Physician Assistants: A Social Innovation in the Delivery of Health Care Services

Physician Assistant History SocietyHonoring our History; Ensuring our Future

By Reginald Carter, PhD PAHistorian EmeritusPA History Society

National Commission on Certification of Physician Assistants

“A Social Innovation is a novel solution to a social problem that is more effective, efficient, sustainable, or just - than existing solutions … and for which, the value created accrues primarily to society as a whole rather than private individual.” - Phills, James A, Deiglmeier, Kriss, and Miller, Dale T. Rediscovering Social Innovation. Stanford Social Innovation Review; Fall 2008; 6, 4; pg. 38.

The Physician’sAssistant

Eugene Stewart Schneller

Innovation in the MedicalDivision of Labor

1978 Lexington Books

1. Exchange of ideas and values

2. Shifts in roles andrelationships

3. Integration of private capital with public and philanthropic support

Social Innovation Drivers

Physicians and Hospitals Low End High End Market Place• Advances diagnostics, therapeutic and rehabilitative services• Increase medical schools enrollments & residency programs

Setting the Stage for the Development of a Social Innovation in Post-WarAmerica 1945-1965

By 1960s Demand >> Supply• GDP Buying Capacity• Blues & Medicare/Medicaid• Technology/Scientific

breakthroughs• Social and Civil Unrest

LBJ signs Medicare Act 1965

• Increase specialist and subspecialist• Geographic/Specialty Maldistribution physicians

by 1965 specialist output surpass generalist leveling off 2:1 ratio by 1985

Unable to Address a Growing Social Problem–Necessity is the Mother of Innovation

As physicians and hospitals struggled to meet the high end demands in the marketplace, their ability to deliver accessible, affordable and quality health care services to the lower end of the marketplace waned

Exchange of Ideas: One Doctor’s Solution to a Growing Demand for Health Care Services

Dr. Amos Johnson and Buddy Treadwell

Treadwell is made anHonorary PA in 1970 by the DUMC PA Program

Exchange of Ideas and Values: A Novel SolutionPresented to the American Medical Association

1961Charles Hudson, MDin the Journal of the American Medical Association, calls for the training of a "mid-level" provider to assist doctors –from a new source of health manpower such as former military corpsmen.

Shifts in Roles and Relationships

Eugene A Stead, Jr and Thelma Ingles, RNNurse Clinicians/Physician’s Assistant

Loretta Ford RN and Henry SilverPediatric Nurse Practitioner/ Child Health Associate

John KirklinSurgeon’s Assistant

Hu C. MyersPhysician’s Assistants Baccalaureate Program

Richard SmithMEDEX

Rapid Deployment Model

Innovators

Exchange of Ideas and Values: Duke Conferencesand National Conferences

Foundation and Federal Funding

Integration of private capital with public and philanthropic support

Conferences

Research &Evaluations

EducationalPrograms

AccreditationProcess

CertificationProcess

10

Legislative Model and National Certification developed to Support the Social Innovation

o Delegatory Authority (CO, KS, AZ, OK;1963-1969)

o Licensure Act (CO; CHA; 1969)o Regulatory Authority (CA, NC; 1970, 1971)o National vs State Certification

AMA and NBME collaborate to produce and administer National Exam initially open to graduates of AMA/JRC-PA accredited programs, nurse practitioners and informally trained PAs (1973)

Commission formed (1974) from 14 participating health professions and organizations; responsible for setting standards, certifying PAs and recertifying PAs in 2 year cycles (CME) and 6 year cycles (by examination).

o AMA, NBME, AHA, AAMC, FSMB (Various Medical Specialty Organizations)

o Veterans Administration Medical Centers Support Education Hospital Privileges Utilization Patterns

o US Public Health Service (corps)o US Department of Defense (commissioning

issues)o Health Workforce Allianceso Political Action Committee Allianceso Pharmaceutical Industryo Private Foundationso Consumer Health Advocacies

External Value Networks formed to Support the Social Innovation (tangible/intangible support)

PAs as a Novel Social Innovation – ExamplesBuilding Alaska pipeline in the 1970s. (value – PAs performed lower end duties more cost effectively than MDs could)

Rural Satellite Clinics in 1970s. (value – cost effective, convenient, decentralized low end services)

Alternative to House Staff in Hospitals in 1970s. (value – reduce dependence on MD housestaff, reduce number of specialist being trained in overpopulated field, as cost effective with more stability in delivery of care)

Military opts to train own Physician Assistants in 1970s. (value- Air Force/Rand Study (1980) showed clearly that USAF PAs could provide same quality of care as MDs for large percentage of patients)

Walk-in or MinuteClinics in 2000s (CVS, Walgreens). (value –cost effective, convenient, decentralized low end services)

Patient Centered Medical Care in 2000s (Health Care Centers). (value – cost effective, improved outcomes, collaborative practice model – team development)

Innovation in the Medical Division of Labor

1978

Performance Autonomy

“The PA is a competency-based occupation. Different PAs do different work. It is based on a "negotiated" role between an individual physician and a PA. This makes it unique.It means PAs can do a very wide range of tasks- and can have roles that change and expand significantly over the course of a career.” – Eugene Schneller

A Social