Congratulations, you made it! You completed all the required courses of study to become a full-fledged Physician Assistant. You went on rotations as a student in real clinic settings and were judged by your preceptors as having the skills and knowledge to become a full-fledged Physician Assistant. You passed the six hour NCCPA exam, you were granted a medical license from your state, and given a DEA license number to become a full-fledged Physician Assistant. Now it is time to get out there and work like a full-fledged Physician Assistant. Finally you get a chance to make your own decisions about the care of your patients. No more professors, or preceptors or anybody telling you what to do with your patients. Your first patient of the first day on your first job is in the exam room and ready for you. You review the chart; he is a 55 y/o male with no significant medical history. His blood pressure is 142/86, and he weighs 206 lbs. You make a mental note to talk to him about his weight and elevated blood pressure. You stand up, check to make sure the PA-C name tag is prominently displayed, stethoscope ready, pen is working (lets do this). You walk up to the room, knock on the door, walk in and are ready to bust out with some serious medical knowledge. This guy is so lucky, he is about to get the best medical visit of his life. You start to talk to him and it turns out he is here for his annual physical exam and blood work. He has a family history of heart disease (his father died of heart disease at 75). Otherwise, he has no real complaints, feels fine, and states that his blood pressure always comes up when he comes to the doctor’s office. His physical exam is unremarkable and yes, you did check the prostate.

Ok, you got this. Yes, his physical exam was unremarkable. Yes, he has no major chief complaints. But, you know better. He is a ticking time bomb!

First, you let him know that his body mass index is 26. He definitely needs to start working on a weight loss program. You take the time to explain all the problems that can be avoided by losing a few pounds.

Second, you talk to him about his blood pressure. Yes, you understand that his blood pressure may become elevated when coming to the doctor’s, but he needs to start watching it closely. To drive the point home you go over the complications exacerbated by “the silent killer”. He should decrease his salt intake. He should monitor his pressure for a week and return for a follow up. And of course, he should lose some weight.

Third, time to school him on some heart disease. You can’t believe this guy has been running around with a family history of heart disease. You spend some time detailing the risk factors for heart disease and how he can avoid dying at 75 from it.

Fourth, you talk to him about his need for a colonoscopy. My god, he could be dying from colon cancer and not even know it.

Finally, you’re done.

Wait! What about tetanus status, Pneumovax, and Zostavax? So you sit back down and explain the benefits of having these injections for preventative health. You make sure to cover in detail the indications and potential side effects of these medicines as well as the risks of not getting the immunizations.

(Be sure to check out the reasons why as a Physician Assistant you will never be number one!)

Now for sure,
you are done with him. You stand up and shake his hand and ask him to wait for the nurse to draw his blood. (Damn you feel good. Can you believe how much you helped this guy? You are a lifesaver. A regular superman. You can’t wait to see how your new supervising physician feels about this bang up job.) You walk up to the nurse’s station to drop the chart for blood work, (smiling like an idiot). You can’t help it; you just hit a home run on the very first real patient of your life.

As you turn the corner to drop the chart off, the supervising physician is there. He grabs the chart (Yea, that’s right, take a look at that office note. It’s like a Picasso, a freakin masterpiece). He looks things over and you keep on smiling. (Like an idiot)

He asks, “What was the patient in for?”

Your response; “A well visit, code V70.0, and I made sure to cover everything. HTN, heart disease, obesity, colon cancer, and immunizations.”

His response to your response, “Did you teach him how to clip his toenails so they don’t ingrow, did you show him how to do a self-testicular exam, is he aware that men can get breast cancer?”

That smile you had slowly drops down and you stand there, (like an idiot).

He continues, “You spent 40 minutes with that patient for a well visit physical and blood work. That code produces about $35 in reimbursement. Subtract from that what I am paying you, the reception, the nurse, and the rent for the room you were camping in and you cost me money to see that patient. Get your ass back in there and get a urinalysis so I can at least cover my costs on this patient.”

You are stunned, mouth open, wide eyed. The reality is, you are an idiot!

What you failed to realize is that this is not Physician Assistant school. You do not have the luxury of spending the day with one patient going over every condition that might or might not exist. Nobody in your real “job” is going to congratulate you on regurgitating text book synopses on disease states. What your boss wants you to do is see patients. Lots of them. They want you to turn and burn through as many as you can in a day. You are to become a cog in the corporate machine, grinding out as much revenue as you can.

Most Physician Assistants don’t want to talk about this, but it really needs to be discussed. In order for the Physician Assistant vocation to continue to grow, we need to deliver some value to the people we work for. As a profession we have to leverage ourselves in any way we can. One of the biggest ways to do this is to recognize our potential as a revenue source for the clinic. Clinics are businesses that must turn a profit in order to keep from bouncing the checks that you depend on to feed your family.

The formula for a Physician Assistant/clinic relationship is simple:

Revenue generated by the PA – Cost of having a PA = (Better be a positive here or you should dust off your CV and start job shopping).

That’s right! you are expected to generate more money for the clinic than the clinic pays you to be there. What most Physician Assistants want to think, and have the public believe, is that we are in existence only to expand the scope of a Physician’s practice. By doing this we can have a positive impact on the healthcare of our society as a whole. This is a great explanation of the humble beginnings for the Physician Assistant, but is definitely not the only reason we exist. One of the main reasons a clinic will hire a Physician Assistant is that the cost to income generation ratio is high. We cost relatively few dollars and we can produce a fairly high revenue stream for the clinic.

It will only serve the Physician Assistant community well to recognize this and to act accordingly. As Physician Assistants become known as producers, we can then demand better salaries and benefits. At your current practice (or potential practice), does the office inform you about what is being collected and how it is collected? (Would they tell you if you asked)? Do you know how much money you are directly responsible for bringing into the clinic? Do you understand the current ICD-9 coding system? Have you ever spoken to your billing department? These are just a few of the questions that you should be able to answer in order to become an income generating machine for your clinic. Invest some of your time in understanding levels of coding so you are not under-coding visits. Evaluate your clinic for opportunities to move any and all ancillary services in house. Work some locum shifts at other facilities and take anything you learn there to your home clinic.

As health care dollars are continuing to shrink due to decreasing reimbursements from insurance companies, medical offices will be looking for any opportunity they can find to offset that loss. Physician Assistants are in a very unique position to be a viable solution to this problem. By bolstering this aspect of your professional life and becoming more collections minded, you will become an invaluable component to the clinic. The first step is for you to recognize what you actually do at the clinic in terms of income generation. The second step is for you to actually do what you recognize.

  1. bill santos says:

    Great article. I applaud your writing. Especially this blog. It is encouraging. We do need to know what we are bringing in. Great call to action!!!

    • qfwm2001 says:

      Thanks for the props Bill. I really want Physician Assistants to be focused on healing, but always remember that this is a business. You must earn your way, and earn your pay. Thanks again, Q.

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