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Commentaries on health services research

Dehn, Richard W. MPA, PA-C, DFAAPA; Coplan, Bettie MPAS; Polansky, Maura MS, MSPE, PA

Journal of the American Academy of PAs: July 2014 - Volume 27 - Issue 7 - p 50–51
doi: 10.1097/01.JAA.0000451522.14598.1b

Richard W. Dehn is a professor in the College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus, and chair of the university's Department of Physician Assistant Studies. Bettie Coplan is an associate professor in the Department of Physician Assistant Studies, College of Health and Human Services at Northern Arizona University's Phoenix Biomedical Campus. Maura Polansky is program director of Physician Assistant Educational Programs at MD Anderson Medical Center in Houston, Tex.

Richard W. Dehn, MPA, PA-C, DFAAPA, and Roderick S. Hooker, PhD, PA, department editors

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PAs and NPs influence healthcare markets


NPs and PAs outnumbered family practice doctors in the United States in 2013 and are the principal providers of primary care to many communities. Recent growth of these professions has occurred amidst considerable cross-state variation in their regulation, with some states permitting autonomous practice and others mandating extensive physician oversight. This study found that expanded NP and PA supply has had minimal effect on the office-based healthcare market overall, but use of NPs and PAs has been modestly more responsive to supply increases in states that permit NPs and PAs greater autonomy. Results suggest the importance of laws affecting the division of labor, not just its quantity.

Stange K. How does provider supply and regulation influence health care markets? Evidence from nurse practitioners and physician assistants. J Health Econ. 2014;33:1–27.

This is the first study to use econometric analysis to assess the market effects of employment increases in the NP and PA professions. Not only is this manuscript remarkable as the first to analyze PAs and NPs from a labor economics perspective, it uses a massive and comprehensive dataset that includes 1990–2008 county-level primary care physician, PA, and NP supply numbers, as well as data from the 1996–2008 Medical Expenditure Panel Surveys (MEPS). The intent was to quantify the effects of increased provider supply and examine how the regulatory environment affects various outcomes. Some evidence indicates that occupational regulation weakly affects the healthcare market by moderating the effects of provider supply. One notion is that by producing more competition in the market for primary care, PAs and NPs lower prices indirectly. Indeed, the growth of PAs and NPs appears to have had labor and output market consequences—more prescriptive authority correlates with lower wages for NPs but higher wages for PAs. Unfortunately, a lack of data at the subnational level inhibits assigning causation to this correlation. Regarding scope of practice laws, granting PAs the ability to prescribe is associated with 5% fewer patient visits. Unfortunately, in the end, the author was unable to identify why a greater number of PAs and NPs in the market have not altered their market demand.

Commentary by Richard W. Dehn

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Does the US needs more specialists?


As the US population ages, the increasing prevalence of chronic disease and complex medical conditions has profound implications for the future healthcare system. This study projected prevalence of selected diseases and health risk factors to model demand for healthcare services. Based on changing demographics and expanded medical coverage under the Affordable Care Act, the demand for adult primary care services will grow by 14% between 2013 and 2025. Vascular surgery has the highest projected demand growth at 31%, followed by cardiology at 20%. Market indicators such as long wait times to obtain appointments suggest that the supply of many specialists throughout the United States is inadequate to meet demand.

Dall TM, Gallo PD, Chakrabarti R, et al. An aging population and growing disease burden will require a large and specialized health care workforce by 2025. Health Aff (Millwood). 2013;32(11):2013–2020.

Training insufficient numbers of specialists could negatively affect the quality of US healthcare. Predicting the number of providers needed in each specialty, however, is tricky business. The authors of this sophisticated modeling study predict higher demand for at least 12 specialties when compared with primary care but acknowledge that their projections are based on the current system, which is ever-changing. New care delivery strategies such as the patient centered medical home aim to improve outcomes by shifting care delivery from specialists to primary care providers. Such a shift could decrease projected demand for some specialists while increasing the need for primary care. The authors mention the potential for PAs and NPs to contribute by improving the productivity of physicians but perhaps fail to recognize that the ability of practicing PAs to change specialties may help compensate for inherently flawed predictions.1 One thing is clear: meeting the complex healthcare needs of the future will require a multifaceted approach with all hands on deck.

Commentary by Bettie Coplan

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1. Hooker RS, Cawley JF, Leinweber W. Career flexibility of physician assistants and the potential for more primary care. Health Aff (Millwood). 2010;29(5):880–886.

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Cancer survivorship models


We surveyed primary care providers (PCPs) and oncologists to assess how physician attitudes toward cancer affect preferences for different cancer survivorship models. The survey was mailed to a randomly selected sample of primary care providers and oncologists to evaluate their perspectives about physician roles, knowledge, and views on cancer surveillance. Of 3,434 physicians identified, 2,026 participants provided eligible responses: 938 primary care providers and 1,088 oncologists. Most primary care providers (51%) supported a primary care provider/shared care model; most specialists (59%) strongly endorsed an oncologist-based model. Less than a quarter of primary care providers and oncologists preferred specialized survivor clinics. A significant proportion of oncologists (87%) did not feel that primary care providers should take on the primary role of cancer follow-up. Most primary care providers believed that they were better able to perform breast and colorectal cancer follow-up (57%), detect recurrent cancers (74%), and offer psychosocial support (50%), but only 32% were willing to assume primary responsibility. Primary care providers already involved with cancer surveillance (43%) were more likely to prefer a primary care provider/shared care than oncologist-based survivorship model. Primary care providers and oncologists have different preferences for models of cancer survivorship care.

de Moor JS, Mariotto AB, Parry C, et al. Cancer survivors in the United States: prevalence across the survivorship trajectory and implications for care. Cancer Epidemiol Biomarkers Prev. 2013;22(4):561–570.

The study's authors note that because nearly half of all Americans will be diagnosed with cancer during their lifetime, and because patients are surviving longer, the population of cancer survivors is rapidly expanding. An estimated 18 million cancer survivors will be around in 2022. The projected significant shortage of oncologists means cancer survivors increasingly will need to receive routine follow-up care within the primary care setting. Residency program standards for internists and family medicine physicians do not specifically require exposure to cancer survivors.1 PA students receive brief education related to cancer patients, often limited to prevention and early diagnosis.2,3 Thus, primary care providers have not been trained to deal with the complex issues facing this patient population. Foundational knowledge of cancer survivorship care must be introduced during entry-level education for physicians and PAs, and additional training during graduate medical educational programs and through CME programs is critical to prepare these providers to assume increasing responsibilities for cancer survivors.

Commentary by Maura Polansky

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1. Yang W, Williams JH, Hogan PF, et al. Projected supply of and demand for oncologists and radiation oncologists through 2025: an aging, better-insured population will result in shortage. J Oncol Pract. 2014;10(1):39–45.

2. Polansky M, Ross AC, Coniglio D, et al. Cancer education in physician assistant programs. J Physician Assist Educ. In press.

3. Polansky M, Kowis A. Physician assistant students' education and training in cancer care. J Physician Assist Educ. 2011;22(1):32–33.

© 2014 American Academy of Physician Assistants.