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Physician assistants may be an important part of the healthcare team, but changing their name to "physician associates" will only confuse patients, several members of the American Medical Association's (AMA) House of Delegates said.

"On May 24, the American Academy of Physician Assistants' (AAPA) House of Delegates voted to pursue a change in their legal title from 'physician assistant' to 'physician associate,'" Cyndi Yag-Howard, MD, a delegate from the American Academy of Dermatology (AAD) who spoke on behalf of the academy, said at a session of the delegates' reference committee on legislation held during the AMA's annual meeting. "Subsequently, the AAPA published on its website the true intent of their title change, which is to fully rebrand PAs in a way that we fear might be perceived by patients as an artificial elevation of PAs' level of training and expertise."

"In fact, their own website states, 'Prematurely using the term "physician associate" might be viewed as confusing to patients and could be interpreted as the PA stepping beyond the scope of their current license,'" said Yag-Howard. "Their website also reveals how much they're willing to invest in changing the name of their professional title -- namely $21.6 million spent on legal endeavors."

The AAD and 16 other delegations are cosponsors of a resolution calling on the AMA to oppose the name change -- which has been widely panned in the physician community -- and to "actively advocate that the stand-alone title 'physician' be used only to refer to MDs and DOs and not be used in ways that have the potential to mislead patients about the level of training and credentials of non-physician healthcare workers." AMA leadership has already taken action, coming out last week with a statement opposing the change.

Many Comments in Support

Michael Simon, MD, a delegate from the American Society of Anesthesiologists, spoke in support of the resolution. "Words matter. Titles matter," he said. "While we have advocated hard for the maintenance of physician-led teams, it has become wildly apparent that mid-level providers are determined to increase their scope of practice and mislead patients." He thanked the AMA for its help in in New Hampshire by nurse anesthetists who wanted to call themselves "nurse anesthesiologists." "We support any efforts the AMA can undertake to prevent patient confusion and disruption in the clinical setting."

"We call this 'Scope-A-Dope,'" said Ray Callas, MD, a Texas Medical Association delegate speaking for his delegation, which cosponsored the resolution. "And until we decide to take this bull by the horns, all they're doing is confusing our patients. If you want to be a doctor, go to medical school." Matthew Gold, MD, a delegate from the Organized Medical Staff Section who was speaking for himself, pointed out that there had been some movement to apply the term "associate physician" to unmatched medical school graduates "who needed a spot in a hospital setting and that was a term that was going to be applied to them."

Hans Arora, MD, a delegate from the American Urological Association -- another resolution cosponsor -- painted a dark picture of the public relations battle in this area. "Despite all the wins we tout, the state scope [of practice] bills that we beat back, the surveys we do that say the American people trust physicians, the truth is that the rank-and-file physicians -- the people we claim to represent -- believe that we're losing," he said. "We're losing the opportunity to prove that the independent practice of medicine falls under the sole purview of the physician." Over the last 5 years, the AMA's spending on advocacy, "one of our core activities, has been essentially flat," he added. "This approach is akin to going out panning for gold but we let the cabin burn down at home. Let this issue be a call to our AMA to refocus its efforts."

Ray Lorenzoni, MD, a member of the Resident and Fellow Section, said that the resolution was missing "a concrete way to wage an offensive." He urged the reference committee to recommend referring the resolution for further study "and have the study group look at the different ways that we can get the offices of the professions involved, health departments at the state level, create patient-facing campaigns and model legislation to prevent patient confusion."

Medicare Advantage Resolution Offered

Delegates were also incensed by another issue: some Medicare Advantage plans' efforts to limit care for their beneficiaries. "There are over 3,500 different Medicare Advantage plans in the United States," said Susan Hubbell, MD, a delegate from the American Academy of Physical Medicine and Rehabilitation (AAPMR). "We are very concerned because we are seeing patients who have diagnoses that automatically would be able to go to our inpatient rehabilitation center -- such as stroke and fractured hip -- but they are being denied by Medicare Advantage plans in our areas."

The AAPMR's resolution calls for the AMA to "ask the Centers for Medicare & Medicaid Services (CMS) to further regulate Medicare Advantage plans so that Medicare guidelines are followed for all Medicare patients and that care is not limited for patients who choose a [Medicare] Advantage plan" and that the AMA also advocate against the plans using "proprietary criteria" to determine patients' eligibility for procedures "when the criteria are at odds with the professional judgment of the patient's physician."

"Medicare Advantage plans are not required to follow Medicare guidelines for beneficiary coverage," asserted Enrica Arnaudo, MD, a delegate from the American Association of Neuromuscular and Electrodiagnostic Medicine, who spoke for the delegation, which cosponsored the resolution. "Many of these plans do not provide the same coverage as traditional Medicare, and patients are often surprised to find out that they are not guaranteed the same level of treatment as a patient insured by standard Medicare ... Even more egregiously, the Advantage plans' marketing provides continuous deceiving information to our elderly patients. They run commercials on TV as if there is the best and the safest option available to seniors, promising more benefits all the while providing less. Let's hold them accountable for what they promise."

CMS Offers An Explanation

Kara Jacobs Slifka, MD, MPH, of the Public Health Service, spoke for CMS and tried to clarify the Medicare rules. "Medicare Advantage plans are required to furnish their enrollees with medically necessary Medicare covered healthcare services," she said. Although it's true that Medicare Advantage plans can make medical necessity coverage determinations, "these plans must not use coverage policies that are more restrictive than Original Medicare."

However, she continued, "they are permitted to do medical management. This would lead to some services being denied, but this is subject to appeal ... The reconsideration appeals process is the remedy for incorrect determination." That was news to Tatiana Spirtos, MD, a delegate from California.

"I never heard of the appeals process myself, as a physician who is constantly facing these burdens," she said. "I have gotten to that delicate age where I'm bombarded with information on Medicare plans ... And I have to tell you, I have great health literacy as well as legal literacy, and yet the information that comes through the mail is quite confusing at times." She asked for the AMA to develop a pamphlet explaining to patients the differences between traditional Medicare and Medicare Advantage -- to "do everything we can to simplify it for our patients, to clarify it, and to educate our patients."

Several delegates spoke of their negative experiences with Medicare Advantage plans' coverage decisions. "It's not uncommon for me to have a patient in the office that needs an acute CT scan of the abdomen," said Carl Wehri, MD, an alternate delegate from Ohio. "And one of the first things my office staff asks is, are they managed Medicare, and then they give me a signal that it is so difficult to deal with them. It is not unusual for me to have to send a patient to the emergency room in order to get a necessary scan because we don't have a couple of days to decide if this test should be done. So please make changes in managed Medicare because we really need it."

The reference committee will meet over the next few days to issue recommendations on each resolution; the House of Delegates will vote on the recommendations during its general session, which began on Friday and continues on Monday.

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