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The material on NCCPA's certification and recertification exams can be organized in two dimensions: Organ systems and the diseases, disorders and medical assessments physician assistants encounter within those systems; and The knowledge and skills physician assistants should exhibit when confronted with those diseases, disorders and assessments.

Please note that while the subject matter covered on the certification and recertification exams is the same, there is some difference in the nature of the questions on those exams. Generally, the questions on the initial certification test are more specific, while questions on the recertification test tend to address broader clinical issues. This difference is most apparent in the questions related to applying basic science concepts and reflects the different functions of the two exams.

Note: Because of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) publication, NCCPA will adapt its content blueprints, disease and disorder lists, and psychiatry-related terminology within test questions to conform to DSM-5 classifications and diagnostic criteria for all of their examinations.
In NCCPA examinations, psychiatry-related terminology within test questions will include the DSM-5 terminology followed by the DSM-IV-TR terminology in parentheses. Example: illness anxiety disorder (hypochondriasis)

Based on delays in implementation of DSM-5 guidelines within the field of psychiatry, NCCPA will continue to present psychiatry-related terminology within test questions in the manner outlined above until further notice.

Beginning in 2019, there was a new content blueprint released for the Physician Assistant National Certifying Examination (PANCE). The content blueprint provides guidance on the information assessed on the Physician Assistant National Certifying Examination (PANCE). The examination is categorized in two dimensions:
Knowledge of the diseases and disorders physician assistants encounter; and Knowledge and skills related to tasks physician assistants perform when treating patients.
The detailed listings provided under each of these two categories represent examples of the material that may be covered on PANCE. It is not possible to include all courses on a single exam, and it may be possible that some questions on the test cover content that is not listed in the examples.

The content blueprint for PANCE is based on information provided from certified physician assistants who participate in profession-wide practice analysis studies. Certified PAs are involved throughout the test development process, including: reviewing results of the practice analysis, writing questions that appear on PANCE, reviewing exams before they are administered, reviewing performance data for test questions, and developing recommendations for the passing standard. Certified PAs work with NCCPA to continuously review the content included on PANCE to ensure it is relevant and current, as the practice of medicine changes and treatment guidelines are revised or new ones introduced.

Cardiovascular System 13%
Dermatologic System 5%
Endocrine System 7%
Eyes, Ears, Nose, and Throat 7%
Gastrointestinal System/Nutrition 9%
Genitourinary System (Male and Female) 5%
Hematologic System 5%
Infectious Diseases 6%
Musculoskeletal System 8%
Neurologic System 7%
Psychiatry/Behavioral Science 6%
Pulmonary System 10%
Renal System 5%
Reproductive System (Male and Female) 7%
History Taking and Performing Physical Examination 17%
Using Diagnostic and Laboratory Studies 12%
Formulating Most Likely Diagnosis 18%
Managing Patients
Health Maintenance, Patient Education, and Preventive Measures 10%
Clinical Intervention 14%
Pharmaceutical Therapeutics 14%
Applying Basic Scientific Concepts 10%
Professional Practice 5%

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putting off Medicare’s Outpatient Ban and Medicare and personal Surgical developments | PANCE Latest Questions and Practice Test

look at Design: A retrospective evaluation of all clinic discharge data in Florida from 2012 through 2018.

strategies: They tracked inpatient vs outpatient performance of TKAs on the state and health facility tiers. They also combined their fundamental records with healthcare professional follow firm information to investigate version in the coverage response according to medical professional-clinic possession popularity. Supplementary analyses examined coverage-induced adjustments in inpatient TKA case combine.

results: They observed an instantaneous shift of roughly 15% of Medicare TKA circumstances to the outpatient setting. Importantly, there turned into a simultaneous near doubling of the number of TKAs performed as a health facility outpatient process amongst privately insured patients more youthful than 60 years. Hospitals allocated a similar share of TKA circumstances to the outpatient environment across the two payer businesses, and they found proof of choice against the probably riskiest Medicare TKA patients for outpatient start. Vertically built-in orthopedic physicians retained their Medicare and privately insured TKA instances inside the inpatient (better-cost) atmosphere.

Conclusions: Market and monetary pressures are encouraging more outpatient care start; despite the fact, the pace of transition is dictated, in part, by way of regulatory constraints. Their consequences imply that Medicare coverage may additionally influence surgical medication tactics for Medicare and privately insured sufferers. Spillover implications should be regarded when weighing future Medicare regulatory choices.

Am J Manag Care. 2021;27(3):104-108.


Takeaway facets

  • in the first 12 months following Medicare’s determination to remove total knee arthroplasty (TKA) from its Inpatient only checklist, Florida hospitals shifted 15% of TKA Medicare cases to the outpatient surroundings.
  • That identical year, the overall variety of outpatient privately insured TKA cases doubled and represented 25% of all privately insured TKA circumstances in the state.
  • Medicare directors and policy makers need to pay consideration to potential for Medicare rulemaking spillovers on care delivery, and hence scientific spending, for non-Medicare patients.
  • _____

    there is a growing shift towards outpatient care birth throughout the us health care equipment, which is expected to benefit patients via reduce charges and greater comfort relative to inpatient medicine options.1 The clinic industry has been compelled to confront these traits as outpatient income is now at near parity with inpatient salary for US hospitals.2 although market forces and monetary pressures underlie some of these movements, regulatory interventions are also critical. notably, Medicare is regularly a major source of care beginning rules, which could affect the specific timing and velocity of inpatient to outpatient care transitions.

    A trendy and modern illustration comes from orthopedic surgery involving knee replacements (ie, total knee arthroplasty [TKA]). each year, approximately 680,000 individuals acquire a TKA, which prices greater than $30,000 on standard.3-6 In 2013, CMS first attempted to eliminate TKA procedures from the Medicare Inpatient best (IPO) listing, which prohibits outpatient surgery for listed processes. The preliminary attempt become subsequently unsuccessful, however the coverage initiative finally won sufficient guide to culminate in TKA’s removal from the Medicare IPO record on January 1, 2018.7 The 2018 rule exchange granted suppliers the skill to function the process for Medicare beneficiaries inside a hospital outpatient department, besides the fact that children inpatient beginning remained permissible.8

    The Medicare TKA rule exchange did not take area in a vacuum, as momentum had been turning out to be towards outpatient beginning due to clinical and procedural improvements that shortened the required length of dwell for predominant surgery. for example, the common length of reside for a joint substitute technique has lowered from 9 days to four days within the final twenty years—with outpatient delivery almost always resulting in identical-day discharge.9-11 Outpatient TKAs have also been estimated to be as lots as 30% to 50% much less expensive than inpatient TKAs,2,12,13 and some forecast as much as half of all TKAs taking location inside an outpatient atmosphere over the next decade.14

    to date, there was restricted analysis on the 2018 TKA IPO choice. facts from 2 experiences documents outpatient start take-up for Medicare instances throughout the us, which averaged $3600 in decrease Medicare funds and generated more than $300 million in savings,15,sixteen but neither study speaks to broader coverage ramifications, specially for non-Medicare TKA patients. Medicare accounts for roughly 20% of all US health care expenditures and is primary to have an effect on contracting and care birth for the privately insured. for instance, prior analysis finds Medicare spillover results onto private assurance fee schedules in addition to providers’ remedy of deepest sufferers following Medicare incentive alterations.17-25 besides the fact that children, Medicare’s regulatory externalities are only starting to be understood. Geruso and Richards offer the most effective familiar analyze that explicitly investigates and documents spillover outcomes from Medicare rulemaking onto the privately insured section of the us health care market.26 They consider such regulatory externalities are central in their context. during this atmosphere, deepest insurers did not have uniform restrictions on the use of outpatient surgical capabilities, however physicians may have been reluctant to function strategies in dissimilar settings or bear better perceived liability risks. suppliers and personal insurers may therefore have adopted the guidelines established by way of Medicare. Carey et al likewise posit that TKA removing from the Medicare IPO list may invigorate private insurer efforts to movement more TKAs into the outpatient surroundings.27

    the use of the universe of information from all Florida hospitals for 2012-2018, they examined developments in inpatient and outpatient TKA surgeries for 2 key payer kinds: normal Medicare and the privately insured (non-Medicare). They additionally explored the degree of correspondence in postpolicy outpatient option across payers inside the same clinic in addition to alterations in inpatient case traits. Importantly, a complementary database allowed us to assess if health center employment of surgeons moderates any trade in outpatient start. The variations in reimbursement throughout settings are salient to hospitals and could have led them to discourage employed surgeons from performing TKA approaches outside the (greater-paying) inpatient surroundings. Taken together, their findings demonstrate even if an abrupt Medicare coverage intervention is associated with the diploma to which different health care suppliers replace lower-charge remedy options.


    analyze pattern

    the administrative facts set turned into received from the Florida company for health Care Administration (AHCA) and comprised the universe of inpatient and outpatient (ambulatory) method discharge statistics from the state of Florida over the 2012-2018 duration. The facts are recorded quarterly; despite the fact, they annualized the analytic records to easy out inside-12 months seasonality in care birth (see the eAppendix [available at] for quarterly-stage analyses). every discharge listing contained counsel on the medical techniques being carried out, the suppliers concerned (eg, surgeons and hospitals), and patient features, together with the primary payer (eg, Medicare or private assurance). TKA instances have been recognized the use of the corresponding international Classification of diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) method codes for the inpatient discharge data and the corresponding latest Procedural Terminology (CPT) codes for the outpatient discharge facts. across each settings, they observed about 17,000 to twenty,000 Medicare TKAs per year and 10,000 to 14,000 privately insured TKAs yearly (see figure 1).


    Our simple analyses longitudinally tracked the treatment setting choices for TKAs throughout their 2 key payer corporations. They examined how frequently outpatient settings have been used in 2018 for Medicare patients and to what extent the fashion for privately insured sufferers corresponded to the timing of the Medicare coverage trade. They also examined the cross-payer concordance in 2018 outpatient use for TKAs in the identical medical institution.

    We then carried out a couple of supplementary analyses. the primary examined the inpatient vs outpatient TKA determination for vertically built-in (ie, employed by way of a sanatorium or health system) orthopedic surgeons vs all others. They adopted a number of accurate experiences and received information on health professional vertical integration popularity from the SK&a health care provider office survey, which they linked to the discharge facts by the use of countrywide provider Identifier numbers.28-33 subsequent, they examined tendencies in web page of care for all non-TKA procedures over their examine period to be sure that 2018 turned into not staggering in other ways. at last, they explored alterations within the inpatient case combine (ie, possibility choice) for Medicare and privately insured TKAs in 2018 by means of evaluating their patient characteristic developments in opposition t all different inpatient methods belonging to each payer (see the eAppendix for full methodological details and consequences).

    The study was permitted by way of the Baylor tuition Institutional evaluate Board, and Florida AHCA was now not accountable for any analyses or facts interpretations.


    determine 1 shows the full variety of TKA techniques carried out per 12 months among Medicare charge-for-service and private payer populations in Florida. The number of TKA procedures expanded for each payers over time; although, neither payer community proven significant TKA boom in 2018.

    figure 1 additionally displays annual percent changes and hence growth in inpatient TKA beginning over their study length for each payer group of hobby. From 2012 to 2016, each payers skilled an identical raises within the quantity of inpatient TKAs that then plateaued between 2016 to 2017. as soon as the Medicare prohibition on outpatient TKA delivery become lifted (2018), there become a sharp decline of inpatient TKAs. Inpatient Medicare TKA cases have been 15% lessen in 2018 in comparison with the 2017 quantity, and the tendencies for privately insured TKA sufferers generally mirrored these for Medicare. peculiarly, after years of tremendous increase, the privately insured TKA inpatient quantity fell via 12% in 2018. on account that 2018 is not characterized by declines in total TKA circumstances, the reductions in inpatient TKAs have to be offset by raises in outpatient TKAs.

    figure 2 gifts the variety of TKA tactics among the many privately insured population performed in an outpatient environment from 2012 to 2018. starting from a low base of 264 tactics (3% of all private TKAs), greater than 1000 such instances had befell throughout Florida by means of 2015. The fashion changed in 2018, despite the fact, with more than 3000 outpatient privately insured TKA circumstances taking region in that year (24% of inner most TKAs). This marked a virtually one hundred% increase from the previous yr (2017) and was concurrent with the Medicare IPO decision for TKA. figure 2 additionally presents these trends in accordance with the employment repute of the working medical professional. Physicians now not employed by using a health center or fitness equipment accounted for 85% of the expanded use of TKAs performed in outpatient settings. although this lack of response to the Medicare coverage alternate by means of vertically integrated surgeons can be suggestive of misaligned incentives and a strategic response by hospitals, they observed a greater share of TKA sufferers coming from rural areas amongst those treated by using vertically integrated orthopedic surgeons. Longer trip distances and doubtlessly constrained fitness care elements near their home dwelling could have altered the cost-benefit calculation for these specific sufferers (eAppendix desk 1).

    figure three items analogous traits for all non-TKA surgical tactics from 2012 to 2018 in Florida across these 2 payers. Neither the inpatient nor outpatient beginning tendencies indicate commensurately sharp and big adjustments in 2018 or some other year. The patterns in figure three therefore present further suggestive proof that the very large exchange in web site of take care of TKAs in 2018 (ie, a doubling of outpatient start for the privately insured) was possible due to factors particular to TKA approaches.

    In figure 4, they plot the 2018 TKA outpatient shares by means of payer neighborhood inside the same health center. there is a primary tendency to the scatter plot (ie, following the forty five-diploma line), implying that orthopedic surgeons and hospitals were commonly substituting toward the outpatient choice to the same degree for Medicare and privately insured TKA patients. there have been also exceptions (ie, favoring outpatient for one payer type relative to the other), however these situations may additionally have had extra to do with the encircling payer mix dealing with the surgeon and health center than the appropriateness of outpatient TKA surgical procedure.

    We discovered restricted alterations in the case mix for inpatient TKAs following the Medicare IPO policy change (eAppendix). the one amazing exception turned into some degree of alternative in opposition t the oldest (ie, 75 years and older) Medicare beneficiaries receiving a TKA as an outpatient, which isn't astounding when because their probably elevated dangers of complications and more desirable postoperative wants. Inpatient privately insured TKA case characteristics seemed unaffected by means of the sharp shift toward outpatient delivery in 2018.


    An increasing share of scientific care is migrating towards outpatient delivery. These developments pose strategic and monetary challenges for US hospitals, but they are not likely to be reversed. Preferences for outpatient care are not the handiest driving forces, however. Regulatory stances, such as those belonging to Medicare, may also be influential.

    We see facts in line with a regulatory barrier when evaluating the contemporary decision to circulation TKAs off the Medicare IPO record and thereby let the outpatient surgery choice for beneficiaries. Fifteen p.c of Medicare TKA situations had been reallocated from the inpatient to the outpatient environment (determine 1), and uptake is observed across numerous hospitals all over the primary deregulation year (figure 4). the important thing and novel discovering from their study is the alignment between the privately insured outpatient TKA trend smash and the Medicare deregulation experience. With an abrupt doubling of outpatient privately insured TKAs in 2018, their effects are at the least according to a Medicare policy spillover implication whereby outpatient provision became probably restrained prior to the Medicare IPO resolution. more advantageous use of outpatient hospital facilities following the deregulation experience from Medicare may have more desirable care convenience for privately insured TKA sufferers and lowered costs for patients and their insurers. Such a good externality as counseled by their records additionally comports neatly with Geruso and Richards’ findings from a contemporary study of a special Medicare surgical legislation from a decade prior.26

    As Medicare makes additional rule adjustments, future analysis will should explore the implications within and beyond the Medicare software. additionally, the long-run outcomes of the 2018 IPO exchange for TKAs will should be tracked as providers have more time to adapt.


    This examine used facts from a single state and for this reason can also now not generalize to different markets. This challenge is balanced, although, with the aid of the timeliness and multipayer dimensions that the Florida records present. Florida is additionally 2d best to California in terms of Medicare inhabitants, which makes it a significant state for Medicare policy evaluation, even in isolation.34 They additionally relied upon an observational look at design, so the linked style changes they look at may now not be causal.


    Medicare medicine restrictions and accompanying fee guidelines sooner or later shape how care is dropped at Medicare beneficiaries. They display that the CMS decision to permit outpatient TKAs was associated with a simultaneous and awesome boost in outpatient TKA birth for privately insured patients. in this method, Medicare rulemaking penalties may prolong past Medicare patients. talents spillover implications deserve enhanced consideration in future policy deliberations because Medicare guidelines can also influence the norms and the pace of trade for care birth right through the USA health care equipment.


    The authors thank the Florida agency for health Care Administration (AHCA) for presenting information for the look at and want to notice that AHCA changed into now not chargeable for any statistics analyses or interpretation of outcomes for this work. Dr Whaley would additionally want to thank the national Institutes on growing old (1K01AG061274) for its generous fiscal assist.

    writer Affiliations: Hankamer faculty of business, Baylor tuition (MRR, JAS), Waco, TX; RAND service provider (CMW), Santa Monica, CA.

    supply of Funding: national Institutes on getting old 1K01AG061274 (CMW).

    writer Disclosures: The authors document no relationship or fiscal hobby with any entity that could pose a battle of activity with the field remember of this text.

    Authorship tips: thought and design (MRR, JAS, CMW); acquisition of information (MRR); evaluation and interpretation of statistics (MRR, JAS, CMW); drafting of the manuscript (MRR, JAS, CMW); vital revision of the manuscript for important highbrow content (MRR, JAS, CMW); statistical analysis (MRR, JAS); and supervision (MRR).

    tackle Correspondence to: Michael R. Richards, MD, PhD, MPH, Hankamer college of business, Baylor college, 1 endure Pl, Waco, TX 76798. electronic mail:


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    2. Edwards PK, Milles JL, Stambough JB, Barnes CL, Mears SC. Inpatient versus outpatient total knee arthroplasty. J Knee Surg. 2019;32(8):730-735. doi:10.1055/s-0039-1683935

    three. Bashinskaya B, Zimmerman RM, Walcott BP, Antoci V. Arthroplasty utilization within the u.s. is expected by way of age-certain inhabitants agencies. ISRN Orthop. 2012;2012:185938. doi:10.5402/2012/185938

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    10. Memtsoudis SG, Della Valle AG, Besculides MC, Gaber L, Laskin R. tendencies in demographics, comorbidity profiles, in-health center issues and mortality associated with fundamental knee arthroplasty. J Arthroplasty. 2009;24(four):518-527. doi:10.1016/j.arth.2008.01.307

    eleven. Berger RA, Kusuma SK, Sanders SA, Thill ES, Sporer SM. The feasibility and perioperative problems of outpatient knee arthroplasty. Clin Orthop Relat Res. 2009;467(6):1443-1449. doi:10.1007/s11999-009-0736-7

    12. Carey ok, Morgan JR, Lin MY, Kain MS, Creevy WR. patient consequences following complete joint replacement surgery: a comparison of hospitals and ambulatory surgery facilities. J Arthroplasty. 2020;35(1):7-eleven. doi:10.1016/j.arth.2019.08.041

    13. Richter DL, Diduch DR. cost evaluation of outpatient versus inpatient unicompartmental knee arthroplasty. Orthop J sports Med. 2017;5(three):2325967117694352. doi:10.1177/2325967117694352

    14. Van Amerongen D, Maroulis C. reimbursement for complete joint substitute in an outpatient web site of care. Johnson & Johnson Institute. 2017. Accessed July 11, 2020.

    15. Barnes CL, Iorio R, Zhang X, Haas DA. An examination of the adoption of outpatient complete knee arthroplasty given that 2018. J Arthroplasty. 2020;35(6S):S24-S27. doi:10.1016/j.arth.2020.01.073

    sixteen. Haas DA, Zhang X, Davis CM III, Iorio R, Barnes CL. The monetary implications of the removal of complete knee arthroplasty from the Medicare Inpatient-best record. J Arthroplasty. 2020;35(6S):S33-S36. doi:10.1016/j.arth.2020.01.074

    17. White C. contrary to can charge-shift conception, lower Medicare health center price prices for inpatient care cause reduce deepest price prices. health Aff (Millwood). 2013;32(5):935-943. doi:10.1377/hlthaff.2012.0332

    18. Clemens J, Gottlieb JD. within the shadow of a giant: Medicare’s influence on deepest physician payments. J Polit Econ. 2017;125(1):1-39. doi:10.1086/689772

    19. Cooper Z, Craig SV, Gaynor M, Van Reenen J. The expense ain’t right? health facility prices and fitness spending on the privately insured. Q J Econ. 2019;134(1):fifty one-107. doi:10.1093/qje/qjy020

    20. Sloan FA, Morrisey MA, Valvona J. effects of the Medicare potential price equipment on sanatorium cost containment: an early appraisal. Milbank Q. 1988;66(2):191-220.

    21. Yip WC. doctor response to Medicare payment discount rates: adjustments within the extent of coronary artery pass graft (CABG) surgeries within the Medicare and private sectors. J fitness Econ. 1998;17(6):675-699. doi:10.1016/s0167-6296(98)00024-1

    22. He D, Mellor JM. clinic extent responses to Medicare’s Outpatient prospective charge system: facts from Florida. J health Econ. 2012;31(5):730-743. doi:10.1016/j.jhealeco.2012.06.001

    23. Baicker okay, Chernew ME, Robbins JA. The spillover results of Medicare managed care: Medicare abilities and medical institution utilization. J fitness Econ. 2013;32(6):1289-1300. doi:10.1016/j.jhealeco.2013.09.005

    24. Weber E, Floyd E, Youngran okay, White C. Peering in the back of the veil: tendencies in types of contracts between inner most health plans and hospitals. Med Care Res Rev. posted on-line July 23, 2019. doi:10.1177/1077558719859724

    25. White C. reducing Medicare health center costs leads to a spillover discount in health center discharges for the nonelderly. fitness Serv Res. 2014;forty nine(5):1578-1595. doi:10.1111/1475-6773.12183

    26. Geruso M, Richards MR. buying and selling areas: Medicare’s regulatory spillovers on medication atmosphere for non-Medicare sufferers. SSRN. posted on-line March three, 2020. doi:10.2139/ssrn.3532685

    27. Iorio R, Barnes CL, Vitale MP, Huddleston J, Haas DA. total knee replacement: the Inpatient most effective (IPO) list and the two midnight rule, patient impact, length of stay, compliance solutions, audits and financial penalties. J Arthroplasty. 2020;35(6S):S28-S32. doi:10.1016/j.arth.2020.01.007

    28. Baker LC, Bundorf MK, Kessler DP. The effect of hospital/health practitioner integration on sanatorium alternative. J health Econ. 2016;50:1-8. doi:10.1016/j.jhealeco.2016.08.006

    29. Richards MR, Nikpay SS, Graves JA. The transforming into integration of health care professional practices: with a Medicaid side effect. Med Care. 2016;54(7):714-718. doi:10.1097/MLR.0000000000000546

    30. Koch TG, Wendling BW, Wilson NE. How vertical integration influences the quantity and cost of care for Medicare beneficiaries. J fitness Econ. 2017;52:19-32. doi:10.1016/j.jhealeco.2016.12.007

    31. Koch TG, Wendling BW, Wilson NE. The outcomes of healthcare professional and medical institution integration on Medicare beneficiaries’ health results. Federal change commission Bureau of Economics working paper 337. July 2018. Accessed July eleven, 2020. professional-health center-integration-medicare-beneficiaries-fitness-consequences/working_paper_337.pdf

    32. Nikpay SS, Richards MR, Penson D. sanatorium-surgeon consolidation accelerated in the past decade in cardiology, oncology. health Aff (Millwood). 2018;37(7):1123-1127. doi:10.1377/hlthaff.2017.1520

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