James F Cawley*
Received: November 25, 2020 Published: December 14, 2020
Corresponding author: James F Cawley, Visiting Professor, Scholar-in-Residence Graduate School, Physician Assistant Leadership and Learning Academy, University of Maryland Baltimore, Baltimore, USA
The United States continues to be faced with anticipated shortages of primary care physicians that, in the near future, will likely worsen. The Association of American Medical Colleges predicts a shortage of 54,100 to 139,000 physicians by 2033 with primary care physician shortages approaching 55,200 . There is a consensus that the Nation’s health workforce will require an increased number of primary care providers and that this requirement includes physician assistants . A key problem across professions is the diminishing fraction of new clinicians who are entering primary care, as opposed to specialties. While shift away from primary care has traditionally been the most apparent for medical doctors and osteopathic physicians), it appears to have spread to PAs as well who have increasingly elected employment within specialty areas. While health care reform (the Patient Protection and Accountable Care Act) has made health insurance coverage available to more than 20 million previously uninsured Americans, questions remain as to whether there will is a sufficient supply of physicians and other health professionals to serve the nation, especially in light of concerns that the nation was facing potentially significant shortages even before health care reform and the Covid 19 pandemic.
Many expect physician assistants (PAs)and other nonphysician clinicians to play a larger role in meeting future workforce demands in primary care [3, 4]. Although the nurse practitioner (NP) and physician assistant (PAs) professions originated mostly in primary care, they too appear to have shifted into specialties partly as the result of more lucrative professional opportunities.
A common pattern on the delivery of primary care services is to staff with PAs and NPs [5-8]. Care managed by PAs and NPs in ambulatory settings increased from 10% in 2001 to 15% in 2009 . While PA employment varied by location; 36% of visits were in nonmetropolitan centers. At the same time the size of the hospital correlated with increased use of PAs or NPs; the smaller the hospital, the more likely PA/NPs were present. PAs and NPs tended to provide more care 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 . 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 . Clinic 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 . As a national safety net PAs and NPs provide a “critical healthcare function” by providing services in medically underserved communities. The role of Federally Qualified Community Health Centers in addressing these shortages is one of the larger initiatives to improved access for MUAs and highly dependent on the utilization of PAs and APRNs. In these settings PA/NPs provide care that is more prevention oriented than physician care and are proportionally more likely than physicians to see patients without private insurance .
In 2020, about one-quarter third of practicing PAs work in the primary care specialties of family medicine, general internal medicine, and general pediatrics.PAs working in primary care have demographics similar to those of medical students who choose general primary care specialties. For NPs, about 60% work in primary care. According to federal studies , hospital outpatient department visits handled by PAs and NPs (and other advanced practice nurses [APN}) increased from 10% in 2000 and 2001 to 15% in 2008 and 2009. This indicates a wider degree of utilization of PAs and NPs, particularly in settings where a good deal of primary care services are delivered. PA and NP 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 outpatient department was related to whether patients were seen exclusively by a PA or NP, with 24% of such visits in hospitals with fewer than 200 beds, and only 10% in facilities with 400 or more beds. PAs and NPs also delivered care more often in clinics associated with nonteaching hospitals and handled a higher percentage of Medicaid, CHIP, or uninsured patients, as well as younger patients. These data suggest that PAs and NPs are used to a greater degree in smaller facilities located in non-urban areas to serve populations that may be otherwise medically underserved, trends that are consistent with the original policy intentions of their creators. PAs and NPs saw a higher percentage of visits where a new problem was the major reason for the visit (22%) compared with visits for a chronic condition (11%) or pre/postsurgery care (6%). Of particular interest to some is the finding that PAs and NPs saw a higher percentage of preventive care visits (17%) compared with visits for a routine chronic condition or pre/postsurgical care. The National Center Health Statistics report confirms that PAs and NPs “continue to provide a critical health care function” by administering care in communities that are prone to physician shortages, including in rural, small, and nonteaching hospitals .
There is a great deal of discussion regarding the primary care
health care team and team practice is both a desired goal as well
as an increasing reality. It is worth noting that this is the model
that has been so successful for PAs over the past 50 years. A large
number of family physicians embrace NPs and PAs and partner
with them in primary care practices. Inter professional squabbles
in health care, like the one still smoldering between NPs and family
physicians, have their roots in decades-old, sometimes genderbased,
injustices. Modern medical practice is typically a complex
multi-layered endeavor that does indeed require a team approach.
It may be time to recognize this reality and replace dated turf
battles with a renewed focus on putting the patient and improved
outcomes first. PA practice trends mirror the practice trends of
physicians. Consequently, actions that increase the number of
primary care physicians are also likely to increase the percentage
of primary care PAs. The PA profession should therefore continue
to support workforce policy measures that successfully increase
the number of primary care clinicians including loan repayment,
improved levels of reimbursement for primary care physicians.
The need to expand and strengthen the primary care workforce should prompt further research on other factors associated with primary care selection by physician assistants. The nation is on a trajectory to rely more heavily on PAs (as well as NPs) for the provision of primary care in the future. Considering the similarities in the practice trends and characteristics of physicians and PAs, determinants of specialty choice for physicians, including lifestyle factors, workload, and prestige, likely impact PA specialty choice as well.
An important difference between PAs and physicians, however, is that PAs can readily change specialties and do. For PAs this is a distinct advantage professionally, and for policymakers at least theoretically holds the promise that more PAs could be attracted to primary care practice. At some point during their careers nearly half of all PAs change specialties and the greatest shift occurs in family medicine. Therefore the potential to attract not only new graduates but also practicing PAs into primary care exists. Income undoubtedly affects PA specialty choice but further research should be aimed at identifying other potential factors that influence PAs to transition into and out of primary care. In addition, the PA profession should support federal health workforce policy reform measures such as loan repayment plans or improved levels of reimbursement, which successfully increase the number of primary care physicians, as these strategies hold the promise to attract greater numbers of PAs and provide more PA employment opportunities in primary care. Nurse practitioners are filling a workforce need in primary care that physicians are neglecting. NPs are stepping into the fray to fill the acute need for primary care services and are willing to provide services in areas that physicians sometimes avoid.
For family physicians, the shortage of primary care providers presents an interesting dilemma. Physicians and the public both perceive nurse practitioners and physician assistants as key players in augmenting the primary care workforce. There are estimates of a deficit of family physicians projected through 2025. It is clear that the physician supply will be insufficient to meet future demands for primary care services. Thus, attention turns to NPs and PAs.
It has long been speculated that PAs and NPs certainly have the potential to provide care that is more prevention-oriented than physician care, and it appears that they may be fulfilling this potential. Further delineation of this trend is warranted. Practicing preventive medicine to a greater degree may offer even further justification not only for the widespread utilization of PAs and NPs in primary care but also for policy changes leading to greater levels of reimbursement for preventive services by third-party health payors.
Longer term trends point to the establishment of PAs and NPs as the principal front-line providers of primary care services with physicians assuming more managerial and executive functions as well as a greater focus on inpatient specialty practice. A former Deputy Dean and Professor of Medicine at Yale School of Medicine recently observed that “in the decades ahead, it is likely that the main role of the generalist physician will be to supervise those providing primary care and to personally care for patients with complex illnesses who are hospitalized, an idea already well established as the hospitalist movement.”
He adds further that “the challenge will be to successfully integrate a new primary care system that relies more heavily on nurses and PAs with specialty-based medicine, hopefully through health care reform and the help of a universal electronic medical record” . When it comes to primary care, clearly PAs and NPs are the health care providers whose time has come and in the future will only increase in utilization and influence.
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