants, which over the last decade have produced suc-
cessful health outcomes in Africa, Asia, Central and South America and
the Caribbean.
I give to the PA Foundation because it is helping PAs serve their commu-
nities by sharing their medical practice skills with those who need them
most. I hope you’ll join me in supporting the PA Foundation’s expanding
program of health philanthropy. Won’t you please make an end-of-year gift
that supports its mission? When you do, you help the PA Foundation
address health inequities both here at home and around the world. To
make a donation, go to the PA Foundation website.
Thank you for giving back.
Jeffrey A. Katz, PA-C, DFAAPA
AAPA President and Chair of the Board
Touro University Nevada PA students encourage the PA community to "Practice
the Power of Giving" to the PA Foundation on #GivingTuesday.
PHOTOCOURTESYOFTOUROUNIVERSITYNEVADA
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 8
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12. LAWS+LEGISLATION
Supporting PAs in the VA
AAPA,VAPAA Work With Congress to Tackle PA Shortages in VA Health
Facilities
B Y S A N D Y H A R D I N G , M S W
M
omentum continues to grow in Congress to
support national recruitment and retention
of PAs in Department of Veterans Affairs (VA)
medical facilities. For many years, AAPA and the Veterans
Affairs Physician Assistant Association (VAPAA) have
voiced their concerns regarding lack of attention to
recruitment and retention efforts and pay inequity experi-
enced by the more than 2,000 PAs employed by the VA.
These messages, combined with recent publicity regard-
ing unacceptable wait times for veterans seeking medical
care at VA medical facilities and the VA’s own Office of
Inspector General (OIG) January 2015 report on the top five
occupational staffing shortages in the Veterans Health
Administration (VHA), are pushing congressional action
on the need to address the VA’s PA workforce issues.
The VA OIG report identifies PAs as being in the“top three
critical occupations difficult to recruit”and as having the
third largest staffing shortage in the VA healthcare system.
According to the VAPAA, the current annual turnover rate
for PAs is 12–14 percent and the vacancy rate for PAs is
among the highest in the VHA. Additionally, approximately
40 percent of PAs currently employed by the VA are eligible
SANDY HARDING, MSW, is
AAPA’s senior director of federal
advocacy. Contact her via email or
571-319-4338.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 10
13. LAWS+LEGISLATION | continued
to retire in the next five years.Yet the VHA has made no commitment to
increase recruitment and retention initiatives for the PA profession.
Congress has been active in several initiatives aimed at requiring the VA
to address challenges related to its PA workforce. For example:
■ Although the VA has the authority to review the pay of its PA workforce,
compared to the local market, through its internal“nurse locality pay
system,”the VA has chosen not to do so. On July 22, 2015, the Senate
Committee on Veterans Affairs unanimously reported legislation to
require the VA to include PAs in the locality pay system review. This provi-
sion is expected to be included in omnibus veterans’legislation to be
considered by the Senate in the upcoming months.
■ S. 1450, the Department of Veterans Affairs Emergency Medical Staffing
Recruitment and Retention Act, was introduced by Sen. Mazie Hirono
(D-HI) to cap the hours for PAs and physicians employed on a full-time
basis by the VA and to provide overtime pay. The bill is expected to be
considered by the Senate Committee on Veterans Affairs in November.
The most creative legislative proposal to advance VHA recruitment and
retention of PAs is S. 2134, the“Grow Our Own Directive: Physician Assis-
tant Employment and Education Act of 2015,”(GOOD) introduced by Sens.
Jon Tester (D-MT) and Jerry Moran (R-KS). A House companion bill, HR
3974, was introduced November 4 by Reps. Ann Kuster (D-NH) and Joe
Heck (R-NV). The GOOD Pilot Program, designed to create a pathway for
veterans to become educated as PAs, is a creative investment for veterans.
The GOOD Pilot Program supports veterans becoming PAs and adds to the
supply of PAs in VA medical facilities. Additionally, the bill would require
the VA to establish a national strategic plan to recruit and retain PAs,
including the adoption of standards leading to competitive pay for PAs
employed by the VA.
In a letter to Sens. Tester and Moran, AAPA CEO Jennifer L. Dorn wrote:
Ready access to quality patient care is among the most critical issues fac-
ing our nation’s veterans. AAPA is thrilled that you have sponsored this
legislation to increase the PA workforce through the GOOD Pilot Program.
This inventive model, along with needed policy improvements, holds great
promise for the recruitment and retention of PAs at the VA. We are particu-
larly pleased that the GOOD Pilot Program will provide priority to veterans
who are from rural communities and who are willing to commit to provid-
ing care as PAs in VA facilities located in rural communities.
AAPA looks forward to working with the VAPAA to better serve veterans
through passage of the GOOD Act and other legislative proposals to create
national recruitment and retention strategies for all PAs who provide qual-
ity medical care through VA medical facilities.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 11
15. PAYMENTMATTERS
Performance Measurements
Take Center Stage
“Hidden Care” May Cause Problems for PAs With Some Quality Metrics
B Y M I C H A E L P O W E
P
As, along with their physician colleagues, were
understandably optimistic when in April 2015 Con-
gress passed the Medicare Access and CHIP Reau-
thorization Act (MACRA), which permanently eliminated
the flawed Medicare payment update system known as
the Sustainable Growth Rate (SGR).The SGR formula,
which attempted to limit the growth in Medicare spend-
ing for Part B professional services, based on annual
spending targets, was responsible for threatening severe
cuts to Medicare reimbursement for all health profession-
als for over a decade. Only the repeated and often last
minute interventions by Congress, with strong support
from AAPA and other healthcare organizations, prevented
those draconian cuts from actually being enacted.
PAs should be aware of the new system that is sched-
uled to take the place of the SGR. Language in MACRA
established that the Merit-based Incentive Payment
System (MIPS) will be the new payment mechanism used
by Medicare as the program seeks to rapidly transition
its reimbursement structure from a fee-for-service to a
fee-for-value payment system. MIPS officially begins in
2019, but performance measurements will be based upon
data from clinical care provided in calendar year 2017.
MIPS
MIPS is a program
that measures Medi-
care Part B health
professionals in four
different categories.
Each category has a
numeric ranking or
score; scores from
the four categories
added together total
to a MIPS composite
performance score
that can range from
MICHAEL POWE is AAPA vice
president of reimbursement and
professional advocacy and an
adjunct assistant professor at The
George Washington University
School of Medicine and Health
Sciences. Contact him via email
or 571-319-4345.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 13
16. PAYMENT MATTERS | continued
0 to 100. MIPS essentially combines the various independent CMS incentive
programs that currently exist—the Physician Quality Reporting System (PQRS),
meaningful use (MU) and the Value-based Payment Modifier (VBM)—and adds
one other category, clinical improvement. As of January 1, 2019, included pro-
fessionals will no longer separately report PQRS quality measures, attest to elec-
tronic health records MU or deal with the negative payment adjustment associ-
ated with the VBM.
Each year a PA’s (or other included professional’s) composite score would be
compared to a performance threshold consisting of the mean or median of the
performance rating for all professionals participating in MIPS. Each PA would
have to meet or exceed that established threshold to be eligible to receive an
incentive payment/higher payment rate. Those who fall below the threshold
would likely see reduced payment rates. Those with composite scores exactly at
the threshold will see no payment adjustments.
Payment adjustments can be as high as 4 percent in 2019 and increase to a
maximum of 9 percent in 2020 and for subsequent years. In 2022, the positive
incentive for the highest performers can be as high as 27 percent and the pay-
ment decrease for low performers can be a negative 9 percent, which equates to
a potential Medicare payment spread of 36 percent!
Here is a look at how each of the four measures will be weighted:
■ Quality (30 points): PQRS
■ Resource use (30 points): VBM program
■ Meaningful use (25 points): Appropriate use of certified electronic health
records technology
■ Clinical practice improvement (15 points): Demonstrated improvements in
care coordination, patient safety and/or population management.
The MIPS program is expected to be administered and managed at the indi-
vidual health professional level, as opposed to some kind of group reporting
mechanism. Initially, not all health professionals are required to participate in
the program. When the program officially starts in 2019, PAs, MDs and DOs,
advanced practice nurses and others deemed by CMS to be“physicians”or doc-
tors—including dentists and oral surgeons, podiatrists, optometrists and chiro-
practors—will be required to participate. Other professional groups will be
required to participate in MIPS starting in year three of the program or 2021.
In addition to their impact on reimbursement, individual MIPS scores
will appear on a public website called Physician Compare. Patients, potential
employers and others will be able to see a professional’s MIPS score
on this site and potentially use the scores to differentiate between
health professionals.
A Unique Concern for PAs
Many medical services that are provided by PAs are not billed for under the PA’s
name or NPI number. Those services are often legitimately billed for under the
name of the physician with whom the PA works, under Medicare’s“incident to”
provision, for example. That lack of transparency in the billing process could have
negative consequences for PAs in programs such as MIPS. It means that the medi-
cal care and productivity that PAs provide is essentially“hidden”or not reported
within the Medicare claim systems and databases. How can a PA be adequately
evaluated on care quality metrics when the care they deliver is attributed to
another professional?
The MIPS program will develop a cut-off point, called a low-volume threshold
(which is different from the performance threshold), to determine which health
professionals will not have to participate in MIPS due to serving a relatively small
number of Medicare beneficiaries. While this is still under discussion, a figure of
10 percent has been suggested. This means that if less than 10 percent of your
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 14
17. PAYMENT MATTERS | continued
patient encounters occur with Medicare Part B beneficiaries, you would not be
subject to MIPS and would not be eligible to receive incentive payments for deliv-
ering high quality care.
So, if a PA treated a high volume of Medicare beneficiaries and most of those
services were billed under the physician it might appear that the PA did not
exceed the 10 percent threshold and, subsequently, is not entitled to a MIPS
incentive payment, even though the PA’s patient mix included a high percent-
age of Medicare beneficiaries. Advanced practice nurses potentially face the
same problem.
AAPA has repeatedly voiced that concern to CMS officials, both in personal
meetings and in formal comments. A remedy for this problem must be found if
the MIPS program is to be an accurate indicator of who provides high quality
care. The Academy believes that the complete recognition of PAs in the delivery
and payment process is the appropriate solution.
Can Participation in MIPS Be Optional?
CMS offers health professionals who participate“significantly”in alternative
payment models (APMs) an exemption from the MIPS performance measures.
While not firmly established in policy, the suggestion is that if at least 25 percent
(increasing to 75 percent in 2023 and subsequent payment years) of a health
professional’s Medicare reimbursement comes from APMs they can opt out of
MIPS and receive a 5 percent bonus rate increase on their Medicare reimburse-
ments. APMs can be described as an effort to align healthcare incentives with
the joint goals of improving care quality, increasing care coordination and
reducing costs. An accountable care organization, a patient-centered medical
home or a bundled payment program are prime examples of an APM.
CMS allows for a lower APM threshold exception, known as a“partial qualifying
APM participant,”in which the APM percentage thresholds are lower. A partial
qualifying APM participant is not eligible for the 5 percent APM payment incen-
tive, but is exempted from participating in MIPS.
Small and Rural Practices to Receive Additional Assistance
Language in MACRA provides special assistance to small practices and practices
in rural communities. Practices with up to 10 eligible professionals (EPs) may
coordinate with similar practices or eligible individuals to form a“virtual prac-
tice.”The virtual group’s performance is then measured as the combined perfor-
mance of all EPs as opposed to a solo professional (perhaps with more limited
resources) having to compare their performance with larger groups.
In addition, $20 million per year will be earmarked to provide technical assis-
tance through entities such as quality improvement organizations or regional
extension centers to practices that have 15 or fewer EPs, particularly in rural and
underserved communities.
Next Steps
Information released by CMS to date regarding specific implementation details
of MIPS is admittedly limited. In order to obtain greater input from health pro-
fessionals and healthcare-related stakeholders, CMS issued an official request for
additional feedback in the form of a Request for Information. AAPA submitted
official comments to CMS aimed at ensuring that (1) PAs are fully recognized in
the MIPS program and confirming that the high quality care that PAs deliver is
accounted for and documented, and (2) the MIPS program represents an accu-
rate and meaningful assessment of the patient care activities associated with
PAs and other health professionals.
PAs should engage in conversations with physician colleagues, practice
managers and billing and coding personnel to express their interest in being
an integral part of the process to ensure a successful transition into MIPS and
other value-based incentive and payment models.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 15
19. STAT | Industry News
AAPA LAUNCHES GROUNDBREAKING
CME COLLABORATION WITH LEADING
RESEARCH CENTERS
AAPA recently announced collaborations with the
University of Michigan Health System (UMHS) and
the University of Texas MD Anderson Cancer Center
to recognize PA participation in new multispecialty
programs that will award the first of many perfor-
mance improvement continuing medical education
(PI-CME) credits to participating PAs.
“PAs are leading the charge in transforming
healthcare to help improve patient access and care,”
said Jeffrey A. Katz, PA-C, DFAAPA, AAPA president
and chair of the Board.“Through these learning
programs, PAs will actively develop new and inno-
vative ways to deliver higher quality care more effi-
ciently while satisfying their medical certification requirements. AAPA is proud to work in partner-
ship with UMHS and MD Anderson, both groundbreaking institutions with exceptional reputations
for patient care.”
In 2014, the National Commission on Certification of Physician Assistants implemented a new
PA certification maintenance process that added two new CME categories: self-assessment and
PI-CME. Among the 50 credits required for Category 1 CME, 20 must be earned via AAPA accredited
self-assessment and/or PI-CME activities. Learn more about PI-CME here.
AAPA LEADERS DISCUSS KEY
HEALTHCARE ISSUES ON NATIONAL
WEBSITES
Several AAPA leaders received national coverage
last month as they talked about key issues fac-
ing the U.S. healthcare system. AAPA President
Jeffrey A. Katz, PA-C, DFAAPA, and James Cannon,
MBA, MS, DHA, PA-C, DFAAPA, immediate past
chair of the National Commission on Certification
of Physician Assistants (NCCPA) recently published
a blog post on the major medical website KevinMD.
com about how PAs can play an important role
in the national mental health crisis by offering
increased access to mental healthcare services.
On the website PhysiciansPractice.com, Lawrence
Herman, PA-C, MPA, DFAAPA, an AAPA past presi-
dent, writes about our need to respond to the obe-
sity epidemic in America. The first week in November
was National Obesity Care Week and AAPA part-
nered with clinicians, scientists and healthcare
providers to bring national attention to issues sur-
rounding obesity, including basic science, clinical
application, surgical intervention and prevention.
TURNING THE TIDE ON PEDIATRIC
OBESITY
A new study published in the journal Obesity
suggests that isocaloric fructose restriction
can reverse virtually every aspect of metabolic
syndrome in children. Funded by the National
Institutes of Health, the study showed that this
reversal occurred irrespective of weight change.
ADOBESTOCK.COM
INGIMAGE.COM
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 17
20. STAT | continued
Researchers found that by replacing foods with
added sugar in children’s diets with starches their
blood pressure and insulin levels dropped and
they showed dramatic improvement in their LDL
cholesterol levels and triglycerides in just 10 days.
Robert Lustig, MD, a pediatric endocrinologist and
the study’s lead author, told media outlets that
triglycerides especially showed a“very, very large
improvement.”
HELP RECRUIT THE NEXT
GENERATION OF PRECEPTORS
If you currently work as a preceptor, you can help
promote precepting and encourage others to
join in by applying for AAPA’s Clinical Preceptor
Recognition Program. Developed in cooperation
with the PA Education Association (PAEA), the pro-
gram acknowledges the commitment of clinical
preceptors to improving PA education.
AAPA fellows or sustaining members who have
been a preceptor for more than one student and
who are endorsed by a PA program are eligible
to apply for this free recognition program. Benefits
include the use of the designation“CPAAPA,”a cer-
tificate of recognition and a Clinical Preceptor lapel
pin. Preceptors who are a part of the program are
encouraged to wear their pins and use them as
a starting point for conversations with other PAs
about the benefits of precepting.
The application and program details are available
on the AAPA website.
SCREENING ADULTS FOR DIABETES
The U.S. Preventive Services Task Force (USPSTF)
recently published a final recommendation statement
on screening for abnormal blood glucose and type 2
diabetes mellitus in adults. A fact sheet that explains
the final recommendation in plain language is avail-
able here.
The USPSTF recommends that adults ages 40 to
70 who are overweight or affected by obesity should
be screened for abnormal blood glucose as part of
a heart disease risk assessment. Clinicians should
refer patients with abnormal blood glucose levels to
intensive programs that can help them lose weight,
eat a healthy diet and be physically active.
EARLY BIRD REGISTRATION FOR AAPA 2016 IS OPEN!
Registration is now open for the world’s largest PA event, and we want to help you get there. Use
one of our three fund-your-trip templates to personalize a funding request to your employer or PA
program.
Many employers and PA programs are willing to provide support for professional conferences like
AAPA 2016. In fact, 78 percent of AAPA 2015 survey respondents told us they received financial assis-
tance to attend the conference.
Do early bird registration and then add on more savings with our“Jolt”promo. Don’t forget to use
the promo code POWERUP when you register.
NEW BREAST CANCER SCREENING
RECOMMENDATIONS FOR WOMEN
AT AVERAGE RISK
The American Cancer Society (ACS) recently
updated its breast cancer screening guidelines on
average-risk women, changing its recommended
starting age for annual screening mammograms
from 40 years to 45 years.
Published in the Journal of the American Medical
Association in October, ACS also recommends that
annual screening should be done in those ages 45
to 54, while those 55 years of age and older should
either transition to biennial screening or continue
annual screening.
INGIMAGE.COM
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 18
21. STAT | continued
2015 PEDIATRIC IMMUNIZATION
SCHEDULE RELEASED
The 2015 recommended immunization schedule
for children and adolescents living in the United
States has been released, with changes to menin-
gococcal B, DTaP, polio and human papillomavirus
(HPV) vaccination recommendations. The updated
recommendations were approved by the American
Academy of Pediatrics, Advisory Committee on
Immunization Practices (ACIP) of the Centers for
Disease Control and Prevention (CDC), American
Academy of Family Physicians and American
College of Obstetricians and Gynecologists.
Read the recommendations on the American
Academy of Pediatrics website and the CDC website.
ADDRESSING OPIOID ADDICTION
Kenneth Dean Wright, PA-C, a representative of
AAPA, and other members of the Collaborative for
REMS Education (CO*RE) joined the Obama admin-
istration in October to announce new efforts to
address the nation’s prescription drug abuse and
heroin epidemic.
President Obama highlighted these efforts at an
event in Charleston, W.Va., where he heard directly
from Americans affected by this epidemic and the
health professionals, law enforcement officers and
community leaders working to prevent addiction
and respond to its aftermath.
He announced commitments by more than 40
provider groups, including AAPA, that more than
540,000 health professionals will complete opioid
prescriber training in the next two years. Watch the
announcement here.
CO*RE offers free CME on how to properly pre-
scribe extended-release/long-acting opioids and
prevent opioid abuse. Go to AAPA’s Learning Central
CME portal for more information.
NEW RECOMMENDATIONS
TO PREVENT CVD
The Community Preventive Services Task Force
recently released two recommendations on self-
measured blood pressure monitoring interventions
for improved blood pressure control. The use of
personal blood pressure measurement devices can
help people manage their high blood pressure and
help prevent cardiovascular disease.
The task force reports that researchers examined
evidence from 52 studies from an existing system-
atic review published in 2013 and found that self-
measured blood pressure (SMBP) monitoring when
used alone led to improvements in blood pressure
outcomes at six months. When these interventions
were combined with additional support, improve-
ments in blood pres-
sure were sustained
at 12 months.
CALIFORNIA IMPROVES CHART
COSIGNATURE REQUIREMENTS
FOR PAs
California Gov. Jerry Brown in October signed
a bill into law that improves documentation
requirements for PAs in the state. Senate Bill 337,
sponsored by the California Academy of PAs
(CAPA), adds flexibility to the state’s current chart
cosignature requirements, which will allow for a
reduction in the number of charts that are required
to be cosigned by a physician. It goes into effect
Jan. 1, 2016.
The bill creates two new alternatives to the cur-
rent 5 percent monthly chart cosignature require-
ment when practicing with protocols. The first
option allows PAs to have a minimum of 10 cases
reviewed through medical records review meetings
that occur during at least 10 months of the year. The
second new option requires a review of at least 10
records per month for 10 months during the year
using a combination of countersignature and the
medical records review meeting documentation
methods. The medical records review meetings may
occur in person or by electronic communication.
The bill also reduces the state’s Schedule II chart
cosignature requirement from 100 percent to
20 percent for PAs that have completed a con-
trolled substance course as outlined in California
regulations.
For more information, contact Keisha Pitts, JD,
director of constituent organization outreach and
advocacy.
STOCK IMAGES: ADOBESTOCK.COM
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 19
22. STAT | continued
DRUG SAFETY ALERT ON CLOZAPINE
The U.S. Food and Drug Administration announced
in September that it had modified monitoring for
neutropenia associated with the schizophrenia
medicine clozapine, and approved a new shared
REMS program for all clozapine medicines. The
agency made changes to the requirements for
monitoring, prescribing, dispensing and receiving
clozapine, to address continuing safety concerns
and current knowledge about the serious blood
condition neutropenia. Learn more here.
NCCPA PROPOSES CHANGES
TO PANRE AND CAQs
NCCPA is soliciting comment for a new recertifi-
cation model that would change the PANRE and
CAQs. The proposal raises significant concerns
and could have negative impact for patients, PAs
and employers.
AAPA invites and encourages all PAs to read more
about the proposal and potential resulting issues
and to join in the discussion on Huddle. There, you
can share any concerns you may have with the
NCCPA proposal. These comments will be used to
inform AAPA’s official response to NCCPA, as well as
any other actions that may be appropriate.
If you are not an AAPA member, you can join here
and get in on the discussion or email us.
PCMH RECOGNITION PROGRAM
WANTS YOUR INPUT
The National Committee for Quality Assurance,
which published its first set of patient-centered
medical home (PCMH) standards in 2011, is work-
ing on“an ambitious redesign”of the recognition
program and would like your input.
Key components of the redesign include:
• Strengthening the link between recognition and
practice performance on quality, cost and patient
experience metrics
• Increasing practice engagement while reducing
non-value-added work
• Leveraging practices’investment in health
information technology to help support PCMH
recognition
• Aligning PCMH recognition activities with other
reporting requirements.
The new process will ask practices to demon-
strate that the changes made during the initial
recognition effort have been anchored in their day-
to-day culture, and that they continue to enhance
their patient-centered approach to care. Learn
more here.
CELEBRATING 20 YEARS OF THE PA PROFESSION IN INDIA
The Indian Association of Physician Assistants celebrated its 20th anniversary at its
annual conference in Kochi in October. Several American PAs were present. The
inaugural edition of a new journal—Physician Assistants Generating Excellence
(PAGE)—was presented to mark the occasion.
There are now five PA programs in India and about 1,000 graduates working
in the country. Government plans for universal healthcare in India, if they go
through, may soon drive up demand for PAs and other healthcare providers and
also provide some public funding for growing the number of PA programs. India
is trying to overhaul its healthcare system, and has increased the percentage of
GDP that it spends on healthcare from 3 percent to 4 percent in recent years.
To learn more, read the recent PAs Connect blog post.
U.S. PA leaders
Rod Hooker, Ruth
Ballweg and Nadia
Miniclier Cobb meet
with their Indian
counterparts during
the IAPA annual
meeting.
PHOTOSCOURTESYOFRODHOOKER
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 20
23. STAT | continued
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TWO NEW COs ANNOUNCED: NEUROLOGY AND CLINICAL ULTRASOUND
AAPA is excited to announce the addition of two new constituent organizations (COs). The AAPA Board
of Directors on Oct. 26, 2015, reviewed and approved two action items submitted by the Constituent
Relations Work Group (CRWG). The Association of Neurology PAs (ANPA) was approved as a specialty
organization. Amy Dix, PA-C, ANPA president, looks forward to this collaborative opportunity. More infor-
mation may be found at www.neurologypa.org.
Additionally, the Board approved a new special interest group (SIG), the Society for PAs in Clinical
Ultrasound (SPACUS). Francisco Norman, PA-C, worked diligently to organize this SIG and is anxious to
promote the group’s mission. Additional information is available at www.SPACUS.org.
With the addition of these two COs, AAPA’s CO community now has 110 individual groups. There are
56 state and federal service chapters representing 50 states, the District of Columbia and five federal
services; 26 specialty organizations for individuals working within a specific medical specialty; eight cau-
cuses for individuals sharing a common goal or interest in healthcare access or delivery; and 20 SIGs for
individuals sharing a common goal or interest.
COs are independent organizations affiliated with AAPA. They provide their members with CME, net-
working opportunities, social gatherings, volunteer opportunities, timely information, advocacy and job
resources. If you’re interested in joining a CO or contacting one for more information, learn more here.
Congratulations, ANPA and SPACUS. Welcome to AAPA!
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 21
24. STRONGER. TOGETHER.
Today, we helped Stephanie
negotiate the salary she deserves.
And helped Ben make the switch from
orthopedics to oncology. Provided
Kelly the CME she needed to maintain
her certification. Educated a large
hospital system about the best ways
to utilize their PAs. And lobbied for
PAs to be included in the recent
MediMedicare legislation.
From career tools to lifelong learning
to national advocacy, put the power of
AAPA behind you every single day.
Explore it all.
aapa.org/memberhome
25. BY STEVEN LANE, MA, MPP
THIS HOLIDAY SEASON, 8-YEAR-OLD ZION HARVEY CAN FOR THE FIRST
TIME DO SOME SIMPLE THINGS THAT MOST CHILDREN TAKE FOR GRANTED,
LIKE HOLD A FOOTBALL OR GIVE HIS LITTLE SISTER A REAL HUG. In July, at
the Children’s Hospital of Philadelphia (CHOP), Zion became the first child in the
world to receive a bilateral hand transplant. The 11-hour surgery involved a
team of more than 40 people, including 12 surgeons, a cardiologist, a nephrolo-
gist, nurses, psychologists, occupational therapists (OTs) and one PA—Christine
McAndrew, PA-C, in the Department of Orthopaedic Surgery at Penn Medicine,
who served in the very important role of coordinator for the team. Pulling
together so many people for meetings and surgery rehearsals took every bit of
her clinical and administrative skills. Her colleagues call her“integral to the suc-
cess of the entire program,”or, simply, a“rock star.”
PA Coordinates Massive Surgical
Team for Historic Surgery
the
of
Gift
Hands
COVER STORY
Click to watch a video
about Zion:
“First Bilateral Hand
Transplant in a Child:
Zion’s Story”
Photos courtesy of Children's Hospital of Philadelphia
PA Christine
McAndrew
and Zion
Harvey at
CHOP.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 23
26. THE GIFT OF HANDS | continued
Now five months post-surgery, Zion has just started feeding himself,
again—in many areas he had learned to compensate for his lack of hands
and must now relearn to do things he had previously mastered—and is
learning to hold a pencil. He faces a lot more hard work to get to full func-
tion in his hands, but his caregivers are very positive about his outlook. The
risk of organ rejection is always present, and every other week Zion must
still travel from his home in Baltimore to Philadelphia, where the surgeons
take a tissue biopsy to check for signs of rejection. Zion also meets with the
CHOP occupational therapists (OTs) who have worked with him from the
beginning, when he was doing therapy more than 40 hours a week. The
team is slowly transitioning Zion’s care to the Kennedy Krieger Institute in
Baltimore, but the CHOP staff will continue to keep an eye on him for the
foreseeable future.
McAndrew checks in with Zion and his mother, Pattie Ray, every other
day or so and will always have some role in his care, she says. She is still
regularly in touch with the first adult bilateral hand transplant patient at
Penn Medicine, whose surgery was in 2011.
“Zion is a patient for life,”said McAndrew.“As long as I’m in this role, I will
be managing his care.”
‘ThePerfectCandidate’
That Zion became the first child to receive two new hands was due to
something of a perfect storm of events. He had lost his hands at the age of
2 due to sepsis, which resulted in his having both hands and both lower
legs amputated, and also caused his kidneys to fail. He was on dialysis for
two years until he received a transplanted kidney from his mother. This
meant that he was already on antirejection medication for the rest of his
life, one key consideration in his suitability as a candidate for the hand
transplant.
Other factors were identified during the rigorous team evaluation that
any pediatric candidate for transplant surgery undergoes. The team,
including McAndrew, found that Zion was psychologically strong, with the
attitude and the ability to put in the work that would be needed during his
long rehab.
Led by L. Scott Levin, MD, FACS, the surgical team involved more than 40 people.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 24
27. THE GIFT OF HANDS | continued
And this has proved to be true. Zion“handled it all remarkably well,”said
Benjamin Chang, MD, one of the senior surgeons on Zion’s operation, codi-
rector of the Hand Transplant Program at CHOP, and associate chief of the
Division of Plastic Surgery at Penn Medicine.“He is mature beyond his
years. He really understands what is going on, never complains; he’s work-
ing really hard to improve his function.”
Zion was also deemed to have the necessary social support, through his
mother and the grandparents, aunts and uncles that live near his home.
And perhaps most remarkably, a suitable donor was found, much more
quickly than anyone had thought possible. The donor had to be a match in
several ways: roughly the same age and size as Zion, with similar skin tone,
the same blood type, and parents who were ready to agree—within a few
hours of their child’s death—to donate the child’s hands. The team thought
that perhaps 10 donors a year might be available. The Gift of Life program,
in Philadelphia, handled the donor procurement and parental consent
process for CHOP.
“Zion was truthfully the perfect candidate,”said McAndrew.
PullingItAllTogether
When the call came that a match had been found, the team had to move
quickly. In less than 24 hours, the 40-strong surgical team had to be
assembled, an operating room secured, and, of course, Zion had to make
the trip up to Philadelphia and be prepped for surgery. The call came in the
evening, too, so the surgery had to be carried out through the night into
the early morning. To ensure that enough of the right kinds of surgeons
and other providers would be in town when the call came, McAndrew
kept a detailed chart of each team member’s availability once the decision
had been made to do the surgery and the quest for a donor match was
under way.
The surgery posed tremendous challenges, both technical and organi-
zational. Four teams of surgeons were involved—one for each of the
CHOP colleagues call McAndrew a“rock star”for the role she played in the surgery.
Zion’s mother, Pattie Ray, shares a moment with him before he goes into the OR.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 25
28. donor’s hands and one for each of Zion’s hands. For each hand, the bones
were first attached together with steel plates by the orthopedic surgeons.
Then the arteries and veins were connected, using microvascular surgical
techniques—a“very difficult”job on a child’s body, McAndrew said.“These
are tiny, tiny vessels.”
Once blood was flowing well through the vessels, surgeons recon-
nected the muscles and tendons, and then finally the nerves, before clos-
ing up. The term for this kind of transplant, involving multiple different
kinds of tissue at once, is vascularized composite allotransplantation (VCA).
These exacting tasks tested the skills of surgeons who are among the
best in the world. But nearly as great a challenge was the coordination of
the team, both in the lead-up to the surgery and the surgery itself. This is
where McAndrew came in.
‘AttheCenterofEverything’
The team spent more than a year preparing for the surgery, including four
full-scale rehearsals on cadavers. For each, one McAndrew had to get 40
medical professionals, from two different institutions, together in one
place, just for starters. This was“definitely challenging,”McAndrew con-
ceded, but there was a will to get it done and she managed to find time
slots early in the morning or in the evenings.
“As the transplant coordinator I am at the center of everything that goes
on,”McAndrew says.
One of McAndrew’s most important tasks was to maintain the very
detailed lists of steps and timing for the entire surgery, which was devel-
oped and modified over the course of the four rehearsals. This is not usual
in more routine surgeries, she says, but“this was different because it’s not
THE GIFT OF HANDS | continued
The CHOP team is one of only a handful in the world that performs vascularized composite allotransplantation.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 26
29. THE GIFT OF HANDS | continued
something you do every day. If you want the best result you need a check-
list to make sure you don’t miss any steps.”
During the surgery, McAndrew checked off each step as the surgeons
talked to her throughout the operation:“Repair of FCR complete!”or
“Tagged ulnar nerve!”as each structure on the donor hands was dissected
out and labelled. The donor hands had a“cold ischemic time”—the maxi-
mum time they could be kept on ice between amputation and reattach-
ment—of only 6 hours, so keeping on time was critical.
McAndrew was also the main point of contact for Zion and his mother,
giving her regular updates throughout the 11-hour surgery. She got to
make the call to Pattie Ray when the donor match had been found.“That
was an exciting day,”she recalled.
JoiningtheTeam
McAndrew has worked with L. Scott Levin, MD, FACS, director of the CHOP
Hand Transplant Program and chair of the Department of Orthopaedic
Surgery at Penn Medicine, for most of her career. Levin had worked with
“two fabulous PAs”when he was a resident at Duke University Medical
Center, and was looking for a PA to join his team. After two years in general
orthopedics, following graduation with the first class of the Salus Univer-
sity PA program near Philadelphia in 2009, McAndrew applied for a job at
Penn Medicine. During her interview with Levin he offered her the oppor-
tunity to be the program coordinator, as well as his PA. She took the job.
Getting up to speed meant training heavily with the solid organ trans-
plant program at Penn and attending conferences to learn about VCA. She
has attended several meetings of the American Society of Reconstructive
Transplantation, the national organization for VCA practitioners. So far she
has been the only PA at those meetings.
Her colleagues have learned to rely on McAndrew’s organizational skills
and her calm presence in stressful situations.
“The success of this program would be nowhere near what it is without
her, and you can quote me on that,”said Levin.“She is an outstanding
healthcare professional and she has impeccable organizational skills. She
communicates well. She is integral to the success of this program. A lot has
fallen on her shoulders and she has stepped up.”
“Chrissy is a rock star,”says OT Michelle Hsia, one of four OTs on the team.
“She put every meeting together. It’s not easy to get high-level surgeons
from two institutions in the same place at one time, plus everyone else. We
had nothing short of 40 emails a day. It was a flurry of craziness. But Chrissy
was hugely instrumental in keeping everyone on the same page.”
McAndrew credits her PA training with giving her the skills to balance the
administrative and clinical aspects of the coordinator role.“I don’t just man-
age appointments,”she says of Zion,“I manage his clinical care—his biopsies
and medications and labs. We review his weekly labs and base his immuno
suppression medications on those labs. There is a big clinical aspect to
being the coordinator. I am involved in the overall clinical care of Zion.”
Levin, Zion and Ray at a press conference following the surgery.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 27
30. THE GIFT OF HANDS | continued
Zion’sProgress
At press time, Zion was continuing to progress well, his team reported. He
is still doing many hours of OT per day at Kennedy-Krieger, where he is
starting to do some schoolwork and will slowly transition toward a more
regular schoolday as his hand function improves.
As with most children, Zion gets bored of his routine sometimes. Zion’s
“tolerance of therapy changes daily,”says Hsia.“Some days he is excited
about the future, but like any 8-year-old he sometimes gets tired of doing
therapy for months on end.”Since Zion is the first pediatric hand transplant
recipient, his likely trajectory is hard to predict, Hsia says, but she notes
that some adult recipients are still doing therapy 15 years later.
If his dedicated team has anything to do with it, Zion will
soon be throwing footballs and picking up his little sister.
Both Hsia and McAndrew came back early from maternity
leave to be part of Zion’s care, and both were taken with the
level of dedication that others on the team showed. Many
had volunteered to be on call from the time that the donor
search began.“It was remarkable to be involved with such
dedicated, amazing people; I was very proud,”Hsia said.
McAndrew too was“honored to be part of this team and
to work with such extraordinary physicians and team mem-
bers”and to be a part of helping a patient she called the
“warmest, kindest little boy. He has amazed us with his
intelligence and motivation. Zion is quite an incredible
8-year-old.”
STEVEN LANE is senior writer for AAPA
and managing editor of PA Professional.
Contact him via email or 571-319-4364.
Zion still has a long way go but he’s progressing well.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 28
31. Neither you or your patients
have time to be sick...
Especially around the holidays!
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Cold Remedy releases zinc ions in the mouth, inhibiting the cold virus from replicating.
Try any one of our Cold-EEZE®
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Visit www.ColdEEZE.com for more information.
At the PA Foundation, we believe in
Empowering PAs
Changing Lives
Encouraging Scholarship
Improving Health
Put your power to work for a
healthier world.
Gifts to your PA Foundation help us support PA
led health improvement projects in communities
around the US and globally.
Donate today: pa-foundation.org/powerofu
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Patient Education Resources
32. Community Care Units:
Taking the Service
to the Patients
PAs Reducing ER Transports Through 911 Response
Home Visits
BY STEVEN LANE
I
t’s a scenario that plays out millions of times a year across the
country. A person in distress calls 911, a dispatcher sends out
an emergency services vehicle staffed with four firefighter-
paramedics, and the patient ends up in an emergency room (ER).
If there are psychological or behavioral issues involved, the patient
may end of staying in the ER for several days until a bed in a psychi-
atric facility is found.
For a sizable number of these patients, a visit to the ER is not
necessary and represents a significant waste of time and money for
all concerned. Wouldn’t it be great if instead of an expensive trans-
port to hospital, those patients could receive a home visit from a PA,
get the immediate treatment and meds they need, and get help
with making follow-up appointments and accessing community
resources?
As you may have guessed, this is, in fact, starting to happen in a
few cities around the country, mostly in the West. Mobile units in
PHOTOSBYJACKIEMERCANDETTI
FEATURE
As a CCU member, PA Jay
Meeks responds to low
acuity 911 calls in a Mesa,
Ariz., program to deliver
quality care and cut down
on unnecessary ER visits.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 30
33. modified ambulances, staffed with firefighter-paramedics and either PAs or
nurse practioners (NPs), are responding to selected low acuity emergency
calls, and finding considerable success in delivering the services the
patients need at home and keeping them out of the ER.
Perhaps the national leader in developing this care model is the city of
Mesa, Ariz., which first piloted a program in 2008, in response to a flu epi-
demic. That initiative was soon quashed by the budget cuts driven by the
financial crisis that year. But the city began a new pilot program in 2011,
which was successful enough to encourage them to apply for a grant from
the Center for Medicare and Medicaid Services (CMS) Innovation Center. A
three-year, $12.5 million CMS grant is now powering a scaled-up and much
more ambitious program, the Community Care Response Initiative. The
program has six mobile units, three staffed with captain paramedics and
PAs, and three that focus on cases with psychiatric aspects, which include
licensed behavioral counselors instead of PAs. The grant is also designed to
pilot a program to try to reduce hospital readmissions through home fol-
low-up visits after discharge, though this portion of the grant is just get-
ting up and running.
Gary Smith, MD, medical director of the Mesa Fire and Medical Depart-
ment (MFMD), considers the program a success already.“We take the ser-
vice to the patients as opposed to taking patients to the service,”he says.
“We provide a way to decrease ER visits by providing point-of-care services
such as would be performed at urgent care centers or fast track ERs. We are
enhancing quality of care. This is a model that needs to be utilized
throughout the health system.”
Smith says that the follow-up surveys sent to the patients soon after
their visits have shown almost uniformly high patient satisfaction.
Saving Lives, Time and Money
Whether a community care unit (CCU) vehicle or an ambulance responds
to a 911 call in Mesa depends on an algorithm. MFMD 911 operators ask
the callers a quick series of yes/no questions to determine the urgency and
nature of their emergency; answers are quickly entered into a computer
and the system flags calls that meet the criteria for a CCU visit. CCU units
can also be called out by fire captains on site.
The real savings—assuming they materialize as expected—realized by
the CCU program won’t be known for some time, when the program has
been running longer and data have been crunched. But the 2011 pilot
program saved more than $3.25 million out of a total of $11.7 million,
according to Tony Lo Giudice, a former firefighter and paramedic who is
now MFMD’s grants projects director.
COMMUNITY CARE UNITS | continued
The team transfers the patient to the CCU, which
will transport him to the ER for more treatment.
PHOTOSBYJACKIEMERCANDETTI
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 31
34. Lo Giudice described a case that illustrates the Mesa mod-
el’s potential for the significant savings. One of the first 911
calls the department received after the new algorithm was
introduced was from a caller who had attempted suicide.“The
individual had slit his wrists,”Lo Giudiuce recalled.“The para-
medic looked at the wounds and determined that they were
superficial. So the PA came, sutured the wounds and gave the
patient antibiotics and a tetanus shot. Then a behavioral pro-
vider came in and took the patient straight to a behavioral
health facility. In the old days it would have taken three days.
We did it in an hour and 45 minutes.”
Providing Community Care
The PAs who staff the Mesa CCUs say they find the work inter-
esting and rewarding. Jay Meeks, PA-C, a 2009 graduate of the
A.T. Still University PA program, fell into the job somewhat by
accident. She was recruited by Tom Morris, an NP who turned
out to be the director of the CCU program, while she was get-
ting her TB test read for a job in urgent care.“It was totally crazy,”she said.
But so far so good.“I really like the atmosphere,”Meeks says.“I like work-
ing with the medics and being at the fire station.”She had worked as a
firefighter for the U.S. Forest Service, so the job was a natural fit for her.
The PAs spend 24-hour shifts at the firehouse, bunking in with the regu-
lar firefighter-paramedics. They eat lunch and dinner with the crew, help
wash the firetruck and take their turns making batches of spaghetti or
burgers.
Being able to fit in with the firefighter culture is an important part of the
job, says Jody Sanderson, PA-C, who was a reserve captain EMT in the fire
department in Page, Ariz., for 11 years before going to the University of
Washington MEDEX Northwest PA program in Seattle.“It helps to be able
to talk fire with the fire guys,”Sanderson says.“It’s not necessary per se, but
it’s helpful; you are going into someone’s house for 24 hours. There’s a cul-
tural aspect to it.”
For Sanderson, working on the CCUs has been a great career move.“I
really enjoy the work, being outside and getting out and about,”he says.
“For me, having a background in the fire service and then becoming a PA—
this was a great way to pull together everything I’ve done in my career.”
The work is interesting and varied, PAs say, and provides a new perspec-
tive on patients’lives. Visiting people’s homes every day has been an“eye
COMMUNITY CARE UNITS | continued
PAs Jay Meeks,
Jody Sanderson
and Char Crandall
are pioneering a
new care model in
Mesa, Ariz.
PHOTOSBYJACKIEMERCANDETTI
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 32
35. opener,”says Meeks.“I used to work at a community health center, and I
thought I’d seen everything. But it can be shocking how some people live,
the cleanliness of their homes. Sometimes there will be people sleeping on
the floor. Often there are social problems, psychological issues, drugs.”
Meeks has also found the insight into patients’home lives to be a bonus for
the PA students she precepts.“You are not going to see some of these
things in an urgent care center,”she says.
Meeks has also been surprised at some of the reasons people make
emergency calls.“It’s shocking what people call 911 for,”she says.“You
think of trauma, but people call for nosebleeds, fevers, back pain,
anything.”
“I’ve worked in the ER so I have seen the other side of folks coming in to
the ER for routine things,”Sanderson says.“That’s why Mesa has said we
have to stop the madness of people calling 911 for earaches.”
Looking Ahead
Based on the interest shown in the Mesa program, CCU type programs
seem likely to start popping up all over the country. Mesa receives visits
once a month or more from fire and medical officials looking to do ride-
alongs and see how the program works. Similar programs have already
started up in other parts of Arizona, California and Colorado.
One concern that Meeks and Sanderson expressed is that some of the
new programs starting up are hiring only NPs, perhaps due to perceived
regulatory difficulties, or perhaps just because the decision makers are just
more familiar with them than with PAs.
“Other cities have come and done visits with us, and we’ve had to do
some education on what PAs can do,”Meeks says. Sanderson suggests that
COMMUNITY CARE UNITS | continued
Sanderson’s
examination will
determine whether
the patient can be
treated at home.
PHOTOSBYJACKIEMERCANDETTI
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 33
36. PAs who want to work in CCU units that are recruiting only NPs go ahead
and apply anyway and make the case that they have the skills needed.
Smith, the MFMD medical director, says that PAs and NPs are both quali-
fied to run the CCU units.“Both NPs and PAs function equally well and do
marvelous work,”he adds. More important than whether the provider is a
PA or an NP is that“they have certain qualities,”Smith says.“You have to be
kind and patient. We have to take the time, and have the patience, and we
can help that person so much better.”
The hardest part of setting up the CCU model, Smith says, is“keeping it
financially stable. You have to be able to bill for the services and have them
reimbursed. That is the biggest hurdle.”Home visits are reimbursed to
some extent, Smith says, but not enough to cover the costs. Right now,
these costs are being covered by the CMS grant, but the long-term hope is
that the three-year duration of the grant will provide data that will con-
vince payers that the home visits can save money and should be fully
reimbursed.
“We want to show the value, the solutions we have come up with, and
to help CMS develop new codes,”Smith says.“This innovation grant is in
play. We believe this model will happen around the country.”
“I see this taking off within five years,”Sanderson said.“FDNY might
even do this. So we want to make sure that people are hiring PAs as well
as NPs.”
STEVEN LANE is senior writer for AAPA
and managing editor of PA Professional.
Contact him via email or 571-319-4364.
Sanderson’s CCU team is dispatched to a call.
Sanderson, right,
says working on a
CCU has been a
great career move.
PHOTOSBYJACKIEMERCANDETTI
PHOTOSBYJACKIEMERCANDETTI
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 34
37. ONE-ON-ONE
JENNIFER L. WALKER is a
Baltimore-based freelance writer
and a regular contributor to
PA Professional. Contact her at
jenniferwalker319@gmail.com.
PA Employer Q&A
Allegheny Health Network Champions PAs
B Y J E N N I F E R L . W A L K E R
A
s part of our PA Employer Q&A series, this month
PA Professional talked with Susan Manzi, MD,
MPH, chair of the department of medicine and
co-director of the Lupus Center of Excellence at the
Allegheny Health Network (AHN), a network of eight hos-
pitals that serve 29 counties in Pennsylvania, as well as
some areas of New York, Ohio and West Virginia. Here,
Manzi, who clearly loves PAs, talks about AHN’s biggest
challenge with PAs (spoiler: they need more of them!), the
creative ways they are utilizing PAs and the future of the
profession.
What has been your experience working with/hiring
PAs, and where do you think you’ve succeeded organi-
zationally with PAs on staff?
SUSAN MANZI: We have had a growing number of PAs
join AHN. We appreciate the tremendous value they bring
to our organization. PAs have played a huge role in provid-
ing access to care for an increasing number of patients
trying to access AHN.
I am a rheumatolo-
gist, and [Brogan
Keane, the PA I work
with] is incredible. My
patients love her.
What are the obsta-
cles/challenges you
see with employing
PAs?
MANZI: Our biggest
challenge is finding
enough qualified PAs
to join the Network.
Right now, the major-
ity of our PAs are working in the subspecialty areas, while
there are significantly less in primary care. We would like
to change that.
Susan Manzi, MD, MPH
PHOTOCOURTESYOFAHN
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 35
38. ONE-ON-ONE | continued
What kinds of issues do you deal with surrounding PAs and scope of
practice/regulatory compliance?
MANZI: We need to keep our physicians and PAs educated about appropri-
ate documentation and insurance-specific regulatory compliance that
impacts reimbursement. We conduct regular audits and overall we have
done very well, but it’s about continual education for the providers.
Are you able to articulate the value of PAs from a monetization
standpoint?
MANZI: PAs are invaluable. When I’m working side by side with my PA, we’re
able to accommodate more patients. She has improved my patients’satis-
faction and she has enabled me to keep up with the growing number of
tasks and activities required to care for patients. Her command of rheuma-
tology has grown exponentially over the past year and the investment in
her training has been well worth it. She is more knowledgeable than many
young physicians out of training. I think I can speak for the other physicians
in this organization when I say that we are fortunate to have PAs.
Are you adding PAs to your workforce? If so, which specialties, service
lines and settings are you using them in?
MANZI: We are adding them to all of our service lines. One of our
strategies has been to partner with the PA schools in the area to provide
clinical experience for their students with the hope of hiring them
after graduation.
Are you looking at new ways to maximize PA utilization?
MANZI: Yes, I think we’re always trying to be creative with maximizing
utilization. We currently have PAs doing inpatient hospital rounding, inten-
sive care unit coverage and outpatient practice. The PAs doing hospital
coverage allow the physicians to remain in the outpatient office and pro-
vide longer hours of service. One size does not fit all and each specialty
utilizes PAs differently.
Have you currently assessed whether your PA workforce is operating
to maximal efficiency, education and experience?
MANZI: I can’t say that as an organization we have systematically done
that. The areas that have PAs have done their own internal evaluations.
Sharing best practices with each other and with other organizations is
something we should be doing.
How comfortable is your team with PAs and regulatory compliance/
scope of practice? Would it be helpful to have additional support
services to stay up to date?
MANZI: You can never overeducate. Having said that, our organization has
done a good job at providing the needed information to our providers.
How comfortable is your team with PA reimbursement and PA billing
practices?
MANZI: We are always reviewing and auditing our practices, so we are
generally comfortable, although the Medicare policies are complicated
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 36
39. ONE-ON-ONE | continued
and vague in some instances. What I am not comfortable with is the con-
cept that PAs should be reimbursed any differently than doctors for the
same level of work. I hope this Medicare policy is revisited as more and
more PAs join the provider teams.
The types of process changes that have the best opportunity to drive
value include: being accountable to the patient and the creation of
advanced care teams. What role do you see PAs playing as you imple-
ment/advance these process changes?
MANZI: Everything is moving toward team-based … and [PAs] are a part
of the team. The PA plays a critical role in our team-based models.
Are there things other hospital administrators and physicians don’t
“get”about PAs that become a source of frustration?
MANZI: There is a perception that patients may not want to see a PA. They
want to see the doctor. It is our responsibility to alleviate those fears by
educating our patients about the value provided by PAs. My approach is
to say,“Meet [Brogan], she is my partner, we are a team, she’s incredibly
knowledgeable, we work well together and she’s going to be participating
in your care.”Advanced care teams are moving toward sharing in the care
of patients and away from physician-centric approaches.
At your organization, is there a career ladder or trajectory for PAs?
MANZI: We are developing a‘lead physician extender’[AHN’s term for PAs
and NPs] role, somebody [who] assumes a leadership position over all of
the PAs and NPs in a practice or subspecialty. This individual develops best
practices, does onboarding and training of new providers and oversees
practice efficiencies and processes. There are other potential roles in edu-
cation, research and training available to our PAs.
Keane, left, and Manzi specialize in rheumatology.
PHOTOCOURTESYOFAHN
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 37
40. ONE-ON-ONE | continued
Have you found success in recruiting and retaining PAs? Or, is it a chal-
lenge for your organization? How do you define success and to what do
you attribute your success?
MANZI: Recruiting and retaining healthcare providers is always challeng-
ing, especially PAs. To recruit and retain our best PAs, we need to provide a
competitive salary structure with a nurturing work environment. PAs are
highly sought after and it is a competitive market place. We are committed
to growing our PA network.
What do you think the future holds for PA utilization in your
organization?
MANZI: I think [their stature] is going to continue to rise. As an organiza-
tion, we have not taken full advantage of PAs, except in certain areas,
including procedural and surgical subspecialties. We are growing the PA
pool in other medical subspecialties and we are committed to building the
PA infrastructure in primary care. I see a future where all patients are cared
for by healthcare teams, including physicians, PAs and NPs, pharmacists,
nutritionists, and health coaches with reimbursement models that can
support and sustain this approach. PAs will be key members of these
care teams.
Are PAs a part of your strategy to successfully transition from fee-for-
service to value-based reimbursement contracting?
MANZI: Yes, we are moving in that direction. The whole organization is.
We are working on new compensation models for our providers in general,
and I’m very excited about that. I think we have a great opportunity as an
integrated delivery system to do that since our owner really wants us to
deliver quality not quantity.
If you would like to highlight the contributions, or advance your ability
to maximize the utilization of your PA workforce, contact AAPA’s Center
for Healthcare Leadership and Management for more information.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 38
41. PROFESSIONALPRACTICE
Nailing the Interview
Exercises and Resources to Help You Get the Most Out of a Job Interview
B Y J E N N I F E R A N N E H O H M A N
A
s a career coach, I frequently help my PA clients
prepare for interviews. In this article, I’d like to share
some exercises that will help you be a more effec-
tive and confident interviewee. They will also help you
explore your current career goals and priorities (additional
career exercises are available at pacareercoach.net).
■ Position Requirements/Your Qualities Exercise: For
each position you apply for, create a skills match list. Draw
a line down a piece of paper and on one side write a bul-
leted list of at least five position requirements that
employer is looking for. On the other side, list the skills,
traits and experience you possess that fit those require-
ments. Think of this list as what you’ll want to share at the
interview and be remembered for.
■ Identify Your Success Stories: Write down four stories of
professional success to share with a potential employer.
What achievements are you proudest of? How and when
have you made the most positive difference as a PA (or PA
student)? Which of these best corresponds to the require-
ments of the job you are applying for? At least one story
should be about a challenge you surmounted/trans-
formed into a positive outcome.
■ Career and Professional Objectives Exercise: This exer-
cise is intended to help you find the right opportunities to
interview for. List your PA career goals and priorities: What
do you most want to accomplish and in what field, whom
do you most wish to serve and in what setting/with what
sorts of team members? From past experience, what sorts
of positions and/or employers do you want to avoid?
■ Elevator Speech Exercise: Create and practice your
speech. In 60 seconds, you should be able to discuss why
you want the job you are interviewing for, what makes you
a great fit for it and what you intend to contribute if hired.
■ Brainstorm Contacts Exercise: Consider contacts in your
network who may know the employer and could boost
your application with a positive word. Write their names
down and reach out to them. LinkedIn can be a wonderful
resource for this! New graduates: Rotation sites are excel-
lent first job resources.
JENNIFER ANNE HOHMAN is
the founder and principal of PA
Career Coach, a service dedicated
to helping PAs create rewarding,
healthy and patient-centered
careers.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 39
42. PROFESSIONAL PRACTICE | continued
■ Researching an Employer Exercise: Researching an employer empow-
ers you in many ways. With insight into an employer’s situation and cul-
ture, you can more effectively pitch your skills, strengths and abilities to
its audience. Participating in an interview from a place of informed curi-
osity about the employer is empowering! Ideally, you’ll be able to gain
some information about the individual(s) who will be interviewing you
and build rapport based on that.
Using a combination of Internet resources (such as DocInfo, where you
can research physician disciplinary records for a small fee) and your local
PA community (via state chapter, local PA programs) research the reputa-
tion of the employer: Is it a stable or high-turnover employer? What is the
reputation of its physicians? Financial stability? Patient care ethos?
Questions to Ask an Employer at the Interview
Questions to the employer are a great way to show your savvy and frame
the discussion in a way that highlights your abilities and how you offer
solutions to the employer’s problems/current needs. They can also help
you assess the quality of position for team practice—an essential quality
of life and practice factor. Sample questions include:
■ What challenges does the practice face? What goals does it have for this
year and for five years from now?
■ How would you describe the financial health of the practice/institution?
■ Is the practice familiar with PAs? Would you say it has an expansive or
more restricted view of delegation? Are there questions about the PA
profession I can address or clarify?
■ What is your philosophy of patient care?
■ How many PAs have been in this position in the last few years?
■ What are the prospects for growth and advancement?
■ Will you be offering a written contract and will I have a chance to review
and negotiate it?
■ How do you envision my role and how I might help the practice achieve
its goals? (Have your own answer to the second question ready.)
Other Interviewing Tips
Be ready to share up-to-date information on PA state licensure and the
essentials of billing for PA services. Bring handouts on these topics from
AAPA’s website for first-time PA employers.
At the interview: Be“present”and attuned to the interviewer. Listen to
questions carefully; pause before answering challenging ones. Remember,
each interview, whether it results in an offer or not, is a chance to polish
your professional narrative and self-knowledge as well as your understand-
ing of the job market.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 40
43. first rounds | A special section for and by PA students
This edition of First Rounds (FR) was produced
by FR Editor Jessica Treiber, PA-S3, MCPHS University–
Boston campus, and FR Assistant Editor Paul Gonzales,
PA-S2, University of Texas Southwestern
Medical Center in Dallas.
How to Thrive in PA School
SARA L. WIENS, MPAS, PA-C
Many folks have advice on how to survive
PA school. I’d like to advocate for a slightly
different approach. Yeah, most of us survive,
but how many really thrive? Your mindset, in
addition to some key habits I will describe be-
low, will help you fully embrace this journey of
PA school, not just survive it.
First of all, don’t forget to be creative. Think
about what helps you recall some of the key
events that have happened in your life? You
have some sort of attachment to these memo-
ries and they are easy to recall because they
have meaning, and they are already in your
memory databank. You will have so much new
information being fed to you in PA school, that
sometimes it’s hard to cram it in and retain all
of it. A technique many students use is coming
up with some rhyme, mnemonic or story while
studying, in order to make connections to new
information. According to the Utah.edu website
on memory, “The more connections and asso-
ciations you can make between new informa-
tion and information already stored in your
memory, the better the chance for recall.” For
instance, the five Ws of post-op fever: wind,
water, wound, wonder drugs and walking. There
are plenty of mnemonics available when study-
ing medicine, but don’t forget to make up your
own. Whatever creative way or silly story you
can conjure up when studying, say, antibiotics,
may end up helping you ace an exam, and may
even stick with you for the rest of your career.
Second, remember you are not alone. Think of
PA school as a collective experience with a
group of individuals much like yourself, who all
share a common end goal. By helping each
other out, you become a collective force. An
example of this “collective mind” is the power
of group studying. For instance, my group
always made tables and shared information on
Google Docs. We studied together as tests
were approaching, and quizzed each other,
which is a must before exams! Even through
rotations, when the end-of-rotation exams
rolled around, having even one other person
give you a different perspective on a subject
you may not have had, really helps solidify
information.
Third, use STEP books. These books are
designed to help medical students study for
their medical licensure exams, and thus offer
concise information on a wide range of topics.
Although I grew out of the STEP books as I pro-
gressed through school, the point is that you
won’t have time to read an entire textbook
front to back, no matter how great your inten-
tions. And, you will soon realize, your time has
to be prioritized. Using summary books like
STEP, which break down diseases to key words
and phrases, can help on exams. Even through
clinical rotations, books like “Surgical Recall” will
help highlight the most common and highest
yield facts. Also, it helps to use a PANCE study
guide to prepare for regular exams. It’s never
too early to start in on one of these. Just don’t
overdo it with resources—find one or two you
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 41
44. first rounds | continued
SARA L. WIENS, PA-C, graduated
from the University of Texas Medical
Branch PA program in Galveston,
Texas, in August of 2015.
really like and stick with those.
Next, realize PA school is like marathon train-
ing. A long-distance runner doesn’t start at 26.2
miles. As a student, you will be given small con-
cepts from which you will build. Use your time
wisely to “train.” Meaning, cram sessions and
all-nighters aren’t going to work anymore. You
chose the PA profession, which entails a lot of
knowledge, and that means using every day
wisely. For example, when walking to school,
have flashcards in hand. While driving to clini-
cals, listen to a podcast or YouTube about a
surgery you’re likely to encounter that day. Do
yourself a favor, set yourself up for success in
your career by building now. Start by being
smart about your time. Slow and steady each
day will get you to graduation.
Lastly, express gratitude. I had a sign up on my
mirror that reminded me of reasons to be
thankful each day. Yeah, it seems a little hokey,
but just keep it in mind as you’re going through
school. There will be experiences during PA
school that will be uniquely yours, and that can
be amazing. Holding a human heart in my hand
for the first time during anatomy dissection was
unbelievable. Being first assist during an open
heart surgery, and seeing the heart beat, was
unforgettable. Take these opportunities to real-
ize you are on the path to becoming a PA.
Sometimes we slip into the mindset of just sur-
viving. Volunteer to do more or give back during
didactic year. Is there a free clinic you can vol-
unteer at, or can you help faculty with inter-
views? Is there a transplant surgery you can ask
to be a part of during your surgery rotation?
These are ways to show gratitude: by giving
back, doing more and reflecting on your experi-
ence. PA school is a short 2-3 year stint of
opportunities. Be thankful for every day you
have during these years.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 42
45. first rounds | continued
I Couldn’t Survive PA School Without My Patient, Walter
JESSICA TREIBER, PA-S3
The waiting room at the Veterans Affairs (VA)
center was crowded and appointments were
running an hour behind. I took a breath and an-
nounced the name on the sheet I was holding.
The chairs of gray haired veterans stirred and
shuffled as their occupants turned to look over
toward me.
“I’m Walter,” said a broad mouth under a well-
worn baseball hat. He raised an arm as he pushed
himself up to stand. You could tell by his posture
that he was once a tall man, now stooped by the
passing of time.
“I’m the PA student working here in dermatol-
ogy today. I’m going to see you and then my
attending will come see you,” I explained as we
walked down the hallway.
“No, nothing,” he responded abruptly when I
asked if he had any concerns or had noticed any
new skin changes in the past year. I handed him
a gown, gave him instructions, and then pulled
a curtain to give him privacy.
While he changed, I pulled the
window shades down so that
the people on the street below
us couldn’t see in. We settled
into the exam and I began to
ask him questions.
I turned the conversation
slowly from social history to
skin care and back again. I kept
doing this while inspecting his
skin. When I asked if he had
children, Walter tilted his
head towards me and his gray
eyes widened. I hit the jackpot.
“I have the best grandson in
the world,” he said. Over the
course of the next seven min-
utes, he would tell me every
detail he knew about his grand-
Find out more about Wreaths Across America at the organization's website.
WWW.WREATHSACROSSAMERICA.ORG
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 43
46. first rounds | continued
son. He was extremely proud of his grandson’s
involvement in collecting donations during the
holidays to place wreaths on the graves of sol-
diers. “He doesn’t want anyone to be forgotten,”
the old man said as his gray eyes sparkled.
Then he said, “You know, I have this one new
spot on my groin. Would you take a look at it?”
The trust in his eyes was sincere and genuine.
On my last day there, I was standing in the
hallway, when a door opened, and out walked
Walter. Unlike our first greeting, his face imme-
diately lit up.
“I am so happy to see you. This is for you,” he
said He pulled out a card with information
about the VA charity that collects wreaths at
Christmas to place on soldiers’ graves.
“Why thank you,” I responded. “How is your
grandson?”
“Oh he is just the joy of my life. Well, him and
my wife. Do you want to meet her?” He
motioned towards the lobby.
The one thing I can’t live without in PA school
is patients like Walter. There have been plenty
of times the endless hours of bookwork and
rigid student schedules have all but crushed me,
but it’s the few moments of genuine, human
connections that make all of the work I’ve done
thus far worth it.
May Walter serve to remind us all that in both
our careers and our personal lives, it is the small
moments when we care personally about what
others hold valuable that can make the biggest
impact on others, as well as ourselves.
JESSICA TREIBER is a third-year PA student
at MCPHS Boston University, scheduled to
graduate in 2016.
PA PROFESSIONAL | DECEMBER 2015 | AAPA.ORG | 44
