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The American Journal of Managed Care October 2013
Dispensing Channel and Medication Adherence: Evidence Across 3 Therapy Classes
Reethi Iyengar, PhD, MBA, MHM; Rochelle Henderson, PhD, MPA; Jay Visaria, PhD, MPH; and Sharon Glave Frazee, PhD, MPH
Utilization of Lymph Node Dissection, Race/Ethnicity, and Breast Cancer Outcomes
Zhannat Z. Nurgalieva, MD, PhD; Luisa Franzini, PhD; Robert O. Morgan, PhD; Sally W. Vernon, PhD; and Xianglin L. Du, MD, PhD
The Mis-Measure of Physician Performance
Seth W. Glickman, MD, MBA; and Kevin A. Schulman, MD
Inefficiencies in Osteoarthritis and Chronic Low Back Pain Management
Margaret K. Pasquale, PhD; Robert Dufour, PhD; Ashish V. Joshi, PhD; Andrew T. Reiners, MD; David Schaaf, MD; Jack Mardekian, PhD; George A. Andrews, MD, MBA, CPE; Nick C. Patel, PharmD, PhD, BCPP; and James Harnett, PharmD, MS
Empirical Analysis of Domestic Medical Travel for Elective Cardiovascular Procedures
Jacob D. Langley, MS-HSM; Tricia J. Johnson, PhD; Samuel F. Hohmann, PhD, MS-HSM; Steve J. Meurer, PhD, MBA, MHS; and Andy N. Garman, PsyD
Physician Capability to Electronically Exchange Clinical Information, 2011
Vaishali Patel, PhD, MPH; Matthew J. Swain, MPH; Jennifer King, PhD; and Michael F. Furukawa, PhD
Currently Reading
Physician Assistants in American Medicine: The Half-Century Mark
James F. Cawley, MPH, PA-C; and Roderick S. Hooker, PhD, PA
Outcomes Among Chronically Ill Adults in a Medical Home Prototype
David T. Liss, PhD; Paul A. Fishman, PhD; Carolyn M. Rutter, PhD; David Grembowski, PhD; Tyler R. Ross, MA; Eric A. Johnson, MS; and Robert J. Reid, MD, PhD
Performance Measurement for People With Multiple Chronic Conditions: Conceptual Model
Erin R. Giovannetti, PhD; Sydney Dy, MD; Bruce Leff, MD; Christine Weston, PhD; Karen Adams, PhD, MT; Tom B. Valuck, MD, JD; Aisha T. Pittman, MPH; Caroline S. Blaum, MD; Barbara A. McCann, MSW; and Cynthia M. Boyd, MD, MPH

Physician Assistants in American Medicine: The Half-Century Mark

James F. Cawley, MPH, PA-C; and Roderick S. Hooker, PhD, PA
Physician assistants work in a broad range of health services and improve organizational efficiency through team-based care.
Background: The concept of the physician assistant (PA) was developed by US physicians in the 1960s as a workforce strategy to improve the delivery of medical services. Then as now there is an anticipated shortage of physicians, particularly in primary care. Use of PAs is viewed as 1 possible strategy to mitigate this growing gap in provider services.

Objectives: To describe the PA in US medicine for policy background and analysis.

Description: In January 2013, approximately 89,500 PAs were licensed: 65% were women. Four-fifths were under the age of 55 years. PAs are trained in 2.5 years at one-fourth the cost of a physician and begin producing patient care 4 years before a physician is independently functional. One-third of PAs work with primary care physicians; 65% work in non–primary care practices. Popular specialties are family medicine, emergency medicine, surgery, and orthopedics. PAs are revenue producers for employers and expand access and clinical productivity in most practice settings. Roles for PAs have expanded into hospital settings and graduate medical education programs. About 7300 PAs graduate annually, and this number is expected to grow to 9000 by the end of the decade. Predictive modeling suggests that demand for medical services will grow faster than the combined supply of physicians, PAs, and nurse practitioners, particularly in primary care. PA quality of care appears indistinguishable from that of physician-delivered services.

Conclusions: Optimal organizational efficiency and cost savings in health services delivery will depend on how well the PA can be utilized.

Am J Manag Care. 2013;19(10):e333-e341
Physician assistants (PAs) receive generalist training that permits their widespread use in most areas of medicine under doctor supervision.
  • The PA concept has been a successful health workforce innovation in US medicine and is spreading globally.
  • The contributions of PAs to primary care involving effectiveness, safety, patient satisfaction, and outcomes of care are comparable to those of physicians.
  • The addition of PAs to primary care teams tends to improve coordinated, comprehensive care and helps to maintain the continuity of care.
A prevailing issue within the US medical workforce is the adequacy of the physician supply to meet the needs of a nation undergoing health service expansion. Despite an increase in the number of medical schools and boosted enrollment, substantial shortages of physicians are predicted. The Association of American Medical Colleges estimates a shortage of 124,000 full-time equivalent (FTE) physicians by 2025, with primary care accounting for the largest share of the deficit (37% or ~46,000 FTEs). Family medicine put this primary care estimated shortage at 52,000 physicians by 2025. Beyond calling attention to a physician shortage in general, and a diminishing supply of primary care physicians in particular, there is a clear  indication that other providers are needed.1 Increasingly, physician assistants (PAs) are expected to help fill workforce shortages. As the profession approaches the half-century mark, an update of the PA profession may serve as a reference point for policy analysis.

The PA was a workforce idea created by physicians in the 1960s as a policy response to the shortage and uneven distribution of generalist doctors. The intention was to increase the public’s access to healthcare.2 The National Commission on the Certification of Physician Assistants records that there are approximately 100,000 PAs who have ever been certified.3 Taking into account those who have left the workforce and  those who are entering as new graduates we estimate 89,500 PAs with active licenses in 2013. There are 173 PA programs, with 60 in development. While all are trained in the generalist model, PAs  are employed in primary care, specialty, and subspecialty medicine, and work in collaboration with physicians in most clinical practice settings.4

DEFINITION AND LEGAL STATUS

Physician assistants are health professionals licensed to practice medicine with physician supervision. They share an interdependent relationship with physicians sociologically described as “negotiated performance autonomy.”5 The PA scope of practice corresponds to the supervising physician’s practice and varies according to the training, experience, facility policy, and state law. Qualifications for PA licensure are (1) graduation from an accredited PA program and (2) passage of the Physician Assistant National Certification Examination administered by the independent National Commission on Certification of Physician Assistants. Licensed PAs have prescribing authority in all states, although laws vary with regard to certain prescribing privileges and supervisory requirements.6

In their work, PAs routinely perform a comprehensive range of medical duties, spanning primary care to high-technology specialty procedures. In primary care, they serve as front-line providers working typically with family physicians. In surgery they serve as first assistants as well as providing preoperative and postoperative care.7 In some rural areas where physicians are in short supply, PAs work semiautonomously, conferring with their supervising physicians as needed and as required by law.8,9

EDUCATION

As of 2013 there were more than 173 accredited PA programs, a number that has grown rapidly over the past decade (Figure 1). An additional 45 programs have applied for initial accreditation; 20 more are in the development pipeline progressing toward accreditation status by 2017 (J. McCarty, CEO of the Accreditation Review Commission on Education for the Physician Assistant [ARC-PA], written communication, April 2013; ARC-PA website updated April 12, 2013). The average program length is 27 months, operates year-round, and typically comprises 1 year of classroom and laboratory instruction and a second year of clinical experience.10 Physician assistant programs graduate, on average, 44 persons per program each year. The 2012 graduating cohort was 7300 (estimated); this number is projected to increase to 9000 annual graduates by 2020.11 Two-thirds of matriculates are female and the median age at graduation is 29 years (range, 23-55 years).

Although accredited PA programs have demonstrated compliance with a core set of educational standards (ARCPA Standards, 4th edition), they have the discretion to offer a variety of academic degrees, with the master’s degree as the norm. The curriculum resembles a competency-based (and shorter) form of medical education with basic sciences and clinical rotations. Students complete an average of 2000 hours of supervised clinical practice prior to graduation with the average length of clinical clerkships approximately 52 weeks.10

From a policy standpoint, PA education has been supported through Title VII, section 747, which provides incentives for programs to have diverse student selection, a primary care training focus, and deployment to rural and underserved settings.12 Since the early part of this century Title VII funding has been reduced for PA education with an exception in 2010 when one-time  funding was created under the American Recovery and Reinvestment Act of 2009. During this phase, Expansion of Physician Assistant Training grants were used to bolster primary care. As of 2012, 39 of the 173 PA programs received some amount of federal training support.

Typical PA programs are sponsored by a university school of medicine, school of health sciences, or similar college within the institution.13 An average start-up cost of a PA program  is approximately $2.5 million (direct cost in 2010 dollars) spread over the first 5 years.14 Without federal start-up funds, the cost is borne by the home institution. Tuition cost of a PA education averages $65,000 (2010 dollars; 28 months).10 Student debt is estimated around $55,00 on average with a range between $0 and $150,000 for 2012.15 

DEMOGRAPHICS

In 2013, more than 89,500 PAs held an active state license to practice. Approximately 80% of all PAs are under the age of 55 years, making this one of the more youthful health professions (Figure 2).3,16 The median age of PAs in clinical practice is 41 years (range, 23-74 years); 65% are women.4,10

Although PAs are widely distributed across the nation, the highest density per capita is in Alaska and the lowest in Mississippi. New York, Pennsylvania, Florida, California, and Texas have the greatest number of PAs and also have the largest concentration  of PA programs per capita. Physician assistants working in nonmetropolitan census tracts are found in every region, but more so west of the Mississippi River.17

The PA profession has grown from 29 graduates in 1969 to 100,000 ever-graduated in 2012, with growth particularly pronounced in recent years.3 More specifically, the number of people with an active license to practice will exceed 100,000 by the year 2016. This annual growth is projected at 7% and an annual attrition rate is estimated at 4% to 5% out to 2025.11

INTERPROFESSIONAL PRACTICE

Team-based care is the byword among various health professionals as the demand for services increases. It is a term mentioned frequently by family medicine practitioners as they face a growing demand for their services.18 Evidence of the benefit of team-based care as it applies to PAs is growing; in 1 health maintenance organization they improved the outcomes of some chronic diseases in the elderly, and at the same time patient satisfaction with care was higher than it was for physician-only care.19 A Wisconsin primary care network study demonstrated that service delivery by physicians, PAs, and nurse practitioners (NPs) was similar regardless of the complexity of the patient and the type of service. In this example, panels of patients assigned to PAs and NPs had higher proportions with Medicaid, disability, and depression.20 Findings on PAs in primary care are growing, and a shortage of primary care physicians in the pipeline suggests that the employment of PAs is  likely to grow more in this domain.21 In orthopedics the use of PAs as first assistants freed up family medicine physicians for more clinical work, increased the throughput of hip and knee replacements by 42%, and decreased the wait times by one-third compared with the preceding year without PAs.7

FEDERAL POLICY SUPPORT

The development of the PA arose from federal health policy initiatives, and the results gained wide support in the public and medical sectors. The major funding source, Title VII, section 747, provides support for PA education and has waned, with roughly one-fifth of programs receiving federal support of less than $10 million.12 This decreased funding is in contrast to the Department of Health and Human Services awarding about $200 million to 5 hospitals to train additional advanced practice registered nurses.

PRIMARY CARE

There appears to be an increasing reliance on PAs and NPs to deliver primary care services.22 A report from the National Center for Health Statistics indicated that care managed by PAs and NPs in nonfederal hospital outpatient departments increased from 10% in 2001 to 15% in 2009.23 This increase indicates that PAs are being more widely utilized, particularly in settings where a large number of primary care services are delivered. Physician assistant involvement in providing services varied by location, with these providers handling 36% of visits in nonmetropolitan centers versus only 6% of visits in urban hospitals. Also, the size of the hospital correlated with increased use of PAs or NPs; the smaller the hospital, the more likely that the hospital was using them.23 Physician assistants and NPs also delivered care more often in clinics associated with nonteaching hospitals and handled a higher percentage of Medicaid, Children’s Health Insurance Program, or uninsured patients, as well as younger patients. Physician assistants and NPs saw a higher percentage of patients where a new problem was the major reason for the visit (22%) compared with visits for a chronic condition (11%) or pre/postsurgical care (6%). In addition PAs and NPs saw a higher percentage of patients with preventive care visits (17%) compared with visits for a routine chronic condition or pre/postsurgical care.23

Ambulatory visit analyses suggest that PAs and NPs are used to a greater degree in smaller facilities located in nonurban areas to serve populations that may be otherwise medically underserved, trends that are consistent with the policy intentions of their creators. The National Center for Health Statistics report confirms that PAs and NPs “continue to provide a critical healthcare function” by administering care in communities that are prone to physician shortages, including rural, small, and nonteaching hospitals. Physician assistants and NPs tend to provide care that is more prevention oriented than physician care and are proportionally more likely than physicians to see patients without private insurance.24,25

 
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