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To qualify to work in the emergency department, a physician assistant (PA) must have:
Emergency medicine physician assistants (EMPAs) may provide emergency care for patients in various settings such as:
PAs practice medicine with the supervision of licensed physicians and, though by law PAs are dependent practitioners, they typically exercise considerable autonomy in clinical decision-making and patient care. Supervision may be provided by varied methods such as onsite, by telephone, and telehealth. Each state has its own supervisory requirements and it is mandatory that the physician/EMPA team follows state law where they are practicing.
There are several types of documents that are used to describe how a physician and PA work together. These documents are often referred to as "supervision agreements", "delegation agreements", "job descriptions", "physician-PA practice agreements", “scope of practice”, or "supervision protocols." Regardless of the title, the purpose of the document is to:
Some state laws require specific information to be included in the practice agreement. The best supervision agreements are general, one- or two-page documents, that allow flexibility and do not require modification as the PA learns a new procedure or takes on a new task.
There are four parameters that determine the scope of practice for an emergency medicine physician assistant:
PAs are utilized in all areas of the ED and in all settings from being the solo provider in a rural ED, working in community hospital EDs, to providing patient care at a Level I Trauma Center. When staffing the ED, the PA commonly sees the same patient acuity mix as the physician(s) with whom they work in the physician/PA team.
In emergency medicine, the ED medical director, primary and secondary supervising physicians, and the EMPAs together reach decisions about delegation. Because medical practice and physician/PA practice are dynamic, specific lists of approved tasks applied to all facilities and to all physician/PA teams are not practical. There are not any "typical" restrictions regarding PA practice in the ED. The physician/PA team and the hospital should be aware of any restrictions on the PA's scope found within state law or hospital policy.
Examples of scope of practice include, but are not limited to, the following:
There are three factors that can determine whether a PA's chart requires a co-signature:
The Centers for Medicare and Medicaid (CMS) program does not require PA documentation to have a co-signature. However, CMS will defer to state law and require chart co-signature if that is a requirement of state law.
Many of the issues concerning the utilization of PAs in the ED are the same issues that confront emergency department physicians including:
Some issues that are unique to PA utilization in the ED include:
Each payer determines credentialing and enrollment policies for PAs. In fact, the same national payer may have different rules regarding PA credentialing and enrollment in different states. Some private payers or Medicaid departments may enroll PAs while others will not.
It is important to understand that enrollment and credentialing are not synonymous with coverage or payment for services. Many payers who do not separately credential PAs will cover their services when billed under the supervising physician's name or the group practice.
The term "incident to" is occasionally used to describe coverage of services performed by a PA, when those services are billed under the name of the supervising physician. That is not correct. "Incident to" is a Medicare term used to describe services billed in the office or clinic setting. The "incident to" billing concept is not utilized in the hospital (inpatient or outpatient).
Non-Medicare payer enrollment policies are made on the local payer level. The policies followed by Medicaid and Blue Cross/Blue Shield programs vary considerably by state. For example, the Medicaid program in one state may enroll PAs, while the Medicaid program in a neighboring state may only recognize physician services. The best way to determine credentialing and enrollment policies is to contact the payers in your specific area to ascertain their policies.
Utilizing PAs in the ED has proven to be both cost effective and efficient. PAs provide similar, and in most cases identical, medical services that are being provided by their supervising physician but typically at a much lower cost. By adding a PA program to the ED, more patients can be seen faster, reducing patients waiting times and improving patient satisfaction. PAs can be utilized to treat lower acuity patients and those patients most likely to be discharged home from the ED, giving the physician more time to care for critical patients.
When recruiting a PA, an emergency department employer should consider its needs. It is important to match the expectations of the ED and the level of the PA’s experience should be taken into consideration. Any organization hiring a new graduate should be mindful that newly trained PAs require more mentoring and closer supervision than experienced PAs or PAs who have completed EM postgraduate training. A seasoned PA with emergency medicine experience will be more likely to hit the ground running, may work at a more rapid pace than a new graduate and be able to handle a higher volume of patients.
Providing rotations for PA students in an ED is an excellent way to recruit new graduates – the staff physicians and PAs have a chance to work with the PA student before making a hiring decision.
When looking for ED candidates, employers might wish to consider individuals with previous ED experience, either as a PA or in a previous career as an emergency medicine technician, paramedic, or nurse, for example. Very often, PAs who are drawn to emergency medicine have worked in emergency medicine in some capacity before they became PAs.
SEMPA has a robust Career Center designed for PAs and employers alike.