Historical Outlook of Physician Assistant Work and Role in The Va

The Department of Veterans Affairs (VA) is committed to serving and providing world-class health care to veterans and their families. The VA helps veterans to transition back home and into meaningful careers. The Veterans Health Administration (VHA) is America’s largest integrated health care system, providing care at 1,250 health care facilities, including 172 medical centers and 1,069 outpatient VHA outpatient clinics, serving 9 million enrolled Veterans each year. VHA, the nation's largest health care system, employs about 306,000 health care professionals and staff.1 The VHA has a history in employing PAs, has been progressive in changing the way PAs practice in the VA, and offers many benefits for PAs who chose to work in the VA.

The first class of PAs graduated from Duke University on October 6th, 1967. The VHA began utilizing physician assistants in 1968 when several of these graduates went to work at the VA in Durham, North Carolina. The VA was the first employer of PAs and is still the largest employer of PAs in the country. Currently, there are 2,300 PAs employed by the VA health system. PAs are present in nearly every specialty including; Anesthesia, Cardiology, Cardiothoracic Surgery, Dermatology, Endocrinology, ENT, Extended Care, Gastroenterology, General Surgery, Geriatrics, Infectious Disease, Mental Health, Sleep Medicine, Neurology, Neurosurgery, Nuclear Medicine, Occupational/Employee Health, Orthopedics, Podiatry, Plastic Surgery, Post Deployment Clinic, Primary Care, Pulmonology, Quality Assurance, Liver Transplant, Hematology/Oncology, Radiation Therapy, Interventional Radiology, Spinal Cord, Telemedicine, Urology, and Woman’s Health Clinic.2 Physician Assistant employment in the VHA has grown steadily and PAs are present in almost all VA medical centers and outpatient clinics.

Although PAs function in multiple roles in VHA settings, many people do not understand their roles in these settings unless they see as PA as their primary care provider. One component of VHA service is the community-based outpatient clinic (CBOC) system. These are small clinics that are geographically separate as satellites of a VAMC and are about 30 to 100 miles from the main VAMC. The development of these CBOCs began in 1995. The intent of these CBOCs is to deliver healthcare that was conveniently close to veterans and their families. As of 2015, there were 150 VAMCs and 1,400 CBOCs that enrolled around 8.9 million veterans. PAs and NPs staff most of the CBOCs and are often skilled in adult primary care as well as some specialty care.3 In the VA health system about a quarter of all primary care patients treated are seen by a PA and roughly 32% of PAs employed by VHA are veterans, retired military, or currently serving in the National Guard and Reserves.2 Despite being the first organization to hire PAs, the VA continues to be a late developer in modernizing practice laws for PAs.

In 2013 the VHA Directive 1063: Utilization of Physician Assistants (PA) was published which provided an updated policy for utilization of PAs in the VHA. It updated the responsibilities of a PA to provide greater clarification, established Core PA Scope of Practice and Expanded Scope of Practice elements, established specific levels of PA practice autonomy, and updated requirements for physician oversight of PA practice. The directive defines responsibilities of the collaborating physician such as providing appropriate clinical oversight, consultation, and patient care management assistance to the PA assigned and providing readily available consultation and collaboration. The responsibilities of a PA are also defined. These include adhering to all applicable Federal, VA, VHA, and facility policies or regulations, ensuring that their clinical activities are within their Scope of Practice and are medically and ethically appropriate, ensuring that no patient care activities are engaged in without a collaborating physician available for appropriate clinical oversight, engaging with their collaborating physician when consultation and guidance is needed, and deferring to the collaborating physician when there is a difference in opinion with the collaborating physician regarding patient care management. The directive also states that full autonomy of PAs is appropriate for most settings in which PAs practice including inpatient, outpatient, Community Based Outpatient Clinics (CBOC), Community Living Centers (CLC), Long Term Care, Home Based Primary Care (HBPC), Telemedicine, and remote sites. This means PAs at these sites practice with a high level of autonomy on a day-to-day basis and require infrequent consultation with their collaborating physician. The physical presence of the collaborating physician at the site is not required. The collaborating physician’s responsibilities for this level of PA practice include periodic monitoring of the PA’s clinical activities through a retrospective review of at least five randomly selected patient encounter notes each quarter to ensure the presence of ongoing competency and medical appropriateness. In addition, the collaborating physician and PA must be in contact at least weekly to discuss any difficult cases.4 The VA, through this directive, was able to distinguish between the level of medical practice autonomy exercised by experienced PAs and newly educated PAs, giving new providers limited autonomy while experienced providers at many sites were allowed full autonomy. Additionally, the directive designed leaders to ensure that all VA medical facilities would be compliant with PA credentialing and utilization of PAs which had been lacking before the directive. There would now be a source of expertise regarding PA education, qualifications, clinical privileges, and scope of practice in the VA which had not been set in place before the directive. The AAPA was in full support of the directive acknowledging that the policy recognized the versatility of the PA workforce and enhanced physician assistants’ ability to deliver high-quality medical care. AAPA applauded the VHA’s efforts in establishing and moving forward with new scopes of practice and PA practice models which implemented new PA utilization guidelines. This directive was a large step forward for PA practice in the VA health system, however, there are still many issues that need to be addressed.

Articles from 2014 cite the salary disparity and other issues for PAs employed by the VA health system. In 2013, the PA workforce had grown far less than other positions within the VHA signaling a retention and recruiting problem. The discrepancy in salary, benefits, and education programs between the civilian sector and the VHA continued to be a barrier. In 2014, Physician Assistants remained in an antiquated pay system resulting in a large pay disparity compared to the civilian sector. Additionally, in 2014, 14.28 % of PAs left the VA due to compensation and only 2.7% Physician Assistants chose the VA because of pay/compensation. In 2015, PAs were identified as having the third largest staffing shortage in the VA healthcare system. The annual turnover rate for PAs was 12 to 14 percent. The vacancy rate for PAs was among the highest in the VHA.5 The disparity in salary, benefits, and educational opportunities was a problem and continues to be a problem as PAs are choosing private sector employment opportunities over working at the VA.

Finally, in 2017, Congress passed the VA Choice and Quality Employment Act that implemented competitive pay for PAs in the Department of Veterans Affairs. Currently, the VA continues to recognize PAs as a solution for increasing timely access to quality patient care for the nation’s veterans. However, starting pay for new graduates is still typically 20-30 percent higher in the private sector than it is in the VA. Physician Assistant salaries at US Department of Veterans Affairs can range from $79,921 - $134,154. It continues to be challenging for the VA to recruit, hire, and retain PAs. In attempt to reduce this deficit, The VA Choice and Quality Employment Act included an estimated $86 million to be spent to ensure PAs are offered competitive salaries by the VA through a provision to move PAs to a locality-based pay system, like the pay systems already in place for NPs and physicians. When compensating PAs, the VA almost must consider local wages in the private sector as well, according to the act.6 When the VA seeks to replace healthcare professionals, it cannot compete with private health care systems. The lengthy process the VA requires candidates to receive employment commitments continues to hinder the VA's ability to recruit and officially appoint new employees. Many measures have been taken to try to reduce the disparity between PAs working in the private sector and those working for the VHA, but the VA is still behind the private sector in terms of salary and loan forgiveness.

In order to try to bridge this gap, there are many benefits that the VA offers its employees including access to cutting edge technology, education support, work/life balance, leadership training, and the ability to live anywhere in the nation. They offer a broad range of scholarships, tuition reimbursement, and loan repayment programs, as well as other educational opportunities to help employees. VA employees with federal student loans may be eligible for the national loan forgiveness program up to 60,000 dollars. There are also scholarship programs available for PA students who are willing to commit to working at the VA upon graduation. Additionally, the VA conducts the largest medical education program in the country, in partnership with over 1,800 academic institutions.1 The VA also supports PA education. The St. Louis University PA program was partially funded by the VA in 1971.7 In addition, employees receive generous vacation and personal leave, including 26 paid days off, 13 sick days and 10 paid federal holidays. Health care professionals at the VA are protected by the Federal Government in cases of alleged malpractice, eliminating the need for personal liability insurance. One state license allows VA employees to practice in any VA facility nationwide. PAs employed in federal institutions often bypass state control of provider services. For example, state PA practice laws do not determine whether a VA facility permits PAs to perform medical or surgical procedures. PAs practice under federal authority and states do not have jurisdiction over the federal health care facilities. Therefore, if the facility approves a scope of practice that includes performing a procedure, it can be granted by that facility under federal law. Furthermore, VA employees can seek employment at any VA facility with an open position and transfer with no loss of benefits.1 With VA’s integrated system, employees are free to explore new areas of career development and pursue opportunities anywhere within VA. Most importantly, VA employees have the chance to give back to America’s heroes and help improve life for them and their families every day. VA patients have experienced wide-ranging military conflicts which means that providers regularly meet new challenges that allow them to sharpen their skills and critical thinking abilities. Overall, the VA has been working hard to make the employment of PAs more appealing by providing benefits, education and loan forgiveness.

In conclusion, PAs have been working in the VA since the start of the profession. PAs are a majority of providers in the VHA and provide medical care and treatment to US Veterans every day. The VHA has worked and is continuing to work with PAs to improve their utilization. The VA provides many benefits for its employees and would provide a good opportunity to work with our nation’s veterans while having autonomy in practice. PA practice in the VA has come a long way and will continue to grow in years to come.