The origins of the Orthopaedic
Physician’s Assistant come from a time period over 40 years ago when a shortage of physicians was projected. It was
during this same period that training and recognition of assistants in various specialties began. Without belaboring all of
the historical events that have taken place, the development of the OPA profession arose from the concept of physician
extenders. Within our specialty of orthopaedics, surgeons were looking for trained individuals who could assist them with
patient care responsibilities, immobilization techniques, and assisting in surgery.
During the decade that followed, the National Board Certification of Orthopaedic Physicians Assistants
(NBCOPA) formed in 1979 and the OPA’s role continued to expand from physician extender to mid-level practitioner. The
NBCOPA, in conjunction with the American Society of Orthopaedic Physician’s Assistants (ASOPA), created a set of practice
guidelines that has defined the function and responsibilities of OPAs. Throughout this time period, other mid-level practitioners
including the physician assistants (PA-C) and nurse practitioners saw increases in their educational training programs and
in the number of individuals entering into these professions.
The mid and late 1990’s saw continued growth for physician assistants and nurse practitioners with
a trend toward licensure in most states. While our profession did not achieve this same robust growth, important recognition
was granted in the State of Tennessee with full licensure for OPAs. Registration was adopted by the State of New York
for OPAs and several other states enacted grandfather clauses that recognized some OPAs.
The role of the OPA in the present healthcare environment continues to change. Increasing
government regulation of healthcare entities, declining reimbursements from third party payors, outward growth of other orthopaedic
health professionals, technology, and sharp economic changes all continue to impact our profession.
The question that is frequently asked is, “How do we classify OPAs? And are OPAs still considered
a mid-level practitioner or rather an allied health professional functioning in the capacity of a specialized technologist
or perhaps both?” The answer to this varies. There is not a universally adopted definition for a physician
extender. In general, it is accepted that mid-level practitioners are considered physician extenders, but another question
arises, “Are all physician extenders mid-level practitioners?” The best example of this I can
provide is athletic trainers. If you were to do a search under the term “mid-level practitioner”, the title
of “athletic trainer” usually does not appear. However, the National Association of Athletic Trainers (NATA) has
adopted a model known as “physician extenders”, including fellowship-training programs for those trainers
who wish to seek employment within physician’s practices. This concept is widely advertised and endorsed by NATA as
a means of continuing to grow their profession in many different directions.
To really define our classification (OPA), we need to look at what our role in an orthopaedic
practice is. Going back to the beginning of our profession:
• assisting with patient care,
immobilization techniques, and
in the operating room
was, and still is, the basis
of our work. Many of us work for orthopaedic group practices in which our specific duties generally fall under these
same three categories.
are responsible for taking patient histories and preparing the patients for the physician-patient encounter. Others go
a step beyond this by performing the physical component of the examination in addition to the history. Regardless, the OPA
presents all of the information to the supervising surgeon. In most states where there is no legislation for OPAs, diagnosing
and medical decision-making is performed strictly by the physician. The OPA’s role is to support the physician by assisting
him or her in providing all the necessary information needed to make the diagnosis and then helping to execute the medical
treatment plan which may include patient education, injections, aspirations, application of orthopaedic appliances, and arranging
for ancillary services. This role shifts in the operating room to assisting the surgeon with managing the care of the
patient including all aspects of positioning and assisting with the surgical exposure, retraction, and wound closures. One
of the unique benefits of having an OPA versus other practitioners who work in the operating room is our knowledge of
the medical devices and implants that the surgeons use. Most OPAs bring a technical component to their work that other practitioners
were not trained on. Additionally, as our work is bound tightly to our supervising surgeon, the OPA is taught to think like
a surgeon and is often aware of many nuances for a specific set of instruments or implants that others outside of the surgeon
may not know.
What are the benefits of
having an OPA if I can’t get paid Medicare dollars for him or her? This is a question frequently
asked by surgeons when discussing an OPA. If you were to step back and look at this issue on a wider scale, one would find
a favorable cost to benefit ratio.
to the surgeon comes in two forms – direct and indirect. Direct reimbursement often comes as a result of surgical
assistant fees. At the present time, OPAs are not eligible to receive payment from Medicare or Medicaid for assisting
in surgery. On the other hand, direct reimbursement for an assistant in surgery is often paid by third party payors. The actual
payments and amounts vary not only from state to state, but also amongst individual insurance plans and procedures performed.
A clear knowledge of what types of cases are reimbursable under a particular plan can help in calculating potential income
from this source.
The second part of the
cost-benefit of OPAs comes from indirect payments. Those OPAs who have a solid level of orthopaedic knowledge and clinical
skills can make an orthopaedic practice more efficient. An example of this is an OPA who spends time with patients educating
them about a particular condition or surgery following the surgeon’s diagnosis. This frees the surgeon and allows
him/her to continue seeing patients and spend more time with those who need it.
From a pure numbers point of view, consider this:
A well-trained, knowledgeable OPA should be able to help a surgeon see a least one extra patient
per hour. Assuming the surgeon sees patients for 20 hours a week, the simple math computes to 20 extra patients per week or
about 1000 per year. Considering current reimbursement rates that vary geographically from about $30 for a simple follow-up
visit to more than $500 for a new patient consultation, we will use a figure of $88 for a moderate level follow-up visit.
Eight-eight dollars ($88) per visit for 1000 patients a year is $88,000 worth of reimbursement that an OPA can bring indirectly
to a physician’s practice.
is a conservative estimate. Those who see more new patients or consultations, along with those who spend more time on a weekly
basis, will find this number to be much larger. Additional revenues to the physician practice include fees collected from
self-administered brace/splint programs conducted by OPAs. Collectively, the direct and indirect reimbursements can help justify
a salary commensurate with a mid-level practitioner. Other in-direct sources of reimbursement which I will call a convenience
factor for the surgeon include areas related to managing clinical research, preparing presentations, and records preparation
for independent medical examinations.
also should be noted that in many practices, OPAs work alongside other mid-level practitioners. While there is some overlap
of the general scope of practice for OPAs with other physician extenders, an efficient orthopaedic practice can effectively
and efficiently employ both.
summary, the OPA working as a physician extender can help improve the efficiency of an orthopaedic practice. Our level
of knowledge and technical skills can offer surgeon’s the opportunity to see more patients, decrease patient waiting
times, allow for better one-on-one care which in turn can produce improved patient satisfaction ratings and overall practice
So where is our profession
going as we come closer to the year 2010? In our constantly changing world of health care, the OPA will continue
to serve orthopaedic surgeons and patients in hopefully, a more expanded role. It is my belief that we need to continue to
market ourselves as physician-extenders rather than mid-level practitioners. We are allied health professionals
who bring the knowledge, skills, and training in all three critical areas of orthopaedics including assisting with patient
management, fracture immobilization, and surgical assisting.
We have a defined role that does differ in many aspects from primary physician assistants (PA-C), nurse
practitioners, and surgical assistants. It is my further belief that we as a profession need to establish strong relationships
and partnerships with other allied health professional organizations that can serve to offer our members great educational
opportunities and skills.
about Medicare/Medicaid Reimbursement? While most of us still cling to the hope of seeing Medicare
reimbursement dollars, the reality is this is probably not going to happen anytime soon. Payments to physicians have
been cut yearly and the system is faltering. A major overhaul of the system is desperately needed before Medicare runs
out of money sometime in the next 20 – 30 years. Adding another payor (OPAs) to the mix is not likely to happen. We
need to look beyond that and consider other avenues to bolster our relationship with our surgeons and to find ways to benefit
our patients. I strongly advocate OPAs continue to learn and obtain additional certifications in specialty areas. This
may include clinical research, coding, wound management, and surgical first assisting. I have heard several of our older
generation of OPAs say that after working in orthopaedics for 20 plus years, they don’t have a desire to obtain
further credentials. While it is true, that more credentials doesn’t always equate to more salary, it does offer the
best chance for further opportunity. The reality is that in our ever-changing healthcare environment, we like every other
provider have to branch out and seek avenues where we can make a difference.
In closing, the OPA profession
has had a defined role to our surgeons and patients for nearly 40 years. It is imperative that we not sit back and wait for
things to happen to us, but rather continue to market our value to our surgeons, patients, and peers. In a time when reimbursement
is down, efficiency and improving patient satisfaction is the key to improving the bottom line for our practices. We as OPAs
have the fundamental knowledge, skills, and training to do this.