How certified physician assistants balance efficiency and quality in orthopedic practice

Practice Management

Orthopedic surgery is a growing field for physician assistants (PAs) for many reasons.

The realities of the Affordable Care Act opened health care access to millions of new patients. What’s more, an aging Baby Boomer population and growing demand for joint replacement surgery and other services to improve mobility and quality of life, have expanded the need for high quality health care services by well-prepared clinicians, including certified PAs (PA-Cs).

 

However, private practices are increasingly bearing the weight of burdensome administrative costs, often forcing surgeons to consider other models of practice, such as employment with health entities and hospitals. RVUs have become the surrogate benchmark for determining salaries and productivity. With increasing administrative demand, it is essential to define and implement best practices that allow all members of the care team to perform at the top of their license.

 

The good news is that thousands of certified PAs in orthopedic surgery are contributing great efficiencies in addition to quality outcomes and patient satisfaction.

 

At MaineGeneral Orthopaedics, I am one of six certified PAs who work with a team of nine physicians to offer specialized care in sports medicine; hand surgery; joint reconstruction of the hip, knee and shoulder; and treatment of complex fractures. We see over 27,000 patients a year.

 

Here are five important lessons we’ve learned in our busy, successful practice that can apply to any orthopedic office today.

 

1. Efficiency starts in the office practice, which is based on volume and billable services. Pre-operative evaluations and post-op care are not billable, and PAs free surgeons to handle more operative cases by:

 

• Completing the pre-operative history and physical establishes the baseline for the entire patient interaction. Pre-operatively, the PA discusses the procedure with the patient and gains insight which can be helpful when preparing for postoperative care and recovery. Patients feel comfortable when seeing the PA on their first postoperative visit because they established a positive working relationship with the PA pre-operatively. The PA has all the information from assisting in the case (as described in the surgical process below) and can explain in detail what was done. If a practice completed 7-14 operative cases per week, the PA can free the surgeon from 14-28 office visits weekly. The PA-MD care model optimizes patient management.

 

• New patients requesting office visits can be reviewed and screened so that non-surgical cases can be evaluated by the PA. Non-operative fractures are reduced and managed by the PA. If there is a positive finding, they are promptly referred to the surgeon.

 

2. The surgical process is highly streamlined. We use two operating rooms and flip between cases. This allows the surgeon to operate almost continuously with minimal interruption. We have a high volume of shoulder and knee surgeries that, on average require 1-2 hours operating time. The procedures vary from total shoulder arthroplasties, proximal humerus fracture ORIF, rotator cuff, labral repairs and ACL reconstruction procedures. Because each of these procedures is close in range of operating time, they can be scheduled interchangeably with some consideration of equipment set up. (The financial modeling for flip rooms is more challenging with longer cases.)

 

The overall timing and the technical ability of the PA ensures a smooth process. When the surgeon feels the procedure is near completion to call for the next case, the anesthesia team begins with the next patient. The PA finishes the first procedure, writes the orders to admit or discharge patient, and completes orders and medicine reconciliation. In the meantime, the surgeon positions and drapes the next patient. By then, the PA comes into the second surgery, and the process continues. The technical ability of the PA includes complete knowledge of each procedure including each step of the operation and all its’ nuances. Here’s how this model can allow each surgeon to do up to 16 more cases per month.

 

• Procedures above range at about 60-120 minutes of actual operating time.

 

• Turn over without a flip room averaged 45- 70 minutes.

 

• Assume five 90-minute cases per operative day with a flip room, realizing that with many 60-minute surgeries this number is low. That is a 7.5 hour day for the surgeon.

 

• Without a flip room, the same surgeon would only be able to do three cases per day, assuming a modest 60 minutes to turn the room. This adds waste time to the process and decreases the number of surgical cases that can be billed by the hospital and the number of patients that can be served. If the physician does surgery two days a week, that is two surgeries less per day, four less per week and 16 less per month per surgeon.

 

• Of note, knee scopes can be very efficiently done with a flip room. These procedures’ actual operative time take 15-30 minutes. When done efficiently, you can perform 8-9 cases in 4-5 hours with a flip room. The PA manages the orders on each case and assists on meniscal repairs, lateral releases and microfractures.

 

3. Quality is measured in surgical outcomes that are consistent with the knowledge and skills of the practitioners.

 

• Surgical outcomes have long been associated with the frequency of doing any procedure. Larger practices have the fundamental ability to have subspecialty practices and can benefit from high volume specialty procedures. So, how does this work in a lower volume general practice? Developing protocols and checklists that can be followed by the physician/PA team to ensure no step is missed, including a method of remediation for less optimal outcomes. This practice has been championed by the aviation medicine community and the military.

 

• The PA’s academic knowledge and skills can be fostered in the practice with financial incentives, journal clubs/case presentations and fracture rounds.

 

• Practical incentives can include an increase in salary for a PA who earns the Certificate of Added Qualifications (CAQ) in Orthopaedic Surgery. This credential from the National Commission on Certification of Physician Assistants (NCCPA) requires a certified PA to have substantial orthopedic surgery experience, CME, and skills and to pass a national specialty exam.

 

• Our staff’s annual reviews include a point system for achievement of academic progress. Points are awarded for: passing the CAQ exam and/or an orthopaedic surgeon review course; becoming ACLS and ATLS certified; and completing a certification course/training in NCV/EMG testing, osteoporosis or ultrasound injection.

 

• Journal club/case presentations. Our practice has two to three sessions per month with a surgeon.

 

• Fracture rounds are presented monthly with the surgeon presenting fractures and discussing the procedure and outcome.

 

4. Continuity of care is a key component to a successful practice. When a physician and PA present themselves as a cohesive and collaborative team, the patient is confident in their treatment by either and accept information interchangeably from the physician/PA team. This is achieved each day in the models described above.

 

5. Back up support is a critical component of the continuity of care. If the surgeon is on vacation or out of the office for CME, the PA can provide the same quality care to the patients.

 

According to NCCPA, there are approximately 11,000 certified PAs in orthopedic surgery. Like physicians, they are educated in the medical model, undergo a rigorous certification process, recertify by national exams throughout their career and are licensed by state medical boards. As the demand for orthopedic services increases, certified PAs are bringing efficiencies to patient care, and profitable practices will increasingly recognize them for their knowledge, additional credentials and skills in this specialty area.

 

Mark Wright, MPAS, PA-C, has been a certified PA for 24years. He earned his the Certificate of Added Qualifications in Orthopaedic Surgery in 2011. For more information on the NCCPA CAQ program in orthopedics visit http://www.nccpa.net/Orthopaedicsurgery

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