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

• assisting 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.

Many OPAs 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.

Reimbursement 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.

This 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.

It 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.

In 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 reimbursement.

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.

What 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.