Civilian physician assistants (PAs) were introduced to Ontario’s health care system in a 2007 demonstration project, a joint initiative between the Ministry of Health and Long-Term Care (MOHLTC) and the Ontario Medical Association. Since then, PAs have been integrated into numerous clinical settings, and PA education programs have been created at 2 Ontario universities (McMaster University in Hamilton, Ont, and the University of Toronto, which delivers the program in collaboration with the Northern Ontario School of Medicine and the Michener Institute of Education), in addition to the Canadian Armed Forces PA program also located in Ontario. According to the Director of Communications and Stakeholder Relations at the Canadian Association of Physician Assistants (CAPA), as of July 2017, there were 587 PAs practising in Canada (personal communication, July 2017), and nearly 70% of them worked in Ontario.1 Although the member census data demonstrate the largest number of PAs graduate from Ontario-based programs and work in Ontario, there have been challenges integrating these PAs into the province’s health care system.1 In this commentary, we argue that the Ontario government needs to do more to address these issues in a timely manner, or risk jeopardizing the future of the profession in this province.
Conference Board of Canada reports
In 2016 and 2017, the Conference Board of Canada (CBoC), at the request of CAPA, produced 4 large-scale reports regarding the value and economic effect of PAs.2–5 Collectively, these reports also represented the successes and struggles of PAs in Canada to date.
Successes of PAs.
The first CBoC report, Value of Physician Assistants, reviews the relevant literature and the present climate of PA utilization on an international scale.2 The report recognizes the scarcity of PA literature in Canada; however, 5 Canadian studies were included in the analysis.6–10 These studies revealed that PAs ...
saved their supervising physicians more than 200 hours per year and increased surgical throughput6;
decreased length of time to in-hospital consultation and decreased hospital length of stay7;
reduced resident workload and decreased late hospital discharges8;
reduced wait times nearly 2-fold and decreased the number of patients not seen in the emergency department by 50%9; and
increased surgical productivity by more than 35%.10
Despite these data, this report concludes that the overall acceptance of the PA profession in Canada, and therefore Ontario, has been more limited than in other countries.2 The report suggests the following critical problem areas to target: identifying appropriate funding models; achieving nation-wide regulation; and ensuring adequate volume of clinical opportunities for PA education and training.
As a logical extension of the first report, the second CBoC report, Gaining Efficiency, uses economic modeling to define the financial effects of PA integration.3 This report analyzes the value of PAs as a function of physician time savings and efficiency gains within 3 practice areas: primary care, emergency care, and orthopedic surgery. Results showed that effectively integrating PAs can result in cost savings when PAs generate productivity enhancements of 30% to 40%. Over 13 years of national PA practice, this could translate to efficiency gains between $89 and $100 million. This report concludes that PAs can efficiently substitute the higher cost of physician services through the process of delegation. The report only briefly addresses the lack of sustainable funding for PA employment, leading to the third CBoC report, Funding Models for Physician Assistants.
Struggles of PAs.
Funding Models for Physician Assistants presents case studies of funding models from experiences in the Canadian province of Manitoba, the United States, the United Kingdom, and the Netherlands; these jurisdictions have successfully integrated PAs into their health care systems. Case studies were generated based on structured interviews and existing literature. These experiences were contrasted with the Ontario PA perspective, and then recommendations were provided based on the comparisons, for example, provincial government funding (Manitoba), a discounted fee-for-service model (United States), employment of a targeted number of PAs within a targeted time frame (United Kingdom), and funding incentives for overtly supportive physicians (Netherlands). One theme identified from interviewees in Ontario was the fear that current funding models for PAs in the province are precarious, “unsustainable and unpredictable,” which stakeholders believe puts both professional advancement and job security at a standstill.4
It is regrettable that many PAs in Ontario, the province that produces and employs the highest number of PAs, experience potential unemployment year after year. It is too early to say whether these CBoC reports will lead to government action in Ontario; however, CAPA has been using the reports in its advocacy work and hopes the findings and financial modeling will inspire policy makers and stakeholders to take action.
Precarious economy, lack of funding, low priority
In 2012, the Ontario government froze base hospital budgets, and many health care workers employed by hospitals went suddenly without jobs after decades of service.11 There was little political appetite to increase funding of a new profession that lacked data to support its economic benefit. Simultaneously, Ontario physicians were faced with fee-for-service payment decreases,12 and physicians were struggling to find jobs after graduation.13 Although both the Canadian Medical Association and the Ontario Medical Association recognized the PA profession and the important role that PAs have in the health care system, budget and physician challenges were at the forefront.
The greatest disappointment in the years after the demonstration project was the MOHLTC’s failure to move quickly to establish a funding model for PAs that is more sustainable and widely used. To date, there are 2 main funding strategies for PAs in Ontario: the “career start grant,”14 and family health team funding.15 The former is a subsidy lasting 1 or 2 years to help hire new graduates. However, once this funding ends, hospitals and clinics are challenged to pay for the PA salary out of their global budgets. The latter funding model, family health team funding, supports patient enrolment in primary care provider groups that include PA positions, but is often limited by its inadequacy as a stand-alone salary.
Between 2008 and 2016, the number of Ontario PA graduates increased 4-fold, yet the job market remained relatively limited despite studies showing PAs were meeting health care benchmarks. Although a report by the Commission on the Reform of Ontario’s Public Services recommends the province shift workload from higher-cost physicians to PAs,16 the government has not taken large strides to promote and invest in the profession.
Opposing stakeholders
The Registered Nurses’ Association of Ontario was an early vocal opponent of PAs, citing inadequate education, patient safety concerns, and unnecessary cost.17 Similar concerns were expressed by the College of Nurses of Ontario, the Ontario Nurses’ Association, the Ontario Association of Medical Radiation Technologists, and the Ontario Society of Senior Citizens Organizations.18 The opinions voiced more than 5 years ago likely reflected the small number of PAs in the work force, the limited exposure working alongside the profession, and the lack of regulatory status. More recently these stakeholders have not publicly criticized the PA profession; rather, they have provided clarification on how to better understand the PA role and process of delegated controlled acts.19 Further, PA stakeholders report a wide variation in the acceptance of their role by other health care professionals.
Lack of regulatory status
Health professional groups in Ontario may apply for self-regulation through the Health Professional Regulatory Advisory Council (HPRAC). Ontario PAs applied to the HPRAC in 2012. According to HPRAC guidelines, “the applicant must present a solid, evidence-based argument … that there is a risk of harm to the public”20 before self-regulation is granted. Ironically, the HPRAC determined Ontario-based PAs did not meet the harm threshold. However, physician and hospital organizations argued in their submissions to the HPRAC that PAs inherently meet the harm threshold because their scope of practice mirrors that of their supervising physician. Therefore, if PAs perform tasks similar to those of a physician, how can they not be a potential safety risk to the public? Nursing and some other health professional associations argued the opposite: that harm to the public is minimal if physicians are providing sufficient oversight of their PAs, as they are required to do.21 Ultimately, the HPRAC determined Ontario-based PAs did not meet the harm threshold and regulation was deemed unnecessary—a further blow to the advancement of PAs in Ontario. Regulation would allow for greater acceptance by other stakeholders and ease professional implementation. This has been especially true when PAs are regulated by the colleges of physicians and surgeons as they are in Manitoba, New Brunswick, and Alberta.
Although the HPRAC has recommended the College of Physicians and Surgeons of Ontario develop a compulsory PA registry, this has not yet happened. In August 2017, Dr Eric Hoskins, who was the Minister of Health at the time, formally requested that the College of Physicians and Surgeons of Ontario consider taking steps toward regulating PAs and to report back to him by the end of 2017.22 At the time of completion of this commentary, no further information was available on how this was progressing; however, in Ontario’s current government and recently published health care reform, there is no mention of PAs or whether they will be part of the government’s plan to reduce hallway medicine.23
Conclusion
The PA demonstration project introduced the profession to Ontario and led to the formal education of civilian PAs. The CBoC reports show that PAs can provide promising financial and system benefits when optimally utilized.2–5 Unfortunately, the lack of more sustainable funding models and the failure to achieve regulation have slowed the profession’s advancement. Meanwhile, other provinces have managed to implement PA practice without much controversy, even in some cases in the absence of a civilian education program. Encouragingly, in September 2017 the MOHLTC formed an Ontario PA working group to address these issues (K. Burrows, personal communication, October 2017). To date there are no concrete developments; however, it is hoped there will be forthcoming solutions. If these challenges can be surmounted, the Ontario government might be able to finish what it boldly started over 10 years ago: the successful implementation of PAs in Ontario.
Footnotes
Competing interests
None declared
The opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.
This article has been peer reviewed.
Cet article se trouve aussi en français à la page 249.
- Copyright© the College of Family Physicians of Canada
