Managing obesity in adults as a chronic condition.

ABSTRACT: Despite extensive evidence-based guidelines, clinicians still face many barriers to reducing the incidence of obesity. Recognizing that obesity is a chronic disease will allow clinicians to properly treat patients and bill for reimbursement. With enhanced education, knowledge of reimbursement, and a push for legislation, physician assistants can pave the way to reducing rates of obesity in adults.

Utilization and Costs by Primary Care Provider Type: Are There Differences Among Diabetic Patients of Physicians, Nurse Practitioners, and Physician Assistants?

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.

Out-of-Network Bills for Privately Insured Patients Undergoing Elective Surgery With In-Network Primary Surgeons and Facilities.

Importance: Privately insured patients who receive care from in-network physicians may receive unexpected out-of-network bills ("surprise bills") from out-of-network clinicians they did not choose. In elective surgery, this can occur if patients choose in-network surgeons and hospitals but receive out-of-network bills from other involved clinicians. Objective: To evaluate out-of-network billing across common elective operations performed with in-network primary surgeons and facilities. Design, Setting, and Participants: Retrospective analysis of claims data from a large US commercial insurer, representing 347 356 patients who had undergone 1 of 7 common elective operations (arthroscopic meniscal repair [116 749]; laparoscopic cholecystectomy [82 372]; hysterectomy [67 452]; total knee replacement [42 313]; breast lumpectomy [18 018]; colectomy [14 074]; coronary artery bypass graft surgery [6378]) by an in-network primary surgeon at an in-network facility between January 1, 2012, and September 30, 2017. Follow-up ended November 8, 2017. Exposure: Patient, clinician, and insurance factors potentially related to out-of-network bills. Main Outcomes and Measures: The primary outcome was the proportion of episodes with out-of-network bills. The secondary outcome was the estimated potential balance bill associated with out-of-network bills from each surgical procedure, calculated as total out-of-network charges less the typical in-network price for the same service. Results: Among 347 356 patients (mean age, 48 [SD, 11] years; 66% women) who underwent surgery with in-network primary surgeons and facilities, 20.5% of episodes (95% CI, 19.4%-21.7%) had an out-of-network bill. In these episodes, the mean potential balance bill per episode was $2011 (95% CI, $1866-$2157) when present. Out-of-network bills were associated with surgical assistants in 37% of these episodes; when present, the mean potential balance bill was $3633 (95% CI, $3384-$3883). Out-of-network bills were associated with anesthesiologists in 37% of episodes; when present, the mean potential balance bill was $1219 (95% CI, $1049-$1388). Membership in health insurance exchange plans, compared with nonexchange plans, was associated with a significantly higher risk of out-of-network bills (27% vs 20%, respectively; risk difference, 6% [95% CI, 3.9%-8.9%]; P < .001). Surgical complications were associated with a significantly higher risk of out-of-network bills, compared with episodes with no complications (28% vs 20%, respectively; risk difference, 7% [95% CI, 5.8%-8.8%]; P < .001). Among 83 021 procedures performed at ambulatory surgery centers with in-network primary surgeons, 6.7% (95% CI, 5.8%-7.7%) included an out-of-network facility bill and 17.2% (95% CI, 15.7%-18.8%) included an out-of-network professional bill. Conclusions and Relevance: In this retrospective analysis of commercially insured patients who had undergone elective surgery at in-network facilities with in-network primary surgeons, a substantial proportion of operations were associated with out-of-network bills.

Understanding Barriers and Facilitators to the Uptake of Best Practices for the Treatment of Co-Occurring Chronic Pain and Opioid Use Disorder.

Objective: Patients with a combination of chronic pain and opioid use disorder have unique needs and may present a challenge for clinicians and health care systems. The objective of the present study was to use qualitative methods to explore factors influencing the uptake of best practices for co-occurring chronic pain and opioid use disorder in order to inform a quantitative survey assessing primary care provider capacity to appropriately treat this dual diagnosis. Methods: Guided by the Consolidated Framework for Implementation Research (CFIR), semi-structured qualitative interviews were conducted with 11 primary care providers (PCPs) to inform the development of a questionnaire. Interviews were audio-recorded and transcribed verbatim. Fifteen comments from an open-ended question on the questionnaire were added to the analyses as they described factors that were not elucidated in the interviews. Barriers and facilitators were identified and categorized using the CFIR codebook. Results: The most frequently described barriers were cost and inadequate access to appropriate treatments, external policies, and available resources (e.g., risk assessment tools). The most frequently described facilitators were the presence of a network or team, patient-specific needs, and the learning climate. Knowledge and beliefs were frequently described as both barriers and facilitators. Conclusions: While substantial funding has been allocated to initiatives aimed at increasing PCP capacity to treat this population, numerous barriers to adopting appropriate practices still exist. Future research should focus on developing and testing implementation strategies that leverage the facilitators and overcome the barriers illustrated here to improve the uptake of evidence-based recommendations for the treatment of co-occurring chronic pain and opioid use disorder.

Reexamining the persisting wage gap between male and female PAs.

OBJECTIVE: To determine the magnitude of any difference in total compensation between male and female physician assistants (PAs) after controlling for personal and workplace factors related to compensation. METHODS: Using data from the 2019 AAPA Salary Survey, the authors conducted a sequential regression analysis to examine the relationship between a variety of personal and practice demographics and total compensation. RESULTS: After controlling for compensation-related factors, a wage gap between male and female PAs persisted: female PAs were paid almost $0.93 for every $1 male PAs were paid in the first year of work ($9,010 less). This wage gap widened by $201 for every year of work experience. CONCLUSIONS: A wage gap between male and female PAs persists even after including all compensation types and controlling for compensation-related factors that may differ between male and female PAs. Proposed policy implications could begin to mitigate the gap.

Diagnostic Imaging Examinations Interpreted by Nurse Practitioners and Physician Assistants: A National and State-Level Medicare Claims Analysis.

OBJECTIVE. Nonphysician providers (NPPs) increasingly perform imaging-guided procedures, but their roles interpreting imaging have received little attention. We characterize diagnostic imaging services rendered by NPPs (i.e., nurse practitioners and physician assistants) in the Medicare population. MATERIALS AND METHODS. Using 1994-2015 Medicare Physician/Supplier Procedure Summary Master Files, we identified all diagnostic imaging services, including those billed by NPPs, and categorized these by modality and body region. Using 2004-2015 Medicare Part B 5% Research Identifiable File Carrier Files, we separately assessed state-level variation in imaging services rendered by NPPs. Total and relative utilization rates were calculated annually. RESULTS. Between 1994 and 2015 nationally, diagnostic imaging services increased from 339,168 to 420,172 per 100,000 Medicare beneficiaries (an increase of 24%). During this same period, diagnostic imaging services rendered by NPPs increased 14,711% (from 36 to 5332 per 100,000 beneficiaries) but still represented only 0.01% and 1.27% of all imaging in 1994 and 2015, respectively. Across all years, radiography and fluoroscopy constituted most of the NPP-billed imaging services and remained constant over time (e.g., 94% of all services billed in 1994 and 2015), representing only 0.01% and 2.1% of all Medicare radiography and fluoroscopy services. However, absolute annual service counts for NPP-billed radiography and fluoroscopy services increased from 10,899 to 1,665,929 services between 1994 and 2015. NPP-billed imaging was most common in South Dakota (7987 services per 100,000 beneficiaries) and Alaska (6842 services per 100,000 beneficiaries) and was least common in Hawaii (231 services per 100,000 beneficiaries) and Pennsylvania (478 services per 100,000 beneficiaries). CONCLUSION. Despite increasing roles of NPPs in health care across the United States, NPPs still rarely interpret diagnostic imaging studies. When they do, it is overwhelmingly radiography and fluoroscopy. Considerable state-to-state variation exists and may relate to local care patterns and scope-of-practice laws.

[First Insights into Scope of Practice and Salary of Physician Assistants, A New Healthcare Profession, in Germany]. / Eine neue Berufsgruppe kommt in der Praxis an: Erste Erkenntnisse über Einsatzgebiete, Tätigkeiten und Gehalt von Physician Assistants/Arztassistenten in Deutschland.

BACKGROUND: In 2010, the first government-approved physician assistant (PA) program was introduced at the Baden-Wuerttemberg Cooperative State University Karlsruhe (DHBW). There are not sufficient data regarding the scope of practice and salary of our graduates. Therefore, the aim of the present study was to obtain information regarding these. METHODS: The survey included all graduates (2 classes, n=27). A specific questionnaire was developed, including 37 questions e. g. on the current employment status, scope of practice, salary and job satisfaction regarding the PA program and career. A descriptive analysis of the data was carried out using SPSS. RESULTS: 25 graduates participated in the survey (96.1%); the average age of participants was 32.2 years (25-53 years). 88% (n=22) were employed as a PA, most of them worked in internal medicine (n=11) or surgery (n=9). Responsibilities that are often or very often assigned to the PAs are preparing final documents, taking over a coordinating role in the therapeutic team, as well as participation in taking patient medical history and conducting physical examinations. In two-thirds of respondents, the gross monthly base salary (full-time position) was about 3000 euros. 77.3% (n=17) of graduates were generally satisfied or very satisfied with their current situation. CONCLUSIONS: It appears that graduates of the DHBW are well integrated into the staff structure of hospitals, as far as the scope of practice and average salary are concerned. Further studies on the integration of this new profession in Germany and on their extended scope of practice in comparison to established healthcare professions will be conducted.

Demonstrating advanced practice provider value: Implementing a new advanced practice provider billing algorithm.

BACKGROUND: Rapid changes in healthcare are driving the adjustment of work flow by which providers serve patients in team-based care. Specifically, there is a need to develop more effective and efficient utilization with accurate attribution of advanced practice providers' (APPs) productivity. LOCAL PROBLEM: The directors of the APP-Best Practice Center conducted assessments of each clinical area at the Medical University of South Carolina (MUSC) Health, a large academic medical center. A knowledge gap was identified, not only regarding billing practices of the APPs (NPs and physician assistants) but also in the use of APPs to practice to the fullest extent of their license, education, and experience. METHODS: By substantiating APPs' contribution margin through the process of implementing a new standardized APP billing algorithm, a change in practice was accepted by senior leadership and a new APP billing algorithm was built that follows updated practice laws, compliance/legal standards, and hospital bylaws and regulations. INTERVENTIONS: A new billing algorithm was implemented on July 1, 2017, and outcomes were evaluated 12 months after implementation. RESULTS: This project uncovered the work already performed by APPs while increasing relative value units, collections, and overall patient encounters by the APP/physician team. Findings suggest improved utilization and appropriate attribution of productivity. CONCLUSIONS: With the APP workforce growing, the implementation of electronic medical record systems, and today's healthcare financial constraints, healthcare systems must standardize their billing practices. The APP billing algorithm is a critical tool that will help to meet this demand.

Medicare Program; FY 2019 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements. Final rule.

This final rule updates the hospice wage index, payment rates, and cap amount for fiscal year (FY) 2019. The rule also makes conforming regulations text changes to recognize physician assistants as designated hospice attending physicians effective January 1, 2019. Finally, the rule includes changes to the Hospice Quality Reporting Program.

The Tanzanian assistant medical officer.

Tanzania, in East Africa, has one of the lowest numbers of physician per population in the world, especially in rural areas where most people live. To address this shortage, assistant medical officers (AMOs) were developed in the 1960s. AMOs are trained in an abbreviated medical school program, work independently, remain the highest-trained practitioners in rural practice, and provide most emergency surgical obstetric care in nonurban settings. Although information on AMOs is limited, no evidence has emerged that their patient care outcomes differ from physicians. These healthcare professionals, similar to physician assistants, have expanded access to care in severely underserved areas of the country. With a growing demand for contemporary healthcare and stretched service delivery, more research is needed on the ameliorating effect AMOs have on Tanzanian healthcare, especially as the country considers converting AMO training programs to medical school programs.

Understanding the role of advanced practice providers in oncology in the United States.

PURPOSE: Advanced practice providers (APPs, which include NPs and physician assistants [PAs]) are integral members of oncology teams. This study aims first to identify all APPs in oncology and, second, to understand personal and practice characteristics (including compensation) of those APPs. METHODS: We identified APPs who practice oncology from membership and claims data. We surveyed 3,055 APPs about their roles in clinical care. RESULTS: We identified at least 5,350 APPs in oncology and an additional 5,400 who might practice oncology. Survey respondents totaled 577 out of 3,055, which provided a 19% response rate. Results focused on 540 NPs and PAs. Greater than 90% reported satisfaction with career choice. Respondents identified predominately as white (89%) and female (94%). NPs and PAs spent the majority (80%) of time in direct patient care. The top four patient care activities were patient counseling (NPs, 94%; PAs, 98%), prescribing (NPs, 93%; PAs, 97%), treatment management (NPs, 89%; PAs, 93%), and follow-up visits (NPs, 81%; PAs, 86%). A majority of all APPs reported both independent and shared visits (65% hematology/oncology/survivorship/prevention/pediatric hematology/oncology; 85% surgical/gynecologic oncology; 78% radiation oncology). A minority of APPs reported that they conducted only shared visits. Average annual compensation was between $113,000 and $115,000, which is about $10,000 higher than average pay for APPs not in oncology. CONCLUSION: We identified 5,350 APPs in oncology and conclude that number may be as high as 7,000. Survey results suggest that practices that incorporate APPs routinely rely on them for patient care. Given the increasing number of patients with and survivors of cancer, APPs are important to ensure access to quality cancer care now and in the future.

Medical Assistant-Based Care Management for High-Risk Patients in Small Primary Care Practices: A Cluster Randomized Clinical Trial.

BACKGROUND: Patients with multiple chronic conditions are at high risk for potentially avoidable hospitalizations, which may be reduced by care coordination and self-management support. Medical assistants are an increasingly available resource for patient care in primary care practices. OBJECTIVE: To determine whether protocol-based care management delivered by medical assistants improves care in patients at high risk for future hospitalization in primary care. DESIGN: Two-year cluster randomized clinical trial. (Current Controlled Trials: ISRCTN56104508). SETTING: 115 primary care practices in Germany. PATIENTS: 2076 patients with type 2 diabetes, chronic obstructive pulmonary disease, or chronic heart failure and a likelihood of hospitalization in the upper quartile of the population, as predicted by an analysis of insurance data. INTERVENTION: Protocol-based care management, including structured assessment, action planning, and monitoring delivered by medical assistants, compared with usual care. MEASUREMENTS: All-cause hospitalizations at 12 months (primary outcome) and quality-of-life scores (12-Item Short Form Health Survey [SF-12] and EuroQol instrument [EQ-5D]). RESULTS: Included patients had an average of 4 co-occurring chronic conditions. All-cause hospitalizations did not differ between groups at 12 months (risk ratio [RR], 1.01 [95% CI, 0.87 to 1.18]) and 24 months (RR, 0.98 [CI, 0.85 to 1.12]). Quality of life (differences, 1.16 [CI, 0.24 to 2.08] on SF-12 physical component and 1.68 [CI, 0.60 to 2.77] on SF-12 mental component) and general health (difference on EQ-5D, 0.03 [CI, 0.00 to 0.05]) improved significantly at 24 months. Intervention costs totaled $10 per patient per month. LIMITATION: Small number of primary care practices and low intensity of intervention. CONCLUSION: This low-intensity intervention did not reduce all-cause hospitalizations but showed positive effects on quality of life at reasonable costs in high-risk multimorbid patients. PRIMARY FUNDING SOURCE: AOK Baden-Württemberg and AOK Bundesverband.

Comparing Use of Low-Value Health Care Services Among U.S. Advanced Practice Clinicians and Physicians.

BACKGROUND: Many physicians believe that advanced practice clinicians (APCs [nurse practitioners and physician assistants]) provide care of relatively lower value. OBJECTIVE: To compare use of low-value services among U.S. APCs and physicians. DESIGN: Service use after primary care visits was evaluated for 3 conditions after adjustment for patient and provider characteristics and year. Patients with guideline-based red flags were excluded and analyses stratified by office- versus hospital-based visits, acute versus nonacute presentations, and whether clinicians self-identified as the patient's primary care provider (PCP). SETTING: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS), 1997 to 2011. PATIENTS: Patients presenting with upper respiratory infections (URIs), back pain, or headache. MEASUREMENTS: Use of guideline-discordant antibiotics (for URIs), radiography (for URIs and back pain), computed tomography (CT) or magnetic resonance imaging (MRI) (for headache and back pain), and referrals to other physicians (for all 3 conditions). RESULTS: 12 170 physician and 473 APC office-based visits and 13 359 physician and 2947 APC hospital-based visits were identified. Although office-based clinicians saw similar patients, hospital-based APCs saw younger patients (mean age, 42.6 vs. 45.0 years; P < 0.001), and practiced in urban settings less frequently (49.7% vs. 81.7% of visits; P < 0.001) than hospital-based physicians. Unadjusted and adjusted results revealed that APCs ordered antibiotics, CT or MRI, radiography, and referrals as often as physicians in both settings. Stratification suggested that self-identified PCP APCs ordered more services than PCP physicians in the hospital-based setting. LIMITATION: NHAMCS reflects hospital-based APC care; NAMCS samples physician practices and likely underrepresents office-based APCs. CONCLUSION: APCs and physicians provided an equivalent amount of low-value health services, dispelling physicians' perceptions that APCs provide lower-value care than physicians for these common conditions. PRIMARY FUNDING SOURCE: U.S. Health Services and Research Administration, Ryoichi Sasakawa Fellowship Fund, and National Institutes of Health.

The Impact of Physician Assistants on a Breast Reconstruction Practice: Outcomes and Cost Analysis.

BACKGROUND: Physician assistants (PAs) are commonly employed in plastic surgery. However, limited data exist on their impact, which may guide decisions regarding how best to integrate them into practice. METHODS: A review of the practices of 2 breast reconstructive surgeons was performed. A comparison was made between a 1-year period before to a 1-year period after the addition of a PA into practice. The practice model was a one-to-one pairing of a plastic surgeon and a PA. RESULTS: A total of 4141 clinic encounters and 1356 surgical cases were reviewed. After the addition of PAs, there was a significant increase in relative value units (1057 vs 1323 per month per surgeon, P < 0.001). Operative times were similar with and without PAs (P = 0.45). However, clinic encounter times for surgeons were shorter for all visit types when patients were first seen by a PA before the surgeon: global follow-up (P = 0.03), other follow-up (P = 0.002), consultation (P = 0.76), and preoperative (P = 0.02), translating to 9 additional patients seen per day. Charges (P = 0.001) and payments (P = 0.007) also increased, which offset the cost of using a PA. However, the financial contribution from PA involvement as first assistant in surgery was limited (5.2%). The peak effect of PAs was observed between the third and fourth quarters. CONCLUSIONS: In breast reconstruction, PAs primarily enhance the efficiency of plastic surgeons, particularly in the clinic, with downstream clinical and financial gains of an indirect nature for surgeons.

[Undergraduate Medical Students "On Call" to Assist in Theatre: Analysis of the Financial Aspects and a Mixed-Method Study Exploring Their Motives for Working]. / Studentische Hilfskräfte im "Operativen Rufdienst": Mixed-Method-Studie zur Analyse des finanziellen Aspekts und der Motive der Studierenden.

Background/Purpose: Surgical patient care has grown in complexity, as hospital workload has continuously increased. We therefore established a pool of "undergraduate medical students on call" to assist in the theatre outside working hours. We aimed to recruit talented students to reduce the burden on physicians and to motivate students into entering surgery. Methods: An exploratory mixed-method study was performed. In a qualitative study, guided interviews were conducted with five students about their reasons for working in the theatre and the results were used to construct an online questionnaire using EvaSys®. This was presented to 16 current and former students in a subsequent quantitative study. Furthermore, the cost of student employment was calculated and compared with physicians' salaries. Results: In 2013 and 2014, 8-9 students worked a total of 1063 and 1211 hours in the theatre, respectively. The difference in salaries between the students and surgical residents was € 28.37 per hour. We calculated that the annual savings were approximately € 60,000. When questioned on their motives during the interview, only a few students emphasised the financial aspects, whereas the majority emphasised the gain in experience. The analysis was based on comparison of the mean values (online survey) with a 4-point Likert scale (1 = high acceptance; 4 = no acceptance). We defined the motives with a mean ≤ 1.3 as primary. Based on this selection, gathering experience, fun/enjoyment, interest in surgery, and the change from studying were considered as distinct motives. In the interviews, students clearly pointed out that teaching and learning opportunities in the theatre were not commonly taken advantage of and that interaction with the surgeons should be improved. Conclusion: Students actively chose to work as assistants in the theatre, for a variety of motives. The financial aspects were subordinate. The concept of students assisting in the theatre is favourable for both employers and students. However, the results also reveal that there is room for improvement in the implementation of the concept.

Female PAs-Where are we today?

As the physician assistant (PA) profession celebrates its 50th birthday, we can be proud of the gains our profession has accomplished. However, despite the positive reports of job satisfaction, a marked increase in female PA leaders, and overall gains in PA compensation, a significant wage gap remains between male and female PAs. The PA profession is flourishing but it is time female PAs are paid equitably.

Analysis of 2011 physician assistant education debt load.

This study seeks to investigate how physician assistants (PAs) finance their education and to characterize the educational debt of PA students. Data from the 2011 American Academy of PAs (AAPA)-Physician Assistant Education Association Graduating Student Survey were used to explore the educational debt of PA students. The median total educational debt of a PA student graduating in 2011 was $80,000. Little financial assistance, other than student loans, is available to PA students. Eighty-five percent of PA students report owing some PA education debt amount, with 23% owing at least $100,000. This study provides a baseline look at PA student debt loads as a starting point for more detailed and robust research into new graduate specialty choices and PA career migration into other specialties. Further research is needed to explore the effect of student debt on students' specialty choices.

PAs: Fifty years young.

The PA profession is 50 years young. Practicing PAs and current students hail from several generational categories ranging from Builders to Generation Z. This article reviews how different generations may have experienced PA program expansion, professional identity, state licensing, and prescription delegation. The authors sampled a cohort of PA program applicants about their views on what evokes optimism and concern for the PA profession. These themes mirror the recently paved professional road, while posing the all-important question: What construction lies on the horizon?

Return on investment of advanced practice medical degrees: NPs vs. PAs.

As the United States faces a predicted physician shortage over the next 2 decades, physician assistants (PAs) and NPs are expected to fill the void. At the same time, because education is expensive, student loan and tuition increases have many potential applicants assessing differences in reimbursement and wondering about their return on investment (ROI). An analysis compared PA and NP salaries by incorporating national salary data, federal income tax, and student loans for a comparative analysis of each career pathway. METHODS: Salaries were abstracted from the 2012 Bureau of Labor Statistics database. The net present value (NPV) of PA and NP salaries was calculated with a 5% discount rate. Principal and interest for student loans was calculated at a 6% interest fixed-rate loan over 30 years. NPVs were then compared with projected ROI at retirement age. Relative career values were also given to each career choice, based on a retirement age of 65 years, which translates to about 41 years of employment for both PAs and NPs. RESULTS: PAs' and NPs' educational loans both equalled $129,484 on total repayment. The median annual salary of a PA was $90,930 and $89,960 for an NP. PA data yielded a 5% NPV of $781,323 compared with $764,348 for NPs. Of note, the 5% NPV of a 4-year nursing degree is $728,436. CONCLUSION: PAs have a slightly higher ROI compared with NPs. These findings may change due to adjustments in nursing training models. Many PA programs allow matriculation immediately after obtaining a bachelor's degree. NP schools often require nursing experience before entering their program. Some schools are considering an accelerated NP program, allowing immediate matriculation after obtaining a bachelor's degree. Because many NP programs have become doctoral degrees, the increased duration of training, higher tuition, and fewer years worked before retirement lower the overall NP ROI. A similar reduction in ROI was considered marginal in PAs who attend residency programs-though these programs are not required for PAs to practice. Comparison of an RN with a 4-year degree to an NP shows little increase in ROI. If interest rates rise, it will become fiscally preferable to remain in a nursing position. Other intangible qualities exist and need further research (for example, weighing the financial aspects with lifestyle or professional satisfaction).

How electronic health records can unmask the hidden value of PAs.

The Fee for Value (FFV) Task Force, a subgroup of the American Academy of PAs' Research and Strategic Initiatives Commission, has examined tools and mechanisms aimed at better clarifying the volume and value of PA work and how that work contributes to improving access to high-quality care. Establishing the value of PAs has been a challenging task for many healthcare providers. Often, PA value has been defined by their clinical productivity, without any clear direction as to what constitutes value versus productivity. The objective of this article is to unmask the value of PAs through the role of electronic health records and highlight PAs' ability to produce services that are value-oriented and quantifiably productive.