Physician Assistants: Underutilized in Ophthalmology?

Physician assistants (PAs) offer eye care practices an efficient and affordable way to handle a large workload. Last week, we went over the benefits that a PA could bring to your eye care practice. This week, we’ll explore the ins and outs of adding a PA to your eye care practice.

How Many Physician Assistants Work in Eye Care?

Although the number of eye care practices that employ a physician assistant is growing, physician assistants are currently underutilized in ophthalmology compared to other specialties. In fact, based on data from the 2014 Commission of Certified Physician Assistants, there are 101,000 PAs in the U.S., trained and ready to work, yet only about 75 PAs work in ophthalmology. That’s less than one-tenth of one percent. Alternatively, there are about 10,000 PAs working in emergency medicine and 10,000 PAs working in orthopedic surgery.

Why do so few PAs work in ophthalmology? Specialty-specific training is one of the biggest barriers to entry, according to Mary Sue Jacka, MBA, COE, FASOA, administrator at Haik Humble Eye Center in West Monroe, Louisiana and a presenter at  last year’s ASCRS·ASOA Annual Symposium & Congress. “At this time, the practice must train the PA themselves,” she says. Physician assistants typically undergo two to three years of schooling and a long clinical rotation. However, they receive little eye care training during their program. The financial and time burden to ramp up PAs in eye care is placed on the practices that hire them. Plus, Jacka adds, “Some states have strong optometric legislation against PAs in ophthalmology.” That’s partly because some physicians view optometrists as the ideal “physician extenders” with specialized knowledge and skills that PAs don’t have.

Is Hiring an Optometrist the Better Choice?

Dr. John Sheppard of Virginia Eye Consultants agrees that optometrists, rather than PAs, provide a greater benefit to an eye care practice. In an article in the Review of Ophthalmology, Dr. Sheppard said that he prefers to use subspecialized optometrists instead of PAs. “PAs are wonderful. They just don’t ideally fill in any of the gaps in an ophthalmology practice.” he said. Echoing the concerns that many physicians have, Dr. Sheppard went on to say, “You can bring her [a PA] up to the level of a good tech, but they cost more. You can bring her up to the level of an optometrist who has had at least five years of formal training, plus hands-on training in the practice, which is a much better head start than a PA would ever have.”

But Jacka’s counterargument is that the practice gets to determine the scope of the work that the PA will do. PAs offer practices flexibility, as long as the main purpose is clear. “No matter how long you choose to utilize the PA,” Jacka says, the purpose of the PA is always to “free up the ophthalmologist to concentrate on the things that only they can do.” Haik Humble Eye Care utilizes their three PAs to help physicians see a full schedule of patients. Financially, the practice’s PA utilization has paid off. In February 2017, the three PAs collected between $20,000 and just over $50,000, not including optical sales. The practice is projected to collect more than $1,100,000 in reimbursement for the year 2017.

How to Use PAs in Your Practice

To reap the reimbursement benefits of PAs, Jacka recommends that PAs see patients with plans that offer lower reimbursement. Alternatively, MDs can see patients first to cash in on a higher reimbursement plan. Then they can “transfer the care to the PA as appropriate,” Jacka says. PAs aren’t cost-effective in surgery because Medicare only pays PAs for a few retina codes. However, PAs “can fast track the patient from exam to surgery,” says Jacka. Appointments with an MD are usually harder for patients to get, but if PAs are available, they can see patients and clear them for surgery that much quicker. Plus, PAs can help the practice sell and perform more out-of-pocket cosmetic procedures like Botox, filler injections, and cosmetic laser work.

Writing Your PA Contract

The line between an ophthalmic PA and an optometrist can get blurry. That’s especially true if the scope of work and job terms aren’t clear. Jacka’s tips below will help you craft a clear PA contract so that your practice actually benefits from bringing a PA on board.

  • Look at a PA contract from a colleague who has already hired a PA, possibly in another specialty, like orthopedics.
  • Follow Medicare’s safe harbor guidelines when writing the contract.
  • Typical terms include $90K-$110K base salary, two-four weeks of vacation, paid continuing education, a provision to be on call at certain times, a possible discretionary bonus of 5% of collections after the cost of goods sold, and scheduled work hours. At Jacka’s practice, PAs work 5 days per week from 8am-5pm.
  • Safe harbor constraints forbid practices from offering PAs an optical bonus.

Sell Patients on PAs With This Script

The benefits of PAs are vast. But for the PA model to work in an eye care practice, physicians, front desk staff, and practice administrators must “sell” their PAs. This is especially true for older patients, some of whom as less open to the idea of physician extenders than Gen Xers and Millennials.

When a patient calls in for an appointment, Jacka recommends that staffers use a script like this:

“Great! I can help you set up your next appointment. You know what, Dr. Parker doesn’t have a super-soon appointment, but I can actually get you in today to see our physician assistant, Mrs. Smith. Have you met her yet? You’ll love her.”

Part of selling your PAs to patients includes treating them like “they’re the cream of the crop,” says Jacka. That means calling them by a formal title—Mr. or Ms.—in front of patients and staff, having a staff member or physician introduce patients to their assigned PA. Be sure to speak highly of their skills in the office, especially in front of patients.

The beauty of ophthalmic PAs lies in the flexibility they offer practices. Their medical, surgical, research, and people skills allow PAs to enhance almost any part of a practice. They also give ophthalmologists more time and energy to focus on their own lives and deliver high-quality care to complex patients. Sure, some practices are more open to utilizing PAs than others. But it’s safe to say that PAs offer a way for practices to thrive in the era of value-based reimbursement.


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