National Nurses United

medical assistants worked in doctors' offices, and 13 percent in hospital outpatient settings. Medical assistants by law cannot work in hospital inpatient environments. Almost 90 percent are women, and in California, 54 percent are of a non-white ethnic background. Their salaries are low: in California, they make on average about $12.50 per hour, and nationwide, about $12 per hour. They are typically paid half, or even one-third of what an RN would be paid. Patients, and even the doctors and nurses that medical assis- tants work alongside, are often surprised to learn that medical assistants are not licensed by any of the 50 state medical boards. Only South Dakota requires medical assistants to "register" with the state and renew their registration every couple years. As the job professionalized over the decades, various state and nation- al groups, such as the California Medical Assistants Association and American Association of Medical Assistants, started offering certification for medical assistants to show they had completed a certain amount of education and training. Though certified med- ical assistants can command a three to seven percent higher salary than uncertified peers, fewer than five percent of the state's medical assistants are certified, and certification is strictly vol- untary—driven only by employer demand. In California, most of medical assistants' allowed duties can be found in Section 2069 of the state's Business and Professions Code and in Title 16, Section 1366 of the Code of Regulations. In general, they are described as personnel performing "basic admin- istrative, clerical, and technical supportive services" for licensed doctors, podiatrists, a medical corporation, or for a healthcare services plan. They are supposed to be working under the license of and supervised at all times by a licensed doctor or podiatrist, though the Board of Registered Nursing has determined that clin- ical supervision can be delegated by the physician to the regis- tered nurse. With a minimum number of hours of training (10 hours for each function), medical assistants can also administer any med- ication, through a variety of forms, after verification by a licensed person, give shots, draw blood, give breathing treatments, and perform other tasks. The law forbids them from administering anesthesia or performing tests that penetrate human tissue and, of course, interpreting test results or triaging patients by phone because doing so would require assessment. Still, however, the laws and regulations can be vague or not comprehensive enough to take into account workflow situations that department managers or medical offices dream up. If the law does not explicitly say medical assistants cannot do something, managers tend to want the medical assistant to do it. As a result, medical assistants often operate in a grey area. "The managers take the law to the farthest extreme," says Calvert, the pediatrics RN from Kaiser Roseville. "Yeah, the law says that, but is that good practice? How does it compare to the hospital? They always say we're overly worried, and they minimize the risks. We have different interpretations." Taché found in one study, where she interviewed 12 med- ical assistants, that job duties did indeed vary widely. One MA appeared to be actively educating patients, which is illegal. Because she claimed the doctors taught them so much, she in turn could educate patients on things such as what foods or activ- ities they should eliminate from their lives if they suffer from high blood pressure. Medical assistants' activities are largely dependent on the way the healthcare practice is organized, how it is run, and who used to be major surgeries that required week-long hospital stays. No group tracks the total amount of dollars spent on outpa- tient care, but hospital outpatient spending consistently tends to be the fastest-growing healthcare spending category, according to data from the Milliman USA Health Cost Index. The annual rate of growth has reached at least 7.5 percent since 1994, and has stayed in the double-digit range since 2001. A 2003 study by VHA Inc., a network of more than 2,200 nonprofit healthcare organi- zations, also found that the market for outpatient services was projected to increase six to 21 percent between 2002 and 2007. "Because it's cheaper to treat people in an outpatient set- ting, there's a huge push to keep people out of the hospital or get them out sooner," said Brian Schilling, a spokesman for the National Committee for Quality Assurance, a non-profit group that tracks managed care plans. "But they're using a less-creden- tialed provider to keep costs down. Whether that's good for patients, I don't know. But it's a really interesting question and a real pressing public health issue." The risks to patient safety are real. More than two-thirds of negligent events leading to malpractice claims examined in a study published April 2004 by the Robert Graham Center, a Washington, D.C.-based policy group on family practice and primary care, occurred in outpatient settings, resulting in 1,200 deaths. Concerns about the misuse of medical assistants are not iso- lated to Kaiser Permanente, but extend to private doctors offices as well—it's just that no one is there to observe and report back what happens in those settings. "There's no one to police them, no RNs to say, Hey, that's not appropriate," says De Calvert, an RN QL who works in pediatrics at Kaiser in Roseville. In the Kaiser outpatient setting, at least, the RNs have greater opportunity and access to observe and collect stories about what functions various staff are performing—so it's useful to take a hard look at what goes on in the Kaiser system to understand the current state of outpatient care. M edical assistants have been around since World War II, when doctors short of nurses trained their medical secre- taries to fill in, but the profession really exploded with the advent of managed care, according to Stephanie Taché, a University of California, San Francisco research fellow and one of the few to have studied this profession. Medical offices needed staff who could both handle "front office" tasks like reception, billing, and other paperwork, and "back office" tasks like rooming patients and taking blood pressures to prepare for the doctor's visit. Conservative figures put the number of medical assistants in California at somewhere between 50,500 and 71,000 as of 2000, and somewhere between 365,000 and 605,000 nationwide. But those figures are rapidly climbing. As the health services industry continues expanding, as people live longer, and as out- patient practice grows more complex and reimbursement pat- terns get more complicated, the state and rest of the country will see a huge demand for medical assistants, write Taché and col- league Susan Chapman in a 2004 paper titled "Medical Assistants in California." Projections over the next decade say medical assisting will be one of the fastest-growing jobs, reaching 60 per- cent growth, and have one of the largest number of job openings in California. "Very few people have looked at this issue of medical assis- tants, even though there are a lot and they're often running out- patient practices," says Taché. As of 2000, almost 80 percent of 14 M A Y 2 0 0 5 C A L I F O R N I A N U R S E

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