Testimony to the Pennsylvania
House Insurance Committee
By: Patrick Ivory, PA-C
Mr. Chairman and members of the insurance committee, good morning! My name is Patrick Ivory and I am the Immediate Past President of the Pennsylvania Society of Physician Assistants (PSPA) and currently chair the PSPA Reimbursement Committee. I have been a Physician Assistant for nearly twenty-six years and continue to practice part time in the emergency medicine arena. I am a fulltime faculty member in the physician assistant program at Lock Haven University. I received my physician assistant training and bachelor’s degree at the combined US Navy/George Washington University PA Program and my master’s degree from the University of Nebraska, College of Medicine. Thank you for allowing me to testify on behalf of the physician assistant profession.
As you are very well aware, Governor Rendell has asked the legislature to provide quality health care for every citizen in the Commonwealth. Part of this initiative is to allow utilization of physician assistants and other non-physician providers to their fullest potential within the laws and regulations as established by the Bureau of Professional and Occupational Affairs, the State Board of Medicine (SBM) and the State Board of Osteopathic Medicine (SBOM).
Physician Assistants are dependent practitioners who are licensed to practice medicine with the supervision of a physician. We do not practice independently nor do we want to. It is the opinion of clinically practicing PAs that the physician led Physician-PA team provides excellent care to patients. When utilized fully within their scope of practice, physician assistants provide compassionate, quality, cost-effective health care to the citizens of the Commonwealth. There are some barriers to practice that exist and this leads to a decrease in patient access to care. For the Governor’s plan to achieve maximum benefit, these barriers must be removed.
One of the first barriers to practice is the difference in the regulations between the State Board of Medicine and that of the State Board of Osteopathic Medicine. While the language in these regulations differs in many ways; the significant difference is that osteopathic physicians are not authorized to delegate prescriptive authority to PAs. This diminishes the effectiveness of DO-PA teams. We are pleased to report that the osteopathic board is addressing this issue however; it may take two or more years to become a reality. Additionally, the difference in language between the allopathic and osteopathic regulations leads to confusion for the physician supervisors, pharmacists, hospital credentialing committees and even the licensed physician assistants themselves. HB700 encourages removal of such barriers, which would eliminate much of the confusion and lead to improved patient care.
Another significant barrier to access to care is reimbursement for services provided by Medicaid and third-party insurance companies across the Commonwealth. Without adequate levels of reimbursement, physicians, PAs, and other health care professionals are unable to: provide necessary medical staffing in the practice, purchase and maintain proper diagnostic equipment and supplies, and spend appropriate amounts of time with each patient. Physician Assistants have been recognized by the Centers for Medicare and Medicaid Services (CMS-formerly HCFA) within the Medicare program for over 20 years. Under Medicare regulations, physician assistants can be reimbursed for virtually every service for which a physician is eligible to be reimbursed in accordance with PA state law. The rate of reimbursement for physician assistant services is discounted to 85% of the customary physician reimbursements. There are a few areas that a PA cannot be utilized, including ordering nursing home admission and certifying the need for extended care, but generally, all other services are permitted. These restrictions are also currently being dealt with on federal level by the American Academy of Physician Assistants (AAPA).
With recent passage of legislation in Arkansas eliminating on-site supervision, the Highmark BCBS and Blue Cross of Northeast Pennsylvania plans are the only BCBS plans in the country that fails to recognize state law guidelines for PA supervision. Both plans require that the physician be physically on-site when PAs deliver care to patients. Data compiled by the American Academy of Physician Assistants (AAPA) reveals that of the twelve third-party payer companies in Pennsylvania, only four actually credential physician assistants, three issue provider identification numbers (PIN), four have supervision requirements that exceed state law and create barriers to access. Eleven of the companies have provisions for physician assistants to first assist in surgery, but with some restrictions. Most require the use of modifier codes and require that billing be done under the surgeon’s provider number and one company requires a statement of medical necessity in the operative report as to why a PA was used.
There are some concerns about the proposed merger between Highmark Blue Shield and Independence Blue Cross. IBC reimburses for PA services under the hospital or group provider numbers and follows state law for utilization of PAs. Highmark on the other hand is the most restrictive in reimbursing for services provided by a PA. Highmark requires direct, on-site supervision, which is not required by Pennsylvania law. They will allow indirect supervision as provided by state law only in federally defined Medically Underserved Areas (MUA). They also will allow PAs to have indirect supervision if the PA is seeing patients in an “independent emergency care unit” and the example of seeing patients in a pharmacy is used. I fear that when Highmark and IBC merge, there is a potential for more restrictive language in their policies and this will lead to a decrease in access to care. In a recent article written by the Associated Press, it appears if the merger is approved, Highmark will be the major player in their combined operations. In the past, the Blues refused to reimburse PAs because they weren’t “licensed health care providers.” This was a matter of semantics because the state regulations referred to PAs as being certified. The language in both the SBM and SBOM was modified by law to make physician assistants “licensed health care providers.” It was at that point that Highmark stated that on-site supervision was required. If the new organization were to adopt the more restrictive language, then there would be further reduction in access to care for their beneficiaries. PSPA highly recommends that the Insurance Commission develop specific guidance, based on the state regulations that would be standardized rules across the spectrum of carriers, which would allow for the appropriate utilization of physician assistants as passed by the SBM and SBOM. This will reduce the ability of insurance carriers to essentially impose regulations from their offices.
The state Medicaid program also presents challenges for the physician assistant profession. Physician assistants are not given provider numbers by Medicaid. Generally, rules pertaining to services provided by physician assistants are not overly cumbersome and reimbursement is made under the physician’s provider number. The problem is that the rates are so low, that many physician groups do not treat Medicaid patients. Another area of concern is Medicaid’s lack of reimbursement for surgical services being provided as first assistant in surgery. Additionally, a PSPA member has brought to my attention that there are physician assistants seeking employment in the area of behavioral health and addiction medicine and cannot obtain employment due to the Medicaid Managed Care Organizations (MMCO) refusal to reimburse for services provided. I have received letters from Dr. Charles Morgan, MD, Medical Director of Parkside Recovery in Philadelphia and Mr John T. Carroll, CAC/CCS Program Director of Northeast Treatment Centers indicating the need for the MMCO to credential and reimburse physician assistants for services provided in the area of opiate addiction and the very high population of patients with Hepatitis C due to drug involvement. I have contacted Medicaid provider services via e-mail with an inquiry about this problem and have not yet received a response. This is an excellent opportunity for patients to receive timely health care by a trained professional in this typically underserved area of medicine. I believe the Medicaid system needs to be looked at in its entirety, not just in the area of reimbursement, but including eligibility, length of time enrolled and receiving benefits, and the all-or-none care of the patients.
The Pennsylvania Society of Physician Assistants believes that Governor Rendell’s proposal for health care reform provides for an excellent opportunity to correct numerous problems associated with the care of our citizens. It affords us the opportunity to improve access to care and the ability to improve outcomes in this population. PSPA wants to assist in the development of this reform package and wants to continue to provide compassionate, high quality and cost effective health care to the citizens of Pennsylvania.
Thank you for the opportunity to address these issues and I am willing to answer any specific questions you may have.
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