Conference Board of Canada Study: Value of PAs in Ontario
There have been two Conference Board of Canada reports published on the Value of PAs and Gaining Efficiency. Since release of the report there has been 21+ media reports about PAs, highlighting how PAs could help relieve strain on health care system.
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Kelly Grimes, Senior Health Research for the Conference Board of Canada was the speaker. She first encountered a Physician Assistant 5 years ago, military trained PAs in a family health team, who had a wide scope of practice. In contrast during her work for Conference Board of Canada she has also comes across other PAs in similar settings where another PA had a smaller scope of practice.
The PA Profession in Canada
PAs are qualified and highly skilled care professionals who provide broad range of medical services under supervision of MD. PAs act as physician extenders. Like other advanced practice providers.
Scope of Practice:
Varies widely across the country. PA/MD conduction patient interviews histories, and physical examinations. Performed selected diagnostic and therapeutic interventions. Providing medical orders and prescriptions on preventative health care. Kelly did interview a PA in Ottawa Hospital in Orthopaedic Surgery who demonstrated 80 page documentation of her medical directives that had her scope of practice.
90% of PAs are employed, and average salaries $75,000 to $110,000
Distribution of PAs across Canada is wide and in military and civilian settings are wide. PAs are increasingly working in private office settings.
Report 1: Impact of PAs
What are the Benefits that PAs can bring to health system
Manitoba longest history in Canada, but 2013 piloted in primary care. Case study for 3rd report because of centralized process and funding to allocate PAs across the province.
Ontario: In 2007 demonstration projects in hospitals, ER, PHC and LTC. Qualitative studies have come out of this.
Alberta: In 2013, demonstration project for two years at 5 sites. Two year evaluation was released this spring, and integrated in the 2nd report.
New Brunswick has dome some work in ER report
Report 2: Gaining Efficiency
The purpose of the report was to calculate how much PAs could save the Canadian Health Care System. What was also exciting about this report was to review funding and payment models to allow PAs to integrate well within the health care system. Publication of this report is a big step in the right direction!
This brief did make headlines. Health care spending is increasing across the country, with exception of Ontario which has decreased by 0.1%.
How the Economic Model Used in the Report:
Three areas were examined: primary care, emergency care services and Orthopaedic Surgery
Projected demand for physician health services until 2030 by area of medical practice. This has been based on the aging population.
Efficient gains by hiring PAs determine by using physician billing data (CIHI) for total cost of medical care.
Cost savings were calculated as the sum of PA earnings and physician earnings under the increased PA scenario less the earnings of physicians in the baseline scenario.
Estimating the Value of Physician Assistants. Conference Board of Canada Report. pp. 13 Cost savings were determined by calculating differences between MD salary and PA salary in 3 different areas of medicine – primary care, ER and Orthopaedic Surgery
In this economic model is BASELINE: 500 PAs (2015 level) and physicians perform every aspect of additional medical care required in each year. Increased PA: 400 PAs added to current stock per next five years until 2000 PAs by 2030.
There was limited information regarding PA productivity and substitution (degree to which PAs could substitute or take on physician tasks). Due to limited evidence so expert panel of 9 specialists the degree to which a PA could substitute for a Physician (e.g. by employing a PA, a physician would have additional time that could be spent on more productive.
With the increasing demand of the aging Canadian population, they found PAs provided a cost-efficient option across all areas of medicine – even when the PA had not yet been fully integrated. As PA gains experience and builds competencies they can take on more tasks which would further add value and cost savings.
Results: Hiring more physician assistant (PAs) and effectively integrating them there is cost savings across all practice areas especially as PAs improve efficiency are able to take on more MD tasks.
Consequences of Aging:
An aging population and the associate rise in chronic disease will increase demand of health services
Physician forecasting model shows demand for health care services, growing at twice the pace of population growth, thus straining the system.
2011 – 5 million 14% of population
2036 – 10 million (24% of population)
Increase demand means more MDs and other types of health providers required
Substitution and Delegation
PAs can be efficient substitute for designated medical tasks in various settings
They need to be seen as taking over health care gaps.
Their flexible role, which depends directly on MD/PA relationships provides opportunity to introduce PAs where they are most needed: where there is greater demand for services, where there are other health professional shortages.The PA’s scope of practice depends on the PA/MD relationship, legislation in their jurisdiction of practice, and experience of the PA. A fresh new PA grad will have less delegated to them than a PA that has been in the field for many years. A PA in Manitoba where PAs are regulated, will practice differently than a PA in Ontario, where PAs are not regulated. The study mentions one U.S. paper that looked at delegation and comparative productivity and found PAs substituted 85% of primary care tasks (1). In an Australian study, PAs performed 62% of Emergency Room tasks (2) .
Supply of PAs
PA s are qualified health care providers, professionally trained and proven to achieve good outcomes in a variety of roles across the continuum of care.The Conference Board of Canada Study has stated that the supply of PAs is low, and comes the following sources:
Four PA schools (3 civilian, 1 military), producing 80 graduates per year
2 schools in Ontario (McMaster, University of Toronto) – Bachelor’s
1 school in Manitoba (University of Manitoba) – Master’s
1 school through Canadian Forces (Department of National Defence)
Alberta may be considering starting a PA school
American PAs (PA-C), who are able to practice
The length of training of a PA, which is approximately 2 years / 24 months in length “US data shows producing a PA is 20% less than that of a physician.” (1)
Any funding models for PA must consider infrastructure such as other provide compensation, building, tech support and other operational costs
Orthopaedics most promise because of high er difference between MD and PA wages
Utilization and Spending
Wide concerns regarding increase utilization of health care system and spending of health care system of PA system
2016 Kaiser Permanente found no evidence when NPs and PAs under a physician’s supervision (they increase input and outputs without increasing HC spending)
2016 US reported similar outcomes with PA or APN as a usual provider of care than MD only care. However exception is greater use of primary care
2015 AB demo project did show in primary care PAs can increase outputs/throughputs in certain areas
Most important barrier is lack of sustainable funding model (with exception of Manitoba)
New and innovative workforce planning and delivery models are required to meet local needs
3rd Brief shows there is no one size fits all, internally especially by setting and source of funding (i.e. private or public payor)
Brief 3: Funding models: USK, UK MB and Netherlands
Conclusions from Reports
PAs can be an efficient substitute for designated medical tasks
PAs are becoming a trusted partner in health care delivery by supporting attainment of good patient outcome in a team environment.
Adequate funding is needed (many provinces are struggling)
Research: Most data about PAs was found int he US, however Canada does need to do more research. More evidence in Canada i s needed to make the case (prospective, and retrospective case studies to prove PAs).
There are two more reports coming:
Brief 3: Funding Models
Brief 4: Recommendations
During presentation of the report findings, CAPA members came up to the microphone to ask clarifying questions and provide comments on the findings.
President Patrick Nelson
Despite benefits of PAs, there is still lack of a robust funding models for PAs in Canada
We know PAs are beneficial and there efficiency and positive impact has been proven in numerous studies in Canada and the United States – but how do we pay for them?
Sources of PA funding currently comes from:
Provincial government (Pilot and Demonstration Project)
Provincial Government Grants (e.g. Career Start Grant Funding for Ontario PA graduates)
Block funding (thru academic specialty groups)
Direct funding from Physicians (e.g. right out of the physician’s pocket).
To date, there has been no robust funding model proposed for PAs in Canada, and this has been a pain point for growth of the PA profession in Ontario. In Ontario, if a physician does not have a grant to hire a PA from the government but would like to work with a PA, they are expected to pay for PAs out of their own pocket (direct funding from solo physicians, physician group, or hospital department). Some are able to manage, and others can see the benefit but cannot afford a PA. There is certainly benefit that comes with improved quality of life, increased access, etc. but when it comes to dollar and cents in an employer’s eyes PAs “should” be at least cost neutral or generate money for the practice. A funding model would certainly help with this dilemma.
The Conference Board of Canada has only briefly mentioned funding models in this report, but teases that funding models are subject of an upcoming report.