Jeffrey G. Nicholson's Dissertation

 

PHYSICIAN ASSISTANT MEDICAL PRACTICE IN THE HEALTH CARE WORKFORCE:
A RETROSPECTIVE STUDY OF MEDICAL MALPRACTICE AND SAFETY COMPARING
PHYSICIAN ASSISTANTS TO PHYSICIANS AND ADVANCED PRACTICE NURSES

 

By
Jeffrey G. Nicholson

A dissertation submitted in partial fulfillment of
the requirements for the degree of
Doctor of Philosophy
(Educational Leadership and Policy Analysis)
at the
UNIVERSITY OF WISCONSIN-MADISON
2008

 

i
ACKNOWLEDGEMENTS
There are many individuals who have been significant influences in both my life and
career as a physician assistant and educator. I would like to thank Dr. Gene Jones for giving me a
start in PA education and for first believing in my teaching and research potential when I was his
student. I would like to thank Dr. Rod Hooker for sharing his incredible research acumen with
me and for his kind words of encouragement at critical junctures in the completion of this
dissertation. I am honored to work with and learn from someone who is recognized as the
foremost researcher in the PA profession. The following individuals have also been inspirations
to me in PA education and deserve my public appreciation for their examples of professional
leadership, education, research, and dedication to the advancement of the PA profession: Nish
Orcutt, Jim Cawley, Tony Miller, Rick Dehn and Dennis Blessing. Thank you for your
mentorship and examples over the years. I am honored and grateful to be considered your
colleague.
Dr. Jerlando Jackson, thank you for allowing me to combine my educational leadership
and medical careers in the choice of this dissertation topic and for your considerable work in
guiding me through the dissertation writing process. Dr. Craig Gjerde, thank you for
participating on my committee and for your encouragement and mentorship during my tenure at
the University of Wisconsin – Madison PA Program. I also thank the American Academy of
Physician Assistants and the Physician Assistant Education Association for supporting this
dissertation with grant funding. And finally, I thank Dean Susan Skochelak and the University of
Wisconsin School of Medicine and Public Health for supporting the completion of this doctoral
degree.

 

ii
ABSTRACT
As the physician assistant (PA) profession has matured, it has become a significant factor
in the nation’s health care delivery system. Quality of care stakeholders are increasingly
concerned about the medical care being delivered by non-physician providers. Stakeholders
include local and national government, health care delivery organizations, health care provider
education programs, the health insurance industry, and the general public. Each is affected by the
liability of physician assistant medical practice. While PAs are being trained and hired at a rate
that assumes adequate competence, quality and safety, current research is absent of a
comprehensive analysis of PA malpractice over time.
This study examined 17 years of data related to unsafe medical practice (i.e., practice that
harms patients or the public). The study analyzed and compared a variety of markers (e.g., civil
lawsuits and Medicare program exclusions filed with the National Practitioner Data Bank) of
safety between physicians, PAs, and advanced practice nurses (APNs). Results of the study
suggested that: a) the overall incidence and ratio of malpractice claims per provider was no
greater for PAs and APNs than for physicians over a 17 year period; b) the average and median
malpractice payments of PAs were less than that of physicians while that of APNs were greater;
c) the trend in median payment increases was less for PAs than physicians and APNs, and higher
for APNs than physicians; d) PAs did not negate their cost effectiveness through the costs of
malpractice; e) the rate of malpractice incidence increased for PAs and APNs over the study
period but remained steady for physicians; and f) the reasons for disciplinary actions against PAs
were similar to that of physicians and APNs. Other study findings included gender differences in
both malpractice payment incidence and malpractice payment amount and disparities between
states regarding the frequency of disciplinary actions as compared to malpractice incidence.

iii
TABLE OF CONTENTS
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . i
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . ii
LIST OF TABLES . . . . . . . . . . . . . . . . . . . . . . . v
LIST OF FIGURES . . . . . . . . . . . . . . . . . . . . . . . viii
CHAPTER I . . . . . . . . . . . . . . . . . . . . . . . . . 1
INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . 2
Statement of the Problem . . . . . . . . . . . . . . . . . . . 2
Background for the Study . . . . . . . . . . . . . . . . . . 3
Rationale for the Study . . . . . . . . . . . . . . . . . . . 6
Significance of the Research . . . . . . . . . . . . . . . . . 6
Research Questions . . . . . . . . . . . . . . . . . . . . 7
Assumptions and Limitations . . . . . . . . . . . . . . . . . 8
Definition of Key Terms . . . . . . . . . . . . . . . . . . . 12
Chapter Summary . . . . . . . . . . . . . . . . . . . . . 17
CHAPTER II . . . . . . . . . . . . . . . . . . . . . . . . . 19
REVIEW OF THE LITERATURE . . . . . . . . . . . . . . . . . . 19
Origin and Evolution of the PA Profession . . . . . . . . . . . . . 19
Impact of PAs on the Health Care Workforce . . . . . . . . . . . . 22
Managing PA Risk . . . . . . . . . . . . . . . . . . . . . 28
Medical Misconduct and Malpractice . . . . . . . . . . . . . . . 31
Chapter Summary . . . . . . . . . . . . . . . . . . . . . 43
CHAPTER III . . . . . . . . . . . . . . . . . . . . . . . . . 45
CONCEPTUAL FRAMEWORK AND METHOD . . . . . . . . . . . . . 45
Conceptual Framework . . . . . . . . . . . . . . . . . . . 45
Methods . . . . . . . . . . . . . . . . . . . . . . . . 57
Limitations . . . . . . . . . . . . . . . . . . . . . . . 62
Chapter Summary . . . . . . . . . . . . . . . . . . . . . 66
CHAPTER IV . . . . . . . . . . . . . . . . . . . . . . . . . 67
RESULTS OF DATA ANALYSIS . . . . . . . . . . . . . . . . . . . 67
Introduction . . . . . . . . . . . . . . . . . . . . . . . 67
Results of Analysis . . . . . . . . . . . . . . . . . . . . . 67

iv
TABLE OF CONTENTS (CONTINUED)
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . 156
CHAPTER V . . . . . . . . . . . . . . . . . . . . . . . . . 158
DISCUSSION, CONCLUSIONS AND RECOMMENDATIONS . . . . . . . . 158
Introduction . . . . . . . . . . . . . . . . . . . . . . . 158
Discussion . . . . . . . . . . . . . . . . . . . . . . . 158
Summary and Conclusions . . . . . . . . . . . . . . . . . . 182
Recommendations . . . . . . . . . . . . . . . . . . . . . 188
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . 195
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . 202

v
LIST OF TABLES
Table 1. Summary of Physician Assistants by Treating Area . . . . . . . . . 23
Table 2. Summary of General Specialty Areas of PA Practice . . . . . . . . . 24
Table 3. Reported Annual Income (Full-time PAs only) . . . . . . . . . . . 25
Table 4. ARC-PA Standards for Health Policy and Professional Practice. . . . . . 41
Table 5. Variables Studied . . . . . . . . . . . . . . . . . . . . . 60
Table 6. National Practitioner Data Bank Entries by Provider Type
(1/01/1991 - 12/31/2007) . . . . . . . . . . . . . . . . . . 68
Table 7. Number of Payment Reports, Providers, and Average Number of
Providers per Report . . . . . . . . . . . . . . . . . . . . 69
Table 8. Average Age (in years) of Provider at the Time of the Event Leading
to the Report . . . . . . . . . . . . . . . . . . . . . . 70
Table 9. Medical Malpractice Payment by Type of Provider and Average Year of
Practice (1991-2007) . . . . . . . . . . . . . . . . . . . 71
Table 10. Malpractice Claims (2004-2007) by Patients’ Age and Gender . . . . . . 72
Table 11. Medical Malpractice Payments by Reason for Payment and Provider Type
(2004-2007) . . . . . . . . . . . . . . . . . . . . . . 74
Table 12. Top Medical Malpractice Reasons for Payment by Provider Type . . . . . 75
Table 13. Medication-Related Medical Malpractice Payments by Reason for
Payment and Provider Type (2004-2007) . . . . . . . . . . . . . 76
Table 14. Duration from Litigation to Payment . . . . . . . . . . . . . . 78
Table 15. Mean and Median Malpractice Payment by Gender for 1999-2007 . . . . 79
Table 16. Number of Malpractice Payments and Adverse Actions Total and by Year,
1991-1999 . . . . . . . . . . . . . . . . . . . . . . . 81
Table 17. Number of Malpractice Payments and Adverse Actions by Work State,
1991-2007 . . . . . . . . . . . . . . . . . . . . . . 96

vi
LIST OF TABLES (CONTINUED)
Table 18. Ratio of Adverse Actions per Malpractice Payments by State, 1991-2007 . . 99
Table 19. Malpractice Payment Amount (2008 Adjusted) for the Period
Jan. 1, 1991-Dec. 31, 2007 . . . . . . . . . . . . . . . . . . 102
Table 20. Malpractice Payment Amount (2008 Adjusted) by Year from 1991 to 2007 . . 103
Table 21. Malpractice Payment (1991 Dollars Adjusted) Amount
Jan. 1, 1991 – Dec. 31, 2007 . . . . . . . . . . . . . . . . . 118
Table 22. Malpractice Payment (Adjusted to 1991 Dollars) Amount by Year
from 1991 to 2007 . . . . . . . . . . . . . . . . . . . . 119
Table 23. Ratio of Payment Entries per Active Provider in 2006 . . . . . . . . . 122
Table 24. Ratio of Malpractice Payments per Provider Type 1991-2007 . . . . . . 124
Table 25. Most Common Bases for Action by Reporting Entities from
Nov. 22. 1999 – Dec. 31, 2007 . . . . . . . . . . . . . . . . 127
Table 26. State and Medical Board Licensing Actions for the Period
January 1, 1991-December 31, 2007 . . . . . . . . . . . . . . 129
Table 27. State and Medical Board Licensing Action by Year 1991-2007 . . . . . . 130
Table 28. State and Medical Licensing Board Actions by State, 1991-2007 105 . . . 131
Table 29. State Rank of Physician Malpractice Payments and State and Medical
Board Licensing Actions . . . . . . . . . . . . . . . . . . 133
Table 30. Clinical Privilege Actions for the Period
January 1, 1991- December 31, 2007 . . . . . . . . . . . . . . 135
Table 31. Clinical Privilege Actions by Year 1991- 2007 . . . . . . . . . . . 136
Table 32. Clinical Privilege Actions by State 1991-2007 . . . . . . . . . . . 138
Table 33. Professional Society Membership Actions for the Period
January 1, 1991- December 31, 2007 . . . . . . . . . . . . . . 140
Table 34. Professional Society Membership Actions by Year 1991- 2007 . . . . . . 141
Table 35. Professional Society Membership Actions by State,
Jan.1, 1991 – Dec. 31, 2007 . . . . . . . . . . . . . . . . . 142

vii
LIST OF TABLES (CONTINUED)
Table 36. Practitioner Exclusion from Medicare and Medicaid Programs
for the period January 1, 1991-December 31, 2007 . . . . . . . . . . 145
Table 37. Practitioner Exclusion from Medicare and Medicaid Programs
by Year 1991-2007 . . . . . . . . . . . . . . . . . . . . 146
Table 38. U.S. D.E.A. Actions for the Period January 1, 1991-December 31, 2007 . . . 149
Table 39. U.S. D.E.A. Actions by Year 1991- 2007 . . . . . . . . . . . . . 150
Table 40. U.S. D.E.A. Actions by State, 1991-2007 . . . . . . . . . . . . . 152
Table 41. Adverse Actions Report Summary 1991-2007 . . . . . . . . . . . 155
Table 42. Adverse Actions 1991-2007 as a Percent of Providers in 2006 . . . . . . 156

viii
LIST OF FIGURES
Figure 1. Framework for Performance Assessment in Primary Health Care . . . . . 46
Figure 2. Model Specification Chart . . . . . . . . . . . . . . . . . . 48
Figure 3. National Practitioner Data Bank at a Glance . . . . . . . . . . . . 56
Figure 4. Physician Malpractice Payment Reports 1991-2007 . . . . . . . . . 83
Figure 5. PA Malpractice Payment Reports 1991-2007. . . . . . . . . . . . 84
Figure 6. APN Malpractice Payment Reports 1991-2007 . . . . . . . . . . . 85
Figure 7. Total Malpractice Payment Reports 1991-2007 . . . . . . . . . . . 86
Figure 8. Total Malpractice Payments by Provider Type 1991-2007 . . . . . . . 87
Figure 9. Average Annual Malpractice Payments by Provider type 1991-2007 . . . . 88
Figure 10. Physician Adverse Action Reports 1991-2007 . . . . . . . . . . . 89
Figure 11. PA Adverse Action Reports 1991-2007 . . . . . . . . . . . . . 90
Figure 12. APN Adverse Action Reports 1991-2007 . . . . . . . . . . . . . 91
Figure 13. Total Adverse Action Reports 1991-2007 . . . . . . . . . . . . . 92
Figure 14. Total Adverse Action Reports by Provider Type 1991-2007 . . . . . . . 93
Figure 15. Average Annual Adverse Action Reports by Provider Type 1991-2007 . . . 94
Figure 16. Physician, PA and APN Average Malpractice Payments by Year 1991-2007 . 107
Figure 17 Physician, PA and APN Median Malpractice Payments by Year 1991-2007 . 108
Figure 18. Average Malpractice Payment . . . . . . . . . . . . . . . . 109
Figure 19. Average of Median Malpractice Payments 1991-2007 . . . . . . . . . 110
Figure 20. Total Malpractice Payments in Millions 1991-2007 . . . . . . . . . 111
Figure 21. Physician Total Malpractice Payments by Year 1991-2007 (in millions) . . . 112
Figure 22. Physician Median Malpractice Payments by Year 1991-2007 . . . . . . 113

ix
LIST OF FIGURES (CONTINUED)
Figure 23. PA Total Malpractice Payments by Year 1991-2007 (in millions) . . . . . 114
Figure 24. PA Median Malpractice Payments by Year 1991-2007 . . . . . . . . 115
Figure 25. APN Total Malpractice Payments by Year 1991-2007 (in millions). . . . . 116
Figure 26. APN Median Malpractice Payments by Year 1991-2007 . . . . . . . . 117
Figure 27. Probability of Malpractice Payment 1991-2007 . . . . . . . . . . . 125
Figure 28. Physician Clinical Privileges Actions 1991-2007 . . . . . . . . . . 137
Figure 29. Physician Exclusions from Medicare and Medicaid Programs 1991-2007 . . 147
Figure 30. PA Exclusions from Medicare and Medicaid Programs 1991-2007. . . . . 148
Figure 31. Physician D.E.A. Actions 1991-2007 . . . . . . . . . . . . . . 151

1
CHAPTER I
INTRODUCTION
This study investigated the growing field of physician assistant (PA) medical practice.
With a relatively short professional history, PAs represent a fast-growing segment of the U.S.
health care continuum (AAPA, 2007). From its military beginning in the 1960s, to its fullfledged,
recognized status as a medical profession, PA practice represents an expanding form of
primary medical care in this country. PA practice is not immune to the concerns of health care
quality, access, and cost. PA practice has brought health care access to thousands of Americans
in health care professional shortage areas (HPSAs) by providing medical services at hospitals
and primary care clinics in these areas (Shafrin, 2006a). However, with the expansion of PA
practice also came the unpleasant issues of liability and lawsuits, thus raising the question: are
PAs safe providers of care?
To answer this fundamental question, the study analyzed growing trends in PA practice,
investigated the medical practice liability of PAs, and compared and contrasted those findings
against similar markers (e.g., lawsuits and licensure actions) for the two provider groups with
whom PAs are commonly compared: physicians and advanced practice nurses (APNs). The
reader is cautioned to bear in mind that the liability and malpractice risk of these three provider
groups are different because each group provides care that varies in complexity and risk of
undesired outcome. This study did not intend to assess or quantify the inherent differences in
malpractice risk between these three provider groups, it simply reported and compared outcome
markers of unsafe medical practice. Physician and APN data was presented for comparison
because these providers are the most similar to physician assistants in medical practice scope and
training, and also because the comparison provides a context for quantifying safety.
2
This study also presented the implications of its findings for educational leaders, health
care policymakers, and researchers. It reviewed the extent of both pre and in-service education
currently provided in clinical practice safety, risk management and medical malpractice, and
made recommendations for educational leaders and education policymakers based upon its
findings.
Statement of the Problem
The American health care system is under constant scrutiny from the public, health care
providers, the government, and multiple regulators (Hooker & Cawley, 1997). Enacted as a
means for increasing healthcare delivery, after 40 years of deployment PAs are entwined into the
complexity of this system. Even with multiple levels of oversight and ongoing research efforts, a
number of authorities and the media continue to point out the shortcomings of America’s health
care system (Sultz & Young, 2006; Pozgar, 2007). Former President Bill Clinton and his wife,
Senator Hilary Clinton, attempted to make health care reform a national priority during their
political campaigns and terms in office. Chief among the shortcomings cited were the lack of
medical practitioners, the spiraling cost of healthcare, and the increasing number of Americans
who lack insurance to pay for their health care (Sultz & Young, 2006). Growing out of similar
concerns that originated in the 1960s, the PA profession was founded to address these very
issues.
Many observers of the health care system, including government regulators, hospital
administrators, and consumers, consider these issues to be at crisis proportions (Hooker &
Cawley, 1997). Many hospitals, especially in low-income and/or HPSAs of the country, have
closed because they were unable to collect reimbursement for their services from an uninsured
population, government programs that changed participation requirements, and because they
3
lacked medical professionals to staff their facilities (Sultz & Young, 2007). Health care
policymakers, politicians, service providers and health care consumers are exploring the use of
physician extenders such a physician assistants and advanced practice nurses to augment the
number of the nation’s physicians and provide quality, cost-effective medical care (Hooker &
Cawley, 1997). Indeed, over the first 40 years of the PA profession’s existence, PAs have
expanded into nearly every medical specialty (AAPA, 2007).
As stakeholders turn to the PA profession to help meet the needs of a health care system
in crisis, there is a need to analyze data from researchers on the quality, cost-effectiveness, and
safety of physician assistant medical practice. A paucity of information is available regarding the
PA profession. Thus, this researcher sought to provide baseline data and a foundation for future
researchers to compare and contrast PA practice to that of physicians and APNs. Of primary
concern is patient safety. Little aggregated data exists that synthesizes liability issues for the PA
profession. Thus, this current study is groundbreaking research that will be of value to multiple
stakeholders.
Background for the Study
The PA profession has a relatively short history in the U.S. The profession originated in
the 1960s as a response to the national need for health care services in the wake of physician
shortages and maldistribution of physician services (Carter, 1992). Dr. Eugene Stead, a North
Carolina Duke University Medical Center physician, is credited with creating the first class of
PAs in 1965 (Physician Assistant History Center, 2007). The first class was comprised of
experienced Navy corpsmen that already possessed military medical training and experience
serving in a medical capacity during the Vietnam War. Dr. Stead based this first program on the
4
fast-track training method used for medical doctors during World War II (Physician Assistant
History Center, 2007).
This fast track approach was that of a physician extender, whereby individuals would be
trained in a relatively short period to provide basic medical care under the general supervision of
physicians. From the humble beginning of four ex-Navy corpsman graduates at Duke
University’s new PA training program in 1967, there are now over 63,000 certified PAs working
in clinical practice as of January 2007 (AAPA, 2007).
The nursing profession was initially approached to take on the PA model of medical care
in the 1960s. AMA leaders were exploring options for training health care professionals – nurses
among them – for advanced clinical role. However, the AMA and American Nursing
Association’s (ANA) dialogue on the PA was often characterized by sharp language and strong
debate over the new profession. Ultimately the ANA rejected the AMA proposal of the PA
concept on two occasions (Hooker and Cawley, 2003). Despite this initial rejection, the nursing
profession since moved forward with advanced practice nurse training in multiple specialties.
Unlike PAs who are trained as generalists and have one national credentialing authority, nurses
choose from a number of advanced practice training designations and certifications such as nurse
midwifery, nurse anesthetist, clinical nurse specialist, women’s health specialist or family nurse
practitioner. Much APN practice, including family nurse practitioner, women’s health nurse
practitioner and geriatric nurse practitioner is identical in scope to PA generalist practice. For
this reason, and because the two provider types have similar histories and timelines, PA and
APN practice is often compared in the research literature. The current study continues this
tradition.
5
For a number of reasons, physicians are critical stakeholders with regard to physician
assistant hiring and utilization (Hooker, 1997). Physicians are legally bound to a supervisory
relationship with their physician assistants and as such are liable for the medical decisions and
actions of their PAs. The quality of their daily interactions and relationship has an impact on the
success of their partnership. Some factors impacted by that relationship include the quality and
quantity of care provided to patients, efficiency in the provision of care, enjoyment of their
chosen professions, and the quality of life of both physician and PA (Manion, 2005). The quality
of life effects are especially noteworthy as many physicians hire PAs for the purpose of reducing
their workloads (Manion, 2005).
Physicians are also stakeholders with regard to the utilization of PAs because physician
assistants have proven their ability to provide similar care to that of physicians at a much reduced
cost (Roblin, 2004). Physicians therefore have a motivated interest in monitoring the number of
physician assistant graduates and their scope of practice. The perception of the physician
assistant profession by physicians may therefore play a significant role in determining the
number of physician assistants hired and utilized. Physician assistant utilization in turn has an
impact on the availability of health care services, especially in medically underserved areas, and
among the medically uninsured or underinsured (Larson, 2003).
However, physicians are not the only stakeholders with regard to physician assistant
utilization, nor are they the only employers. Other stakeholders that are impacted by PA
utilization include organizations that provide health care services: hospitals, clinics, health
maintenance organizations, insurance companies, the federal government, and the health care
consumer (Larson, 2003). If the physician assistant profession is perceived as an instrument that
can provide high quality, cost-effective and safe medical care, all of these entities will be
6
impacted by PA utilization. An examination of the historical trend in hiring practices indicates
that many of these stakeholders are demonstrating increased interest in PA utilization. The
number of PAs employed in the U.S. increased from 40,000 in 1992 to over 50,000 in 2005, and
is projected to be 80,000 by 2010 (AAPA, 2006).
Rationale and Significance of the Study
Existing studies (e.g., Hooker, 1997; Shafrin, 2006a, 2006b) on the physician assistant
profession focus on a number of issues important to the health care system. These include PA
cost effectiveness, patient satisfaction, PA specialization, provision of care in medically
underserved areas, and PA job satisfaction. But no recent published studies exist that examine
the malpractice of physician assistants. This study was intended to fill the void, as it examined
the scope of malpractice that exists in the PA profession and compared it to that of physicians
and other health care professionals.
The PA profession is the third fastest-growing health care discipline in the United States
according to the U.S. Bureau of Labor Statistics (Medical News Today, 2004). Projections call
for the PA profession to grow by 49 percent by 2012. According to AAPA estimates,
approximately 192 million patient visits were made to PAs in 2003, up from 183 million patient
visits in 2002. Of the other health care professions making the top ten for fastest-growing
occupations, the PA profession requires more postsecondary education to enter the field and is
the only health care profession classified in the top quartile ranking by the Occupational
Employment Statistics in annual earnings (Medical News Today, 2004).
The utilization of PAs in the health care workforce has made social, political, and
economic impacts on health care consumers, providers, and delivery systems. Health care
policymakers need to determine whether the expansion of the PA profession and increased
7
utilization of physician assistants across medical specialties is good for the nation’s citizens and
health care systems. While the federal government has historically supported the expansion of
the PA profession through Title VII training grants to PA educational programs in meeting the
health care needs of Americans who are medically underserved (Shafrin, 2006a), a central
question that still needs examination is whether PAs are safe medical practitioners? Further, are
PAs at least as safe as their physician colleagues and mentors?
Attorneys, insurance companies, state and federal governments, health care policymakers
and health care consumers are all stakeholders in the safety of care provided by physician
assistants. Published data on the safety of physician assistant medical practice are nearly nonexistent.
To date, only two studies (i.e., Brock, 1998; Cawley, Rohrs, & Hooker, 1998), have
investigated the safety of PAs by comparing data sets found in the National Practitioner Data
Bank (NPDB). Brock’s work, based on data collected from 1991 to 1996, found that physician
claims reported to the NPDB were 420 times that of PA claims (100,750 for physicians and 240
for PAs). He noted that since the NPDB began collecting data, total physician payments were
946.6 times the total for PAs. Cawley’s group, examining six years of data from the NPDB,
found that the average malpractice payment of PAs was $55,241 while that of physicians was
$139,581.
Purpose of the Study and Research Questions
The purpose of this study was to research PA liability and malpractice issues to determine
if PAs are a safe choice for health care provision. This study reviewed the literature on PA
practice and litigation trends, investigated national practitioner databases, examined the
professional organizations that govern PAs to determine the viability and future of PAs and
explored issues related to safety for health care consumers. The intent of this study was to
8
determine whether the practice of medicine by physician assistants is as safe as the practice of
medicine by physicians and advanced practice nurses? Specifically, research questions for this
study included: (a) Do PAs negate their cost effectiveness through the costs of malpractice?; (b)
Is the rate of malpractice for physician assistants at the same trajectory as that of physicians and
advanced practice nurses?; (c) Is the ratio of malpractice claims per provider the same for
physician assistants, advanced practice nurses and physicians?; and (d) Are the reasons for
disciplinary action against PAs and APNs the same as those for physicians? Based upon an
analysis of the data, recommendations were made to health care policymakers and researchers on
PA utilization and to educational leaders in the PA profession on the provision of pre and inservice
education regarding PA practice safety.
Assumptions and Limitations
There were several assumptions regarding this research study. The researcher assumed
that PA practice will continue forward, building on its current success as a significant factor in
health care delivery. The research undertaken was believed to provide a solid, more
comprehensive and updated foundation for the profession to integrate as it considers patient
safety, quality, and medical care efficacy. For the purpose of the study, it was assumed that PAs
within the data set are practicing within their legal scope of practice and physician supervisory
requirements as defined by state regulations and state medical examining boards. It was also
assumed that civil courts generally hold PAs liable for their medical practice decisions and
actions independently of their supervising physicians. Additional assumptions included that an
analysis of the data can be used to accomplish the following: (a) to predict malpractice and
adverse action trends of provider types; (b) to determine the likelihood of malpractice payments
and disciplinary actions of providers during their careers; (c) to reveal the effectiveness of states
9
or jurisdictions in sanctioning providers with malpractice payments and therefore provide one
indicator of the effectiveness of states and jurisdictions at protecting patients; and (d) to provide
recommendations to PA, physician, and APN training programs and professional organizations
on the most appropriate type and amount of education to reduce professional liability and
promote patient safety.
Liability and Specialty Differences
This study of PA practice and currently observed liability issues also has limitations. No
comparison of malpractice incidence across disciplines is fair without an understanding of the
liabilities undertaken by each discipline. While this study demonstrated differences in
malpractice incidence, payment amounts, and adverse action incidence between PAs, APNs and
physicians, the reader is cautioned and reminded that each of these medical provider groups is
comprised of a different compilation of medical practice specialties with a subsequent difference
in malpractice risk. The data set utilized did not allow for direct comparisons across the three
provider groups by specialty of practice. Only APN midwives and anesthetists were reported
separately and only because they are certified separately from other APNs.
Role Differences
Additionally, physician assistants at their founding were designed to be dependent
practitioners, working alongside physicians as their assistants rather than as their substitutes.
Although PA practice has become more autonomous than its founders may have anticipated in
the 1960s, it is generally recognized that PAs are not expected to possess the full medical
knowledge base of physicians nor are they expected to manage the most complicated of patients
without assistance from a supervising physician. Likewise, licensing and regulatory agencies
recognize that APNs do not possess the same degree of training as physicians and therefore
10
require a collaborating physician for APNs in much the same manner as a supervising physician
is required for PAs.
The reader is therefore cautioned to bear in mind is that PAs and APNs may not as a
whole take on the same level of malpractice risk as physicians. It is not the intent of this study to
determine what that difference in risk is between these provider groups. The study is not
intended to determine, define or quantify the differences in liability or malpractice risk between
PAs and physicians or PAs and APNs. It is solely intended to analyze available data and report
the differences in actual malpractice incidence, payments and other known outcome markers of
safety over a 17 year period.
Autonomy Differences
In order to assess the inherent differences in malpractice risk and liability between
physicians, PAs and APNs, one would need to both quantify the differences in autonomy
between PAs, APNs and physicians and to account, compare and proportion the variety of
medical specialties of each provider group, each having its own inherent risk. These tasks are
complex and well beyond the scope of this study. The question of autonomy differences alone is
difficult to quantify because the level of autonomy of a PA or APN is determined by multiple
factors and may vary greatly not only from one specialty to another but from one employer,
employment setting or supervising physician to another. The amount of autonomy of a PA or
APN is largely determined by the provider’s own confidence and comfort with the level of care
being provided. Since these two practitioner types were founded on the principle of extending
physician care as much as possible, state regulations have been written broadly to allow
physician extenders to push their training, knowledge and skills to its limits. Physicians, rather
than envisioning their role as delegating minor tasks or acting as gatekeepers of physician
11
extender practice, have allowed mid-level practitioners to set their own limits of care within the
supervising physician’s practice specialty. State regulations state simply that PAs may not
practice outside the scope of their supervising physician’s board specialization. The PA or APN
approaches the supervising or collaborating physician for assistance on an as-needed basis.
Autonomy may also vary by employment setting or employer guidelines. For example,
some emergency room physician groups require their PAs to discuss or “staff” every patient seen
by the PA, while others more commonly prefer that the PA only come to the supervising
physician when questions in care arise. Some emergency physicians allow PAs to see any patient
in line for service without regard to patient acuity or level of care, while others restrict their PAs
to seeing only “minor” emergencies or “urgent care.” The difficulty in generalizing or in
quantifying the autonomy issue has been an obstacle to research in this area. While there is some
limited research on the tasks that PAs perform as compared to physicians, there is no literature
on the level of autonomy in performing those tasks or the inherent malpractice risk in performing
those tasks.
Other Limitations
Other limitations include that the research was confined to available data. These data may
not be representative of all current malpractice or liability cases that involve PAs. It is possible
that many cases involving malpractice or liability with regards to PAs: (a) have never been
reported; (b) were settled outside of the courts or regulatory agencies; or (c) are reflected in a
supervising physician’s record instead of the PAs or APNs. While the NPDB staff has made
assurances that PA and APN reporting has always been requested separately from supervising
and collaborating physician reporting, there will always be human error in interpretation of
reporting instructions and even attempts by reporting agencies to underreport or misrepresent
12
data in order to minimize the appearance of poor outcomes. Another limitation of the study was
that not all adverse action categories were required reporting elements for PAs and APNs. Many
states voluntarily reported these data, but reporting was not required by the act of Congress that
established the NPDB. For those particular adverse actions categories, caution is advised about
drawing conclusions from the comparative data.
Definition of Key Terms
As with any study, there are several key terms and phrases that must be identified to
provide clarity and define the study’s scope. Those key terms include:
American Academy of Physician Assistants (AAPA) is the professional organization that
represents PAs in the U.S. (AAPA, 2007).
Advanced Practice Nurse (APN), also known as Advanced Practice Registered Nurse (APRN,) is
a registered nurse with advanced education, knowledge, skills, and expanded scope beyond that
of a registered nurse. APNs include the subcategories of Certified Nurse Midwife (CNM); Nurse
Practitioner (NP); Clinical Nurse Specialist (CNS); Advanced Practiced Nurse Prescriber
(APNP); and Certified Registered Nurse Anesthetist (CRNA). All advanced practice nursing
credentials require specialized training, continuing education and certification. Most APNs have
a master’s or doctoral degree in nursing (Bryant-Lukosius & DiCenso, 2004).
Adverse action is a broad term with many meanings. For the purposes of this study, this term
refers to (a) any action taken against a practitioner’s clinical privileges or medical staff
membership in a health care entity, or (b) a licensure disciplinary action (NPDB Guidebook,
13
2007). This term also refers to an action of any entity, including a governmental authority, health
care facility, employer or professional organization. Actions include revocation, suspension,
censure, reprimand, fine, required continuing education, counseling or monitoring
(Massachusetts Board of Registration in Medicine, 2007).
Clinical privileges refer to privileges, membership on a medical staff and other memberships
(including panel memberships) in which a physician, dentist, or other licensed health care
practitioner is permitted to furnish medical care by a health care entity (NPDB Guidebook,
2007).
Health care entity is a (a) hospital; (b) an entity that provides health care services and follows a
formal peer review process for the purpose of furthering quality health care; or (c) a professional
society or a committee or agent thereof, including those at the national, state, or local level, of
physicians, dentists, or other health care practitioners, that follows a formal peer review process
for the purpose of furthering quality health care (NPDB Guidebook, 2007).
Health care practitioner is an individual other than a physician or dentist (a) who is licensed or
other wise authorized by a state to provide health care services, or (b) who, without state
authority, holds himself or herself out to be authorized to provide health acre services (NPDB
Guidebook, 2007).
Health care quality is a broad-based term derived from both operational factors and from
measures or indicators of quality selected and the value judgments attached to them. Previously,
14
quality was defined as “the degree of conformity with present standards” and encompassed all of
the elements, procedures, and consequences of individual patient-provider encounters. However,
the notion of health care quality has moved to measurements and outcomes looking toward peerreview,
accrediting bodies, and ongoing credentialing and auditing (Sultz & Young, 2006).
Liability refers to any legal responsibility, duty, or obligation. This term also relates to damages,
or an obligation one has incurred or might incur through a negligent act (Pozgar, 2007).
Licensure disciplinary action is (a) revocation, suspension, restriction, or acceptance of surrender
of a license; and (b) censure, reprimand, or probation of a licensed physician or dentist based on
professional competence or professional conduct (NPDB Guidebook, 2007).
Malpractice refers to professional misconduct, improper discharge of professional duties, or
failure to meet the standard of care required of a professional that results in harm to another
person; the negligible or carelessness of a professional person (Pozgar, 2007).
Medical malpractice payment is a monetary exchange as a result of a settlement or judgment of a
written complaint or claim demanding payment based on a physician’s, dentist’s, or other
licensed health care practitioner’s provision of or failure to provide health care services, and may
include, but is not limited to, the filing of a cause of action, based on the law of tort, brought in
any sate or federal court or other adjudicative body (NPDB Guidebook, 2007).
15
Medical misconduct generally includes obtaining a license fraudulently; practicing a profession
fraudulently, beyond its authorized scope, with a gross incompetence; practicing a profession
while impaired by alcohol, drugs, physical disability or mental disability; refusing to provide
professional services to a person because of that person’s race, creed, color, or national origin;
permitting, aiding, or abetting an unlicensed person to perform activities requiring a license; and
being convicted of committing an act constituting a crime (Pozgar, 2007).
The National Practitioner Data Bank (NPDB) was created by Congress through the Health Care
Quality Improvement Act of 19896 as a national repository of information related to medical
practitioners. The NPDB’s primary purpose is to facilitate comprehensive reviews of physicians’
and other health care practitioners’ credentials (Pozgar, 2007). The Health Care Quality
improvement Act of 1986 was intended to improve the quality of medical care by encouraging
hospitals, state licensing boards, and other health care entities, including professional societies,
to identify and discipline those who engage in unprofessional behavior; and to restrict the ability
of incompetent practitioners to move from state to state without disclosure or discovery of the
practitioners’ previous damaging or incompetent performance (NPDB Guidebook, 2007).
Practitioner safety refers to the extent of protection of the public and individual patients from
harm by medical care providers (Sultz &Young, 2006). For the purposes of this study, the term
refers to ensuring quality care to meet community standards of patient care.
16
Physician is a doctor of medicine or osteopathy that is legally authorized to practice medicine or
surgery by a state, or who, without authority, holds himself or herself out to be so authorized
(NPDB Guidebook, 2007).
Physician Assistant (PA) is a U.S. designation for non-physician clinicians licensed to provide
medical care. PAs may use the post-nominal initials of PA, PA-C, RPA, or RPA-C where the C
indicates “Certified” and the R stands for “Registered.” PAs generally have a master’s degree in
medical studies from an accredited university along with a national certification. PAs are
specially categorized as mid-level practitioners with the authority to prescribe medications. The
scope of PA practice encompasses nearly all medical specialties including primary care, surgical,
and orthopedic (AAPA, 2007).
Standard of care is a description of the conduct that is expected of an individual in a given
situation. It is measured against which a defendant’s conduct is compared (Pozgar, 2007).
Supervising Physician is a legal or regulatory designation defining the relationship between a
physician assistant or other non-physician provider (NPP) and a physician. The defined
relationship commonly includes a delegation of services agreement that delegates medical
practice actions and prescription writing authority to the NPP (American Academy of Family
Physicians, 2008).
Supervision means to coordinate, direct, and inspect on an ongoing basis the accomplishments of
another, or to oversee, with the power to direct, the implementation of one's own or another's
17
intentions. The supervising physician must have the opportunity and the ability to exercise
oversight, control, and direction of the services of a NPP. Accordingly, it is the responsibility of
the supervising physician to direct and review the work, records, and practice of the NPP on a
continuous basis to ensure that appropriate directions are given and understood and that
appropriate treatment is rendered. Supervision includes, but is not limited to: (a) the continuous
availability of direct communication either in person or by electronic communications between
the NPP and supervising physician; (b) the active overview of NPP activities including direct
observation of the NPP's ability to take a history and perform a physical examination; (c) the
personal review of the NPP's practice at regular intervals including an assessment of referrals
made or consultations requested by the NPP with other health professionals; (d) regular chart
review; (5) the delineation of a plan for emergencies; and (6) the designation of an alternate
physician in the absence of the supervisor. The circumstance of each practice determines the
exact means by which responsible supervision is accomplished (American Academy of Family
Physicians, 2008).
Summary
Chapter I provided an introduction to the PA profession and the current issues of liability
and malpractice related to medical care provision. This chapter outlined the study’s purpose,
research questions, significance, and defined key terms. The PA profession has become a
significant factor in the nation’s health care workforce. And while PA practice safety is
tantamount to both the quality and cost-effectiveness of PA medical practice, no comprehensive
research exists that examines how PAs compare with physicians and other similar medical
practitioners in terms of their safety record. The need for research on PA safety is clear, and
research results will impact whether and how PAs are utilized in the future. In Chapter I the
18
reader was cautioned to bear in mind that the liability and malpractice risk of these three provider
groups are different because each group provides care that varies in complexity and risk of poor
outcome. The reader was reminded that the study did not intend to assess or quantify the inherent
differences in malpractice risk between these three provider groups, it simply intended to report
and compare outcome markers of unsafe medical practice. Physician and APN data was
presented for comparison because these providers are the most similar to physician assistants in
medical practice scope and training.
The next chapter, Chapter II, investigates the current literature germane to this study.
Chapter II provides the historical underpinning of the PA profession, examines the impact of the
PA profession on health care delivery in the U.S., analyzes risk management issues related to the
PA profession, and investigates the current state of medical misconduct and malpractice of PAs.
19
CHAPTER II
REVIEW OF THE LITERATURE
Chapter II, the review of current literature, provides a basis for this study. Chapter II is
divided into four main sections with several sub-sections within each category. The first section
provides an historical underpinning of the Physician Assistant professional field. The second
section analyzes the current impact of PA utilization on the nation’s health care work force. Risk
management is the main topic of the third section. The fourth section synthesizes literature
related to medical misconduct and malpractice. The final section outlines the extent of practice
safety education in the PA profession. The chapter summary integrates the section together in
preparation for Chapter III, study methods.
Evolution of the PA Profession
Unlike physicians, osteopaths, and nurses, PAs have a relatively short professional
history. Beginning with four trained military corpsmen in 1967 the ranks of PAs have swelled to
over 60,000 certified practitioners in 2007 (AAPA, 2007). This type of growth is unprecedented
for any other health care field including nursing, physical therapy, and dentistry (Medical News
Today, 2004). Federal health policy changes served to spur the profession forward. Following
the 1964 Stead beginning discussed in Chapter I, the first legislative support for the PA
profession was the 1966 Allied Health Professionals Act (PL-751). This public law encouraged
the development of training programs aimed at new types of primary care providers. The Health
Manpower Act (PL-490) was passed in 1968 funding training for health care providers including
PAs (Shafrin, 2006a). This year also saw the incorporation of the American Academy of
Physician Assistants (AAPA), the singular organization that represents all PAs in the United
States. Important marketplace movements also supported the early fledgling PA profession. In
20
1970 Kaiser Permanente became the first health maintenance organization (HMO) to employ
PAs (Shafrin, 2006a). This led to the 1972 development of certifications for accredited PA
educational programs under the auspices of the National Board of Medical Examiners (AAPA,
2007).
Further federal legislative issues followed in successive years with the 1976 Professionals
Assistance Act (PL94-484) which provided monetary support of PA education, and the
watershed 1977 Rural Health Clinic Services Act (PL95-210). The Rural Health Clinic Services
Act was a major turning point for a profession that up until 1977 was struggling to be reimbursed
by Medicare, state Medicaid programs, and many private insurers. This act provided Medicare
reimbursement for PAs and nurse practitioners that provided services in rural clinics (Shafrin,
2006a).
Almost nine years transpired before the 1986 Omnibus Budget Reconciliation Act
(PL99-210) allowing for Medicare Part B reimbursement for PA services in hospitals and
nursing homes. In the following year (1987), the federal government strengthened this legislation
by allowing Medicare reimbursement to PAs in a larger portion of the rural underserved areas
and designated health professional shortage areas (HPSAs) (Shafrin, 2006a). It should be noted
that though HPSAs are found in many rural locations, many also exist within metropolitan areas
(Shafrin, 2006a). A full ten years later the Balanced Budget Act of 1997 (BBA97) became law.
In this most recent Federal act affecting PA practice, PA reimbursement rates increased to 85%
of that of physician costs across all practice settings. Previous to the BBA97, PAs were
reimbursed at 75% in hospitals, 65% for assisting in surgery, and 85% for work in skilled
nursing facilities (Shafrin, 2006a).
21
Throughout the ensuing years, the PA profession worked to ensure that PAs were able to
practice in every state. Mississippi was the last state to enact legislation to authorize PA practice,
and this occurred in the year 2000 (AAPA, 2007). The PA profession has enjoyed unparalleled
success in the last 40 years. While the numbers of certified and registered professionals grew, the
acceptance of this professional as more than a physician extender also grew. The profession is
well-positioned to address critical issues of affordability, access, and quality. However, the PA
profession, similar to other professional medical entities, is plagued by factors that prevent
further growth. These include (a) lack of schools and universities that can subsidize their
expensive training programs; (b) lack of growth of new training programs; and (c) lack of
appropriate faculty to train the next cadre of practitioners. Similar to the physicians that the PA
profession found a niche to fill, there now appears to be the problem of more demand and not
enough practitioners (Crane, 2007).
Training and Certification
PAs spend an average of 25 months in core curriculum following a shortened form of
traditional medical education. The foundational emphasis has been as a generalist serving in
primary care (Simon & Link, 2001). To be accepted to a PA training program, most students
already have at least two years of health care or health care related experience. Competition is
fierce for acceptance with a reported five applicants for every open position nationwide. Because
of the close working relationship PAs have with physicians, PAs are educated in a medical
model designed to complement physician training. PA students are taught, as are medical
students, to diagnose and treat medical problems (AAPA, 2000). Education consists of classroom
and laboratory instruction in the basic medical and behavioral sciences (such as anatomy,
pharmacology, pathophysiology, clinical medicine, and physical diagnosis), followed by clinical
22
rotations in internal medicine, family medicine, surgery, pediatrics, obstetrics and gynecology,
emergency medicine, and geriatric medicine. To become accredited as a PA, a student must pass
the national certifying examination of the National Commission on the Certification of Physician
Assistants, an independent accrediting body. To remain certified, every PA practitioner must
complete 100 hours of continuing medical education every two years and pass a recertification
examination every six years (AAPA, 2007).
PA Impact on the Healthcare Workforce
Prior to PA and NP licensure, the only individuals permitted by law to perform a variety
of medical procedures were physicians. But PAs now practice medicine in more than 60
specialty fields, treating patients with diverse disorders (AAPA, 2007). Table 1 provides a
snapshot of where PAs were employed as of 2007, the most recent year that accurate data are
available. It is interesting to note that the most common employer listed was a single specialty
physician group. Hospitals, as employers came in second, while other physician groups followed.
Community health clinics employ close to 6% of PAs reported in the 2007 AAPA Census. The
data indicate that PAs have moved beyond serving rural and underserved areas to a demographic
pattern similar to physicians.
23
Table 1. Summary of Physician Assistants by Treating Area
______________________________________________________________________________
Primary Employer Percentage
______________________________________________________________________________
Single Specialty/physician group 31.0%
Other hospital 14.2%
Solo physician practice 12.6%
Multi-specialty physician group 12.9%
University hospital 8.6%
Community health center 5.8%
Self-employed 2.9%
HMO 1.9%
Freestanding urgent care center 1.9%
Other 18.2%
______________________________________________________________________________
Note. These are aggregated data from the 2007 Census of the AAPA as reported by the AAPA (2007) “Other
hospitals” include those acute care centers not otherwise categorized in the list. “Other” includes federal facilities
such as prisons and the military, medical staffing agencies ,nursing homes, home health agencies and practice
management, and unreported.
Physician assistants are beginning to specialize into diverse fields of medicine. Table 2
provides information that reviews the most recent reported specialty practice areas of PAs. While
family medicine remains the most common medical field of practice, surgical subspecialties and
almost all areas of medicine are represented by PAs.
24
Table 2. Summary of General Specialty Areas of PA Practice
______________________________________________________________________________
Area of Practice Percentage
______________________________________________________________________________
Family medicine 24.9%
Surgical subspecialties 22.2%
Other 12.8%
Internal medicine subspecialties 11.3%
Emergency medicine 10.3%
General internal medicine 6.9%
General surgery 2.7%
General pediatrics 2.4%
Obstetrics and gynecology 2.4%
Occupational medicine 2.4%
Pediatric subspecialties 1.6%
______________________________________________________________________________
Note. These are aggregated data from the 2007 Census of the AAPA as reported by the AAPA (2007). The “other”
category includes all areas that PAs may practice that are not included in this list.
PA annual income for a full-time practitioner is found in Table 3. This represents data
retrieved from the AAPA website and based on its annual census (2007). The living wage of PAs
is rising, offering an upper middle-class standard of living.
25
Table 3. Reported Annual Income (Full-time PAs only)
______________________________________________________________________________
Benchmark Amount
______________________________________________________________________________
Mean $86,214
10th percentile $64,374
25th percentile $71,908
Median $82,223
75th percentile $96,010
90th percentile $112,889
______________________________________________________________________________
Note. These are aggregated data from the 2007 Census of the AAPA as reported by the AAPA (2007).
Cost Effectiveness
The last decade of health claims analysis has found physician extenders to be a costeffective
strategy to reducing overall health care expenses. Though salaries started relatively low
15 years ago, PAs now enjoy salaries that approach those of newly trained physicians (Sultz &
Young, 2006). It seems this ongoing trend of salary growth will go unchecked unless there are
other, unforeseen economic pressures, or an unanticipated surplus of physicians. Realistically,
PAs supported by evidenced-based practice guidelines and computerized treatment protocols
may become the patient’s first point of entry into the health care system (Amara, 2000).
Health policy analysts have been interested in health care costs and methods to reduce
costs while providing effective care. Hooker (2000) completed a thorough review of literature
focusing on cost effectiveness in the use of PAs. The cost benefit model used by Hooker
suggests that PAs can perform at least 75% of a physician’s tasks at a cost of 44% of the
physician’s salary. He extrapolated the data finding a cost-benefit to using PAs, pointing out that
26
the cost of training a PA is one-fifth the cost of that to train an allopathic physician. Due to the
difference in length of training between PAs and physicians, the PA will provide five years of
patient care valued at $380,000 (1999 U.S. dollars) before the physician completes training.
Thus, factors to consider in the cost-effectiveness of PAs include the compensation-toproduction
ratio which establishes the PA as a cost-effective clinician.
The Hooker cost benefit model was used by this study to determine if PAs negate their
cost effectiveness through the costs of malpractice. In brief, the Hooker model, based on a
comprehensive view of the literature, asserts that PAs are at least 75% as productive as
physicians, are capable of managing at least 83% of all primary care encounters, and are salaried
at least 50% less than physicians (Hooker & Cawley, 2003).
Researchers Anderson and Hampton (1999) provided an alternate view to costeffectiveness
of PA in their work analyzing reimbursement for PAs and NPs. Though their
research supported other research efforts (e.g., Pan, et al., 1996) noting that there is a significant
rural-urban difference between payment sources and use of PAs and NPs, they had surprising
results when considering prepaid and HMO reimbursements. They found that prepaid or HMO
reimbursement had no affect on utilization as to whether a client saw a physician versus an NP or
PA. They observed this phenomenon in both rural and urban settings. After controlling for other
influences, this study did show that physicians, PAs, and NPs are each as likely as the other to be
present at a rural managed care visit. However, physicians are much more likely than PAs or NPs
to be present at an urban managed care visit (Anderson & Hampton, 1999).
PAs Cost Effective Impact on Rural America
Rural America has benefited from the advent of PAs. Researchers Bergeron, Neuman,
and Kinsey (1999) studied survey data from 285 small rural hospitals along with case studies
27
from 36 of those hospitals to determine the extent to which physician extenders benefited those
facilities. In the aggregate study, 70% of the surveyed hospitals used nurse practitioners, 30%
used PAs, and 20% used both. The hospitals in this study reported that the use of physician
extenders reduced recruitment costs, operating costs, and staffing needs of those hospitals. A
further benefit noted was that physicians cover only half of their own costs in the first year of
practice, while PAs generate enough revenue to cover their own costs in year one of
employment. Once hired, PAs reduced the average cost of operations by over 40% (Bergeron,
Neuman & Kinsey, 1999).
Supporting these findings, Staton, Bhosle, Camacho, Feldman, and Balkrishnan (2007)
completed a comprehensive study of the PA profession and its effect on rising health care costs
and inaccessibility of many patients to physician services. These researchers performed a
retrospective analysis of the National Ambulatory Medicare Care Survey Data (1997–2003) on
outpatient visits. The researchers found that patients who paid out-of-pocket had higher odds of
visiting PAs compared to patients with private insurance. Further, patients in rural areas were
more likely to visit PAs than were patients in urban areas. The researchers concluded that
“considerable use is made of PAs in all settings, and they tend to be utilized in otherwise
underserved, rural populations who do not have health insurance” (p. 34).
Patient Satisfaction
Patient satisfaction and acceptance of the PA profession has helped propel the profession
forward. The first patient satisfaction survey conducted soon after the first PA class graduated
found that upper middle class communities more readily accepted PAs (and NPs) than lower
middle class communities (Hooker & Cawley, 1997). Patient satisfaction surveys that date back
to 1972 noted an inverse proportion of satisfaction when compared to the complexity of the
28
needed service. That is, patients were less satisfied with care the greater the medical care need.
However, these are very old data and may hold little relevance to today.
Work by Hooker, Potts, and Ray (1997) examined patient satisfaction comparing PAs,
NPs, and physicians. Through a mailed questionnaire method, members of a large HMO were
surveyed regarding their satisfaction with care provided in 1995 and 1996. The findings suggest
that patient satisfaction is dependent more on communication and style than type of provider.
Thus, the authors suggest that policy decisions should move toward incorporating PAs and NPs
into more medical practices as patient acceptance is gained (Hooker, Potts, & Ray, 1997). A
study published in 2000 investigated patient satisfaction with PAs and wait times in an
emergency department of a hospital. The findings reported that patients were very satisfied with
care rendered by PAs, and few patients were willing to wait longer to see physicians versus PAs
(Counselman, Graffeo, & Hill, 2000).
Managed care organizations (MCOs) have been working on methods to redesign primary
care delivery systems while improving patient satisfaction. One of the cost-containment
strategies targeted by MCOs is the use of associate practitioners, PAs and NPs, in care delivery
systems. A study by Roblin, Becker, Adams, Howard, and Blumberg (2001) studied this MCO
strategy. Their findings indicated that indeed PAs and NPs were a viable option for MCOs to
employ, and that patients were very satisfied with this service delivery mode.
Risk Management and the PA
Risk management is a broad term that explores risk, risk assessments, and developing
strategies to reduce potential problems or negative results (U.S. EPA, 2004). For the PA
profession, risk management is related to analyzing the risk of practice and developing methods
to eliminate or significantly reduce the chance of liability or lawsuits. The PA profession has
29
been taking steps toward risk management as a profession. Licensure for PAs in all 50 states
assured that licensed and certified PAs had at least a basic PA education and had passed rigorous
licensure exams (Hooker & Cawley, 1997). Physicians had been licensed since the late
nineteenth and early twentieth century. Thus, the PA profession recognized the value of licensure
and followed other health care professions that were also in the midst of state licensure efforts.
Licensure and state practice acts protect the public against quackery, commercial
exploitation, deception and professional incompetence. Licensure boards have created methods
for consumers, peers, providers, and the health insurance industry to report PAs who may be in
violation of practice acts or been detrimental to the public good. Such reporting mechanisms
complete with discipline procedures allow for the profession to perform internal risk
management.
Unlike physician licenses, PA licensure is more complex (Hooker et al., 1997). Current
contemporary issues for PAs concern the distribution of job tasks and duties. Physicians have
unlimited licenses to perform all functions; the critical questions are what functions they may
delegate to physician assistants, and under what conditions such delegations may occur.
Functions within the scope of PA practice may be either “independent” or “dependent” of a
supervising physician’s orders, direction, or supervision (Kohlhepp, Rohrs, & Robinson, 2005).
Autonomous yet dependent is a phrase often used to describe the PA scope of practice
relationship with the supervising physician. The complexity of this relationship continues to be
examined for both the PAs and their physician counterparts. Ongoing efforts to further define
distribution of tasks, while ensuring that state practice acts stay current, is an area that requires
ongoing risk management analysis by PAs.
30
Communication
Communication is the key element to all risk management efforts. Multiple studies
demonstrate that effective communication with patients is the best way to avoid malpractice
claims (Lester, 1993; Kaplan, Greenfield, Gandek, et al., 1996; Frankel, 1995). Communication
was one of the earliest values given for the hiring of PAs. It was speculated that a PA could
reduce the risk of malpractice judgments for supervising physicians since the mere presence of
PA allowed the physician more time to concentrate on more complicated cases (Charles,
Gibbons, Risch, et al., 1992). Further, the thought was that PAs might prevent patients from
feeling rushed or deserted during a physician visit.
The AAPA Guidelines for Ethical Conduct state that PAs should disclose errors to
patients if such information is significant to the patient’s interest and well-being. Through
serious consideration, the AAPA Government Affairs and Reimbursement Committee (GARC)
presented a policy paper regarding acknowledging and apologizing for Adverse Outcomes (Gara,
2007). The committee put forward a policy that was adopted by the AAPA in 2007. The policy
encourages PAs to apologize for errors. The policy also supports laws that limit the admissibility
of such apologies in lawsuits (Gara, 2007).
This AAPA work mirrors the current national movement called Sorry Works (Braxton,
Poe, & Stimmel, 2007). A majority of states have adopted or are considering apology laws that
exempt apologies, expressions of regret, sympathy, or compassion from being considered as
admission of liability for medical malpractice lawsuits. The intent of the legislation is to
encourage physicians and other health care providers to sincerely apologize to patients. The idea
behind Sorry Works is that open, honest discussions are the best policy. These types of
conversations appear to reduce medical malpractice lawsuits (Braxton, Poe, & Stimmel, 2007).
31
Report Cards
Physician report cards are fast becoming a method for savvy consumers to assess how
well their own provider performs on evidenced-based measures (NCQA, 2007). The initiation of
such report cards met with large resistance in the 1970s when the Code of Ethics of the
American Medical Association (AMA) determined that “information that would point out
difference between doctors” would be strictly prohibited (Sultz & Young, 2006, p. 15). However
contentious, report cards and reporting on physician practices have become commonplace. For
example, Health Employer Data Information Sets (HEDIS) criteria are collected every year at
every primary care clinic across the U.S. (NCQA, 2007). State health departments are further
using these data to determine health care priorities and to investigate providers who are outside
the collected norms of the data. Several states have begun initiatives that further take the HEDIS
aggregate data dividing it into clinics and in some cases, providers. It will not be long before
individual PA data become readily available for consumers, providers, and other professionals to
view. It is this researcher’s belief that report cards will assist with appropriate assessment of PA
risk and promote the true value of PAs.
Medical Misconduct and Malpractice
In 1999, the Institute of Medicine released To Err is Human, which estimated that
medical errors in hospitals alone cause as many as 98,000 patient deaths and more than one
million patient injuries, at a cost of up to $29 billion each year (Kohn, Corrigan, & Donaldson,
2000). The last section of this review investigates medical misconduct and malpractice in the PA
profession. Medical liability insurance costs remain on a steep upward trend (Kessler, Sage, &
Becker, 2005). Rising costs are a concern for all health care professionals, particularly physicians
who bear the brunt of these costs (Moses & Feld, 2007). These increased costs are a direct result
32
of ever-increasing malpractice jury awards and a public perception that someone needs to pay
when an unfortunate medical outcome occurs (Sultz & Young, 2007). PAs are not immune from
these trends. As physicians explore ways to reduce their own risk exposure, there is push-back
for PAs to become individually responsible and liable for the care they provide without harming
an overseeing physician or increasing his insurance liabilities.
Brock (1998) wrote a seminal article on the malpractice experience of PAs. He examined
five years of data from the National Practitioner Data Bank (NPDB) that revealed that PAs had a
very low rate of malpractice judgments. He asserted that this factor would actually lead providers
to hire PAs as a way to reduce the risk of malpractice liability. Brock used data published in
1996 to determine that there were significant differences in malpractice experiences of PAs and
physicians. Brock (1998) found that one claim was paid for every 46.6 physicians, but only one
paid for every 808.1 PAs.
Cawley, Rohors, and Hooker (1998) also published an examination of the NPDB data in
1998. Their findings were similar to those of Brock. They examined NPDB data from
September, 1990, through December 1, 1997, and found that PAs had a mean malpractice
payment of $55,241 while that of physicians (MDs/DOs) was $139,581. By controlling for the
number of PAs and physicians in practice, they found that physicians had a malpractice payment
ratio of 2.4% while PAs had a ratio of only 0.76% (Cawley et al., 1998). One interpretation of
these data are that on average, PAs had one-third the liability cost of physicians for malpractice
payments. Another interpretation is that they carried one-third the risk of such payments over
that time period.
The Brock and Cawley findings are now a decade old and require revisiting. At the time,
only six years of data were available. Thus, this researcher integrated the findings of Brock and
33
Cawley as a foundation to studying the current experiences of malpractice claims. The number or
PAs in practice has expanded significantly since 1998, and three times the data are now available
in the NPDB for analysis than was available in 1998. Additionally, the earlier data which they
relied upon may have underreported the true malpractice of PAs due to confusion regarding
reporting requirements.
Historically, physicians were liable for the practice of the PAs that the physician
supervised. This may have led to an underreporting of actual cases where the PA was involved in
a medical error. The data that Brock and Cawley used were the first six years of NPDB existence
during which time the underreporting concern may have impacted these data. More recently,
there has been legislative movement to limit the liability of the supervising physician, shifting
the liability to the treating PA (Gore, 2000). As professionals, PAs welcomed this movement as
it ensured more accurate data that reflects PA practice alone that is not entwined with
confounding variables such as supervising physicians or health care facility reporting problems.
Inclusion of all available years of NPDB will therefore reflect a more accurate perspective of PA
malpractice than the data used by the researchers in 1998.
Research provided information about three legal theories that are used to impute
physician liability from a PA: (a) respondeat superior; (b) negligent supervision; and (c)
negligent hiring (Hooker, 2000). To assess a physician’s liability for PA mistakes, it is important
to understand each of these legal theories and the basis for the actions that distinguish these
theory applications from the typical claims.
The first legal theory is respondeat superior, a term referring to “let the master answer.”
This is a legal doctrine that states the principle or employer is liable for harms done by agents or
employees while acting within the scope of their employment. This doctrine has been used to
34
determine medical malpractice by holding a supervising physician liable for malpractice or
negligence of a PA that the physician supervises (Regan & Regan, 2002). Through this doctrine,
to hold a physician or other provider individually liable for malpractice, one must demonstrate
“(a) the standard of care, (b) that the provider deviated from that standard, and (c) that as a
proximate result of the provider’s negligent act or omission, the patient suffered injuries which
would not have occurred otherwise” (Regan & Regan, 2002, p. 546).
The case of MacDonald v United States demonstrates the successful use of the
respondeat superior theory. In this case, the patient was under treatment for a hiatal hernia with
reflux. The patient presented to the PA with severe upper abdominal pain for which the PA
prescribed laxatives for constipation and then attempted to discharge the patient. However, the
patient felt the pain was too severe and refused to leave; a subsequent electrocardiogram revealed
an evolving myocardial infarction. The patient suffered extensive heart damage. The physician
was found liable as the court stated that, “In this case the oversight required by the standard of
care was missing” (p. 548). Another case attests to the respondeat superior theory along with
standard of care issues. The 1994 case Oliver v Sadler resulted from an instance where a patient
had an anaphylactic reaction leading to multi-organ system failure. The patient claimed that she
was unaware that she had been treated by a PA and believed that the treating practitioner was a
physician. The jury found for the plaintiff.
Negligent supervision is the second legal theory that has been used to impute physician
liability for the actions of a PA. The legal relationship between physicians and PAs has become
well-established by tradition, case law, statutes, and regulations. Due to this dependent
relationship, in many cases the liability for PA negligence is imputed to the physician even if the
physician did not employ the PA. State laws vary with regards to negligent supervision. For
35
example, in Ohio, the law states, “A physician assistant’s supervising physician assumes legal
liability for the services provided by the PA.” In Vermont, the supervising physician delegating
activities to the PA shall be legally liable for such activities of the PA, and the PA shall in this
relationship be the physician’s agent” (Younger, 1997, p. 380). Since the work of Younger, the
practice of PAs has changed such that many state laws no longer directly require the direct
supervisor/supervisee relationship between PAs and physicians. With federal legislative
movements including BBA97, PAs may practice without a referring physician and may even
open private practices. This theory is now used less often than previously for medical
malpractice that includes a PA with a supervising physician. Negligent supervision was the basis
of Andrews v United States. In this case the court found the physician provided inadequate
supervision in negligently failing to investigate a report of sexual impropriety with a patient
treated by a physician assistant in which the physician had supervisory responsibility (Moses &
Feld, 2007).
Negligent hiring is the third legal theory used to assert liability against a physician who
employs a PA. Within this theory, an employer physician may be held liable for malpractice
claims brought against a PA where the issues include inappropriate hiring, training, supervision,
or monitoring; or for the physician failing to establish required or appropriate policies to ensure
that their employees understand their responsibilities and job requirements (Hollowell, De Ville,
& Warner, 2006).
The issue of negligent hiring is highlighted in the case Khan v Medical Bureau of
California. This case dealt with the hiring of a PA by a physician. The physician hired an
individual as a licensed and nationally certified PA on the basis of the individual’s attestation of
licensure. The individual was not licensed. In this case the physician had his own license revoked
36
for aiding and abetting the unauthorized practice of medicine. The courts found “if… a
practicing physician…can claim that he could not tell from the paperwork whether an individual
was licensed, than what hope is there for the average person seeking medical care?” It is the
responsibility of the employer to contact the licensing agency and ensure that a license does exist
for any purported licensed individual upon hire (Moses & Feld, 2007, p. 7).
Negligent hiring along respondeat superior may be determined to be a type of vicarious
liability. Vicarious liability is a type of indirect legal responsibility for an injury. It refers to the
liability of a physician for the negligence of another based solely on the nature of the relationship
between the two parties. Where physicians are employers of a PA, the employing physician may
be held liable for negligence of PAs within their scope of employment (Kachalia & Studdert,
2004).
The most common form of a malpractice suit against any type of health care provider is
the tort of negligence (West Group Publishing, 1999). A tort is defined as a civil wrong for
which a remedy may be obtained, usually in the form of monetary damages (Druss, Marcus, &
Olfson, 2003). For a plaintiff to be successful in a medical malpractice lawsuit, the plaintiff’s
attorney must prove four things. First, that the provider has an obligation or duty of care for the
patient. Second, this duty was violated or breached by practice that was below the accepted
standard of care. Third, that this substandard practice caused the harm. And fourth, that the
plaintiff suffers compensable damages (Moses & Feld, 2007).
The basis of malpractice claims brought against non-physician providers, such as PAs,
most often includes one or more of the following five allegations. The five allegations are: (a)
lack of adequate supervision by a physician; (b) untimely referral to a consultant; (c) failure to
diagnose properly; (d) inadequate examination; and (e) negligent misrepresentation (Moses &
37
Feld, 2007). Each of these allegations has been used in malpractice cases against PAs or NPs.
AAPA provided a series of articles termed “Issues in Quality Care” in the Journal of the
American Academy of Physician Assistants. Davidson (1996) addressed each high risk allegation
area through case scenario examples. The outcome of the series was to direct PAs to take proper
precautions to reduce risk of liability and subsequent lawsuits. Risk reducing activities include:
(a) ensuring that one has adequate physician supervision; (b) making timely referrals; (c)
knowing the limits of one’s own diagnostic skills and remaining within the permissible scope of
PA practice; and (d) conducting an examination that is appropriate for the patient complaint
(Davidson, 1996).
PA state practice acts are moving toward more autonomy for PAs. This means that PAs
are beginning to practice with less supervision than was required even five years ago. Further,
physicians may not always be held liable for the negligent acts of PAs. With practice act
revisions nationwide, PAs are now encouraged to purchase their own malpractice insurance and
be responsible for their own negligent acts (Pozgar, 2007). However, case law is still scant in the
move to sue PAs without including a supervising physician in the lawsuit.
National Practitioner Data Bank
The National Practitioner Data Bank (NPDB) was established under Title IV of Public
Law 99-660, the Health Care Quality Improvement Act of 1986. It has acted as a clearinghouse
of information relating to medical malpractice payments, certain adverse actions taken against
practitioners’ licenses, clinical privileges, professional society memberships, and eligibility to
practice in Medicare/Medicaid. These databank is germane to this current research and was the
source data used in the methodology portion of this research. The most recent annual report of
the NPDB was placed in the public domain in 2006, containing data through 2005 (NPDB,
38
2006). However, the public use data file, which was used for this research, is updated
continuously throughout the year.
The NPDB receives reports of malpractice payments and adverse actions concerning
health care practitioners in the U.S. The NPDB is the depository for medical practitioner
misconduct whose reporting is required by federal law from the following sources: medical
malpractice payers; medical/dental state licensing boards, hospitals and other health care entities,
professional societies with formal peer review, the Department of Health and Human Services
Office of Inspector General, the U.S. Drug Enforcement Agency (DEA); federal and state
government agencies, and health insurance plans.
In 2005, the majority of reported actions were for medical malpractice payments for
physicians, dentists, and other licensed practitioners. The report also included adverse actions
taken against a provider’s ability to practice. Such adverse actions included: licensure actions,
clinical privileges actions affecting a practitioner’s privileges for more than thirty days,
Medicare/Medicaid exclusion actions, professional society membership disciplinary actions, and
actions taken by the DEA concerning authorization to prescribe controlled substances. The work
of Brock (1998) and Cawley, et al. (1998) was based on data culled from the NPDB. This current
research included datasets and findings that were more comprehensive than earlier work based
on 1991-1996 data.
In 2005, physicians had more reports per practitioner than any other practitioner group.
However, the report cautions that NPDB reporting of state licensure, clinical privileges, and
professional society membership actions are only required for physicians and dentists. Thus, not
all PA state licensure actions may be part of the current database sets. Physicians were
responsible for eight out of ten malpractice payment reports in 2005. However, the number of
39
physician malpractice payments reported decreased by 2.5 percent from 2004 to 2005. During
2005, physicians were responsible for 14,034 malpractice payment reports equating to 81.1
percent of all malpractice payment reports received during the year. In contrast, only about two
out of 100 malpractice payment reports were for all types of nurses while less than one percent
was for PAs.
Health insurance plans, HMOs, and providers all use the NPDB in hiring processes for
medical practitioners that are covered by reporting criteria for the NPDB. These entities are
required by the Centers for Medicare and Medicaid (CMS) to investigate licensed practitioners to
ensure that sanctioned and non-licensed individuals are not treating patients (NPDB, 2006).
Education in Clinical Practice Safety
As a science with new treatments and discoveries occurring on a daily basis, education in
medicine is a life long process. The education of physician assistants may be divided into preservice
and in-service aspects. As noted earlier, the education of physician assistants most often
begins after the completion of an undergraduate degree and plan of study that includes courses in
the basic sciences and health sciences. Once accepted into the average two-year graduate
professional program, further courses are taken in the clinical sciences which parallel those of
medical students (Simon & Link, 2001). The curriculum of PA programs is dictated by the
Atlanta-based Accreditation Review Commission on the Education of Physician Assistants, Inc.
(ARC-PA). All PA professional programs must adhere to the standards outlined by this
organization to attain and maintain accreditation. Graduation from an accredited PA program is
required by all 50 states for graduates to receive professional licensure. Standard B6 outlines
curricular requirements for the provision of education in health policy and professional practice
issues including quality assurance, risk management, legal issues of health care, political and
40
legal issues that affect PA practice, and professional liability. Table 4 provides an outline of the
accreditation standards relevant to health policy and professional practice. Specific requirements
relevant to medico-legal education and patient safety are bolded.
41
Table 4. ARC-PA Standards for Health Policy and Professional Practice
______________________________________________________________________________
Standard Standard
Designation
______________________________________________________________________________
B6.01 The program must provide instruction in:
a) the impact of socioeconomic issues affecting health care.
b) health care delivery systems and health policy.
c) reimbursement, including documentation, coding, and billing.
d) quality assurance and risk management in medical practice.
e) legal issues of health care.
f) cultural issues and their impact on health care policy.
B6.02 The program must provide instruction in medical ethics to include:
a) the attributes of respect for self and others.
b) professional responsibility.
c) the concepts of privilege, confidentiality, and informed patient consent.
d) a commitment to the patient’s welfare.
B6.03 The program must provide instruction on:
a) the history of the PA profession.
b) current trends of the PA profession.
c) the physician-PA team relationship.
d) political and legal issues that affect PA practice.
e) PA professional organizations.
f) PA program accreditation.
g) PA certification and recertification.
h) licensure.
i) credentialing.
j) professional liability.
k) laws and regulations regarding prescriptive practice.
______________________________________________________________________________
Note. This table is taken from the ARC-PA Standards, page 14, Third Edition with clarification, 10.07.
On the in-service side, continuing education for physician assistants may take many
forms. To remain certified, every PA practitioner must complete 100 hours of continuing
medical education (CME) every two years and pass a recertification examination every six years
(AAPA, 2007). Certification and recertification is provided by the National Commission on
Certification of Physician Assistants (NCCPA). During every two-year period, PA-C designees
must earn and log a minimum of 100 hours of CME and submit a certification maintenance fee
42
to NCCPA by June 30 of their certification expiration year (NCCPA, 2008). The 100 hours of
CME may include clinical and professional topics. One of the most common means for clinically
practicing PAs is to attain CME credits at state and national professional conferences where the
CME has been pre-approved for credit by the American Academy of Physician Assistants
(AAPA), American Academy of Family Physicians, American Medical Association or other
approved body. According to Shelly Hicks, the CME planner for the AAPA professional
conferences, seminars on practice risk management, PA malpractice experience and other legal
aspects of PA practice are annually offered by the AAPA and are well attended (Hicks, S.,
personal communication, April 16, 2008). A review of the 2008 CME offerings lists nine
seminars with a medical-legal topic. A sample of the titles of the 2008 seminars include: a)
“Medical Malpractice/Risk Management for the Allied Healthcare Professional;” b) “The
Anatomy of a Medical Malpractice Case;” c) “Saying ‘I’m Sorry’ for the Physician Assistant;”
d) Public Reporting of Medical Statistics and Outcomes in Hospitals: Gaming the System;” and
e) Asset Protection for the Physician Assistant: Could I Lose It All?” (AAPA, 2008).
A second area of CME opportunities on legal issues for physician assistants includes
periodicals of the American Academy of Physician Assistants and the Physician Assistant
Education Association. While a recent search for articles going back 10 years in the PAEA
Journal retrieved no results for legal or malpractice searches, a similar search in the Journal of
the American Academy of Physician Assistants revealed only three articles since 2000, one on
apologizing for medical errors, one on avoiding malpractice for breast cancer diagnosis through
documentation and one on reducing medical errors in primary care. The AAPA also publishes a
monthly professional newsletter, AAPA News that contains a monthly article on PA malpractice
issues and malpractice insurance. It is written by a representative of the malpractice insurance
43
industry who is a member of the AAPA services staff. The AAPA contracts with a private
insurer to provide AAPA members with optional individual malpractice insurance. As previously
described, most PAs are covered by their supervising physician’s malpractice policy, but the
AAPA still encourages its members to purchase additional individual policies. A future study of
interest would include a survey to determine how many PAs carry their own malpractice policies
in addition to the coverage from the supervising physicians’ policies and to determine if those
duplicate policy holders are sued more or less frequently than their peers without duplicate
coverage.
Summary
Chapter II, the comprehensive review of current literature, began by tracing the historical
growth of the PA profession. From this historical underpinning, this researcher investigated the
literature related to the impact of the PA profession on the health care work force. The impact on
health care access has been significant, especially in rural and medically underserved areas
where the profession was first developed. Cost-effectiveness and patient satisfaction with the PA
profession has also been well documented. The third section of this chapter analyzed risk
management as it relates to PAs while the last section synthesized available information
regarding medical misconduct and malpractice. The researcher included several cases to
highlight the types of malpractice cases that have been successfully prosecuted against PAs. The
courts are challenged in determining the extent of liability and culpability of PAs as practitioners
independent of their supervising physicians, though the trend is to hold PAs separately
accountable.
The extent of accountability of medical practice between the PA and the supervising
physician may be treated differently in different courts. This literature review laid the foundation
44
for the investigation into the safety of PAs. Through the literature review of Chapter II, the
researcher highlighted the concern of patient safety in the integration of PAs into health care
practices. This researcher attempted to show that the PA profession is relatively new with little
research into the safety of PAs as determined by malpractice cases or NPDB reports.
Additionally, it was demonstrated that PA practice safety and malpractice education is required
in PA training programs, that some literature on malpractice issues is available to in-service
practitioners, and that very few articles with a medico-legal topic are published in PA
professional journals. Next, Chapter III, presents the methodology section of the study and lays
the conceptual framework and methods to be employed in data collection and analysis.
45
CHAPTER III
CONCEPTUAL FRAMEWORK AND METHOD
Conceptual Framework
The conceptual framework of the study was based on Donabedian's classic
structure/process/outcome (SPO) model as a tool for assessing health care quality (Donabedian,
1966; Burns, 1995). Donabedian defined structural measures of quality as the professional and
organizational resources associated with the provision of care, such as staff credentials and
facility operating capacities. Process measures of quality refer to the tasks done to and for the
patient by practitioners in the course of treatment (Gustafson & Hundt, 1995). Outcome
measures are the desired states resulting from care processes, which may include reduction in
morbidity and mortality, and improvement in the quality of life (Kane & Kane, 1988).
Practitioner safety is a factor in the process of the SPO model while patient safety is the desired
outcome. This is exemplified by an adaptation of the Donabedian SPO health quality assessment
model proposed for the Australian government’s national health care system (Sibthorpe, 2004)
(see Figure 1).
Donabedian (1988) noted a distinction between two types of outcomes. Technical
outcomes encompass the physical and functional aspects of care. Examples of technical
outcomes include the absence of post-surgical complications and the successful management of
hypertension and other chronic conditions. Interpersonal outcomes encompass dimensions of the
"art" of medicine. These include patient satisfaction with care and the influence of care on the
patient's quality of life as perceived by the patient. Within Donabedian's framework, these two
types of outcomes are interdependent, so that one cannot be considered in isolation from the
other in evaluating the quality of care.
46
Figure 1.1 Framework for Performance Assessment in Primary Health Care
GOVERNMENT PRIMARY HEALTH CARE SERVICES AND PROGRAMS
I.
STEWARDSHIP
II.
ORGANIZATIONAL
STRUCTURES
III.
PROCESSES
OF CARE
IV.
OUTCOMES
Australian
National
Health
Performance
Framework
Policy development
- clear
objectives
Financing and
Funding
- +/-
incentives
Implementation
- contracting
- reporting
requirements
Workforce
development
IT infrastructure
support
R &D
Physical facilities and
equipment
Staffing, including
deployment
Staff training and
development
Human resources
management
Service organization and
management, including
protocols
Financial management
Information systems
Needs assessment
Performance assessment
Sick care
(including
curative,
rehabilitative,
palliative)
Health
promotion
Disease
Prevention
Advocacy
Community
development
Levels of health
risk behaviors in
client
populations
Levels of
clinical status
measures in
client
populations
Levels of
satisfaction
with care in
client
populations
TIER I
Health Status
and Outcome
TIER II
Determinants of
Health
TIER III
Health System
Performance:
Effective
Appropriate
Efficient
Responsive
Accessible
Safe
Continuous
Capable
Sustainable
Further, Donabedian (1966) asserted that the three categories of quality measures,
structure, process and outcome, are not independent but are linked in an underlying framework.
Good structure should promote good process and good process in turn should promote good
1 Adapted from Beverly Sibthorpe, Australian Primary Health Care Research Institute, 2004
47
outcome (Donabedian, 1988). This provided a theoretical rationale for linking outcome with
structure.
The variables of this study on practitioner safety were linked to structure, process and
outcome elements of Donabedian’s model. The elements of the Donabedian model that were
linked to study variables are bolded in Figure 1. The independent variables, the medical
practitioners, comprise a key staffing and deployment component of the organizational structure.
Their performance is influenced and affected by the organizational structure through the amount
of staffing provided, staff training and development, human resource management, adherence to
service protocols and practitioner performance assessment. The practitioner variables are also
key components of the process of care as they comprise the corps of care provision. The study
dependent variables, markers of practitioner safety, were linked to the organizational structure as
they are affected by staff training and development, human resource management, practitioner
adherence to protocols and practitioner performance assessment. The outcomes of patient
satisfaction and the safety of care provision were linked to both independent and dependent
variables. Patient satisfaction is influenced not only by the type of provider but by the provider’s
characteristics as portrayed by each dependent variable. In the study’s linkage to the Donebedian
model, safety of care itself was measured by the dependent variables as markers of safety. Figure
2 provides a model specification chart demonstrating the relationship between elements of the
Donabedian model and the study variables.
48
Figure 2. Model Specification Chart
Donabedian
Framework Category
Donabedian Framework
Factors
Proxy Variables
Organizational
Structure
Staffing, including deployment Physicians, PAs, APNs; Average
years of practice; Practitioner gender
Organizational
Structure
Human resources management Physicians, PAs, APNs
Organizational
Structure
Service organization and
management, including
protocols
Physicians, PAs, APNs; Average
years of practice; Practitioner gender
Organizational
Structure
Performance Assessment Malpractice incidence, malpractice
payments, clinical privileges actions,
professional society actions, Federal
program exclusions, DEA actions
Processes of care Sick Care Physicians, PAs, APNs
Outcomes Levels of satisfaction with care
in client population
Malpractice incidence (patient driven);
Malpractice amounts
Outcomes Overall Safety of Care
Provision
Malpractice incidence, malpractice
payments, clinical privileges actions,
professional society actions, Federal
program exclusions, DEA actions
Health care consumers play a significant role in the reporting and documentation of
practitioner safety as poor outcomes and patient harm are often brought to the attention of
authorities by consumers themselves. Donabedian further studied the role of the consumer in
quality assurance in the 1990s (Donabedian, 1992). Donabedian contended that consumers have
three main roles in the assurance of quality in health care: (a) consumers can be contributors to
quality by ?helping to define it, evaluating it, and providing information which will allow others
to evaluate it; (b) consumers can be targets for quality assurance ?by conceiving of practitioners
and patients as jointly engaged in the production of care,? when they are used as a means to
49
regulate practitioner’s behavior; and (c) consumers can be reformers of health care by direct
participation at the patient care level by provision of support by the administration which
empowers consumers to have an effect on the systems of care, ?by influencing the “markets” of
health care provision and by political action. Quality assurance is defined as “an activity aimed
to elicit information about clinical performance, and based on that information, to readjust the
circumstances and processes of health care” (p. 246). Donabedian concluded that when
consumers are allowed to help practitioners, they can make a considerable contribution to
enhancing the quality of care.
Donabedian’s framework of consumer participation in the assessment of health care
quality was essential to this study. The data used to drive the study have their bases in consumer
actions. That is, concerns about the quality of one’s medical care or that of a loved one are often
initiated by the health care consumer. Consumers have a variety of mechanisms for making
concerns known. The first mechanism is to approach the entities whose purpose includes the
monitoring of health care quality and consumer protection. These entities include hospitals,
better business bureaus, state medical licensing boards, insurance agencies, professional
associations and federal and state government regulatory agencies. A second option available to
consumers is to take civil action through the courts. A third is to voice concerns of safety through
the news media.
Since 2000 six states have enacted legislation supporting the creation of a state patient
safety center. These entities include: the Florida Patient Safety Corporation; the Maryland
Patient Safety Center; the Betsy Lehman Center for Patient Safety and Medical Error Reduction
(Massachusetts); the New York Center for Patient Safety; the Oregon Patient Safety
Commission; and the Pennsylvania Patient Safety Authority (Rosenthal & Booth, 2004).
50
All six centers are designed to house and coordinate statewide patient safety activities.
Specifically, patient safety centers are charged with promoting patient safety through a variety of
activities, which vary by state but may include:
• Educating health care providers and patients regarding processes that may reduce future
occurrences of adverse events;
• Developing systems of near miss and/or adverse event data reporting, collection,
analysis, and dissemination to improve the quality of health care;
• Fostering the creation of safety cultures to identify and determine the causes of adverse
events and near misses;
• Informing consumers about patient safety issues;
• Serving as a clearinghouse for the development, evaluation, and dissemination of best
practices;
• Promoting ongoing collaboration between the public and private sectors and
• Coordinating state agency initiatives (Rosenthal & Booth, 2004).
This study utilized data reported by the entities whose role is consumer protection,
entities that encourage consumer participation. The study’s data came directly from state medical
licensing boards, hospitals, professional societies with formal peer review, the office of the
Inspector General of the U.S. Department of Health and Human Services, malpractice payers,
and the U.S. Drug Enforcement Agency (see Figure 3).
With Donabedian’s SPO model as the theoretical and conceptual basis of the study, the
study itself set out to update, build upon and expand the limited work of researchers in the 1990s
who examined malpractice of physician assistants. Brock (1998) and Cawley et al. (1998)
independently examined the malpractice experience of PAs using data from the National
51
Practitioner Data Bank (NPDB). At the time, the data revealed that PAs had a very low rate of
malpractice judgments. Brock asserted that this factor would actually lead providers to hire PAs
as a way to reduce the risk of malpractice liability. Brock used data published in 1996 to
determine that there were significant differences in malpractice experiences of PAs and
physicians. Brock (1998) found that for one claim paid for every 46.6 physicians there was one
for every 808.1 PAs. The findings of Cawley’s group were similar and have been outlined in
Chapter II (Cawley et al., 1998). This study set out to develop a better and current understanding
of the earlier research and conclusions drawn.
There are several shortcomings to the earlier 1998 work which necessitated the further
investigation of this research. The researchers utilized only a subset of the data available - they
examined only medical malpractice payments. Additionally, the dataset used in 1998 was limited
to the first six years of the existence of the NPDB. During the first years of the NPDB,
underreporting of PA malpractice and misconduct was likely due to agency reporting of PA
misconduct under the name of the supervising physician. The current research examined not only
medical malpractice payments, but a variety of other adverse actions taken against PAs, APNs,
and physicians. Those actions are contained in the NPDB records database as outlined in Figure
3 and constituted the variables that were studied.
The methodology of the study was an analysis of the independent variables between the
three provider types for comparisons, relationships and statistical significance. The methodology
examined 324,285 total entries of medical malpractice payments and adverse actions taken
against providers in a 17 year study period. As outlined above, these variables were linked to
Donabedian’s framework of health care quality assessment though the framework’s inclusion of
patient and provider safety outcomes.
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Research Questions
The intent of this study was to determine whether the practice of medicine by physician
assistants is as safe as the practice of medicine by physicians? Specifically, research questions
for this study included: (a) Do PAs negate their cost effectiveness through the costs of
malpractice?; (b) Is the rate of malpractice for physician assistants at the same trajectory as that
of physicians and advanced practice nurses?; (c) Is the ratio of malpractice claims per provider
the same for physician assistants, advanced practice nurses and physicians?; and (d) Are the
reasons for disciplinary action against PAs and APNs the same as those for physicians?
Hypothesis
Based on the limited prior research, it would not be unreasonable to assume that
physician assistant medical practice is at least as safe as the medical practice of physicians.
However, enough time has passed for a meaningful exploration, reliable national data are now
available, and the PA profession has grown considerably in size and scope. Therefore, this study
assumed the null hypothesis. That is, there is no statistically significant difference between the
safety of physician assistant medical practice, advanced practice nurse medical practice, and
physician medical practice as determined by malpractice medical payments and actions taken
against a practitioner’s ability to practice. The null hypothesis was also applied to each
dependent variable and for the research sub-questions. That is, it was hypothesized that PAs do
not negate their cost effectiveness through malpractice payments, the rate of malpractice
payments is the same and the ratio of malpractice claims per provider is the same for PAs,
physicians and APNs. Finally, it was hypothesized that the reasons for disciplinary action are the
same for these three provider groups.
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Data Source
Data utilized in the study are a subset of data available in the National Practitioner Data
Bank (NPDB). The NPDB is a repository of national data on the incidence and amount of
malpractice payments by health care providers and actions taken by regulatory bodies against
health care providers’ ability to practice in the interest of patient and public safety. The NPDB
was created by the 1986 congressional Health Care Quality Improvement Act, also known as
Title IV of Public Law 99-660. According to the NPDB Guidebook, the intent of Title IV of
Public Law 99-660 was to improve the quality of health care by encouraging state licensing
boards, hospitals and other health care entities, and professional societies to identify and
discipline those who engage in unprofessional behavior; and to restrict the ability of incompetent
physicians, dentists, and other health care practitioners to move from state to state without
disclosure or discovery of previous medical malpractice payment and adverse action history.
Adverse actions can involve licensure, clinical privileges, and professional society memberships
(NPDB Guidebook, 2007). The Health Quality Improvement Act of 1986 requires hospitals,
other health care entities, professional societies, medical malpractice payers and the Office of the
Inspector General to report malpractice payments, adverse licensure actions, professional review
actions, clinical privilege actions, exclusions for Medicare and Medicaid programs and Drug
Enforcement Agency Actions to the NPDB within 30 days of the activity. All of the above
reporting is required for physicians and dentists. All of the above are required reporting for PAs
and APNs except licensure actions, clinical privilege actions and professional society actions.
The law also requires hospitals to query the NPDB prior to the granting of hospital privileges for
any credentialed health care provider and every two years thereafter.
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This research study was a secondary analysis of the publicly available data file of the
NPDB. Reporting of the malpractice and adverse actions by states and U.S. territories to the
NPDB is required by federal law, although some data in the databank are voluntarily reported.
The NPDB 2007 data contain information on disclosed reports of malpractice payments and
adverse actions of health care practitioners from September 1, 1990 through December 31, 2007.
The full NPDB data consist of 414,404 cases and dozens of variables, including information
about the characteristics of a variety of healthcare providers with medical malpractice payments
and practice-limiting actions, not just physicians, PAs and APNs. The categories of actions
which define medical misadventure reported by the NPDB include those outlined in Table 5. The
NPDB maintains a website, and the public data are available for downloading and analysis
(http://www.npdb-hipdb.hrsa.gov).
Sample
A 17 year selection of all data collected by the National Practitioner Databank was used,
from January 1, 1991 through December 31, 2007, to examine a variety of factors and trends in
medical misconduct between three groups of practitioners (NPDB, 2008). The first and current
years of data were not used because data is incomplete. The number of total data entries for
physicians, physician assistants and advanced practice nurses during the period of examination
was 324,285.
Demographic Data
Demographic data on the number of active practitioners in each of the three provider
groups came from the considered most reliable sources. The number of physicians came from the
American Medical Association master file as reported in the AMA annual publication Physician
Characteristics and Distribution in the US. Physician assistant demographic data came from the
American Academy of Physician Assistants, a national association that conducts annual surveys
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of its members. Procuring reliable data on APNs was more difficult. There is no central or
national professional association that represents advanced practice nurses. APN is a term that
encompasses at least four different advanced practice nursing professional designations including
nurse midwife, nurse anesthetist, clinical nurse specialist, and nurse practitioner. There are
multiple certifying bodies for these designations and competing national professional
associations, none of which survey all designations. To compound the difficulty in obtaining
accurate demographic data, nurses in advanced practice often designate themselves in multiple
advanced practice categories. For example, a clinical nurse specialist may also consider
themselves a nurse practitioner and report themselves as both on surveys. This is reported as an
inherent problem in the only national survey that includes all advanced practice nursing
designations, the National Sample Survey of Registered Nurses (NSSRN) conducted by the
Health Resources and Services Administration of the U.S. Department of Health and Human
Services, Bureau of Health Professions. The NSSRN disclaimer reports in part that NSSRN
samples RNs who may also claim APN preparation, numbers may include many who are not
currently practicing in their specialty but who were once prepared and completed an APN
program earlier in their careers, and that respondents could be certified in multiple specialties by
multiple organizations (U.S. HRSA, 2004). Although the APN numbers are known to be inflated,
researchers recognize that there is no other or better national database containing APN
demographic information over time and so researchers continue to use the HRSA APN data.
Therefore this researcher has also chosen to use the HRSA APN demographic data for numbers
of APN providers.
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Figure 3.2 National Practitioner Data Bank at a Glance
2 Adapted from the National Practitioner Data Bank (2006). Retrieved from http://www.npdbhipdb.
hrsa.gov/pubs/Data_Banks_at_a_Glance.
National Practitioner Data Bank at a Glance
The National Practitioner Data Bank was established under Title IV of Public
Law 99-660, the Health Care Quality Improvement Act of 1986. NPDB is an
information clearinghouse to collect and release information related to the
professional competence and conduct of physicians, dentists, and other health
care practitioners.
Who Reports?
 Medical malpractice payers
 Medical/Dental State Licensing Boards
 Hospitals and other health care entities
 Professional societies with formal peer review
 HHS Office of Inspector General
 US Drug Enforcement Administration
 Federal and State Government agencies
 Health plans
What Information is Available?
 Medical malpractice payments (all health care practitioners)
 Adverse actions - based on reasons relating to professional competency and conduct (primarily
physicians/dentists)
o Licensing actions: revocation, suspension, censure, reprimand, probation, surrender, denial of an
application for renewal of license and withdrawal of an application for renewal of license (reported
as a voluntary surrender)
o Clinical privileges actions
o Professional society membership actions
 Medicare and Medicaid exclusions (all health care practitioners)
 US Drug Enforcement Administration actions (all health care practitioners)
Who Can Query?
 Hospitals
 Other health care entities with formal peer review
 Professional societies with formal peer review
 Boards of Medical/Dental Examiners and other health care practitioner State Licensing Boards
 Plaintiffs’ attorneys or plaintiffs representing themselves (limited)
 Health care practitioners (self-query)
 Researchers (statistical data only)
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Health care providers in this study were selected and reclassified into three types: (a)
physicians including allopathic physicians (MDs), osteopathic physicians (DOs) and physician
interns/residents; (b) physician assistants; and (c) advanced practice nurses (APNs) which
include nurse anesthetists, nurse midwives, nurse practitioners, advanced practice nurses and
clinical nurse specialists (see Appendix B).
Method and Research Design
The NPDB Public Use Data File was downloaded from the NPDB website (www.npdbhipdb.
hrsa.gov/publicdata.html). Data from January 1, 1991 through December 31, 2007 was
extracted for analysis. Four report types were reclassified into adverse action reports employing
data with formats in use before and after 11/22/1999. Malpractice payments were examined
using data formats before and after 1/31/2004. Health care providers in the study were
reclassified into three types: (a) physicians, including allopathic physicians (MDs), osteopathic
physicians (DOs) and physician interns/residents; (b) PAs; and (c) APNs. All other practitioners
were excluded.
The identified data were used to determine the following: trends in malpractice incidence,
payment amount and adverse action incidence; ratios of medical malpractice payments by
provider type; and comparisons of PAs to physicians and APNs in all variables studied. Payment
averages, median of payment, total of payment and total amount of payment (provided as 1991
dollars for prior study comparisons and also adjusted for inflation to constant 2008 dollars).
Inflation adjusted amounts were calculated using inflation percent for each year with a formula
generated by the Consumer Price Indexes of U.S. Department of Labor. Other variables in this
study included adverse licensing or credentialing actions, professional society actions, age group,
time in practice, gender, state of license, and basis for action.
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A chi-square test (also chi-squared or ?2 test) is any statistical hypothesis test in which
the test statistic has a chi-square distribution when the null hypothesis is true, or any in which the
probability distribution of the test statistic (assuming the null hypothesis is true) can be made to
approximate a chi-square distribution as closely as desired by making the sample size large
enough. Specifically, a chi-square test for independence evaluates statistically significant
associations between proportions for two or more groups in a data set (Wikipedia, 2008). The
proportions of the groups being compared may be different but statistically associated. For this
study associations are being tested between dependent variables for three groups in the dataset:
physicians, PAs, and APNs. The chi-square distribution is a family of probability density curves
defined by the number of degrees of freedom. The degrees of freedom depend on the number of
categories and is calculated as (number of rows-1) X (number of columns-1). For example, if
there is a 2x2 table, the degrees of freedom are calculated as (2-1) x (2-1) = 1.
The formula used to calculate: ?2 = ? ?
ExpectedValue
(Observed ExpectedValue) **2
Statistical analyses used in this study included chi-square analyses to explore associations
among the dependent variables including provider’s year of practice, state of license, number and
amounts of medical malpractice payment, and number of type of adverse action reports. The chisquare
is a good choice since we are most often comparing three groups and looking for
statistically significant associations between these three groups in the data set.
One-way analysis of variance (ANOVA) is used for a continuous outcomes for >2
(unpaired) independent groups. It is used to test for a difference in the mean outcome level
between three or more independent groups. If we have a significant result from ANOVA, we
may be interested in testing which of the groups differ from each other (post hoc tests) by using a
selected method such as that of Tukey or Scheffe for multiple comparisons. An ANOVA result is
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significant if the result of at least one pair is significant (in our case we will describe this as a
significant difference). The null hypothesis is rejected if a statistically significant difference is
found to exist. When there is an unequal size such as among Physician, PA, and APN data,
Scheffe’s method ANOVA is used because it is a better choice.
A one-way ANOVA method was used for pair-wise comparisons among three types of
healthcare providers: PAs and physicians; APNs and physicians; and PAs and APNs. The
significance level was set at p ? 0.05. SAS version 9.1.3 for Windows was used to analyze data
(SAS Institute, Carry, NC).
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Table 5. Variables Studied
______________________________________________________________________________
Independent Variables Dependent Variables
______________________________________________________________________________
Physician Assistants Total Number of Malpractice Payments
Physicians (MD, DO) Average Amount of Malpractice Payments
Advanced Practice Nurses Average Years of Practice
Total Number of Adverse Events/Actions
State and Medical Board Licensing Actions
Clinical Privileges Actions
Professional Society Membership Actions
Practitioner Exclusions from Medicare and Medicaid
Programs
U.S. Drug Enforcement Agency (DEA) Actions
Year of Adverse Action
Basis for Action
State of License
______________________________________________________________________________
The independent variables used in the study were reported by the NPDB as the field of
license. The independent variables were defined in Chapter 2. Field values from the database for
each category of clinician, the independent variables, are presented in Appendix A. The total
number of adverse events variable included 52 different types of actions taken against a clinician
or clinician’s license (see Appendix B). The variables of state and medical board licensing
actions, clinical privileges actions, professional society membership actions, practitioner
exclusions from state or federal programs, and U.S. DEA actions were all reported separately by
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the NPDB as sub-fields of adverse actions (see Appendix B). The variable of malpractice
payments included payments made by insurers, state patient compensation funds, excess
judgment funds or other similar state funds. Payment amounts were analyzed unadjusted and
adjusted for inflation by the researcher to 1991 dollars. The basis for action variable contained
149 causes for action against a clinician or clinician’s ability to practice (see Appendix C).
The following was determined: trends in malpractice incidence and amounts, trends in
other defined adverse actions, ratios of medical malpractice payments and defined adverse
actions, ranking from most common to least common bases for actions, ranking of malpractice
and adverse action incidence by state and comparisons between physicians and PAs, physicians
and APNs, and APNs and PAs for all variables studied. For the malpractice variables, payment
averages, median of payment and total amount of payment was calculated. Dollar values were
adjusted for inflation by changing all payments to 1991 dollars using inflation percent for each
year with calculated formula adapted from consumer price indexes of U.S. Department of Labor.
1991 dollars were chosen so that direct comparisons could be made with the work of Brock and
Cawley et al.
Data Presentation
The data were presented in table, graph and chart formats. The following data
presentations were presented:
• A set of tables, comparing the thee provider groups in each of the variables for
the full 17 year period
• Tables and graphs of trends in adverse actions for each dependent variable by
year
• Ratios of adverse actions per provider group and adverse actions per provider