Inpatient physician assistants and nurse practitioners
PAs and NPs are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. A study describes the roles of PAs and NPs in inpatient medicine at Veterans Health Administration (VHA) hospitals by surveying chiefs of medicine and nurse managers. Daily caseload was reported to be similar with few significant differences between tasks. The presence of PAs and NPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. NPs and PAs work on inpatient medicine services with broad, yet similar, scopes of practice, and few differences between their roles and perceptions of care.1
Commentary by Tricia Marriott: The authors of this study, and those of the corresponding editorial, highlight important considerations and limitations; most notably that the VHA setting might not be representative of other inpatient medicine settings and the perceptions of chiefs and nurse managers might not reflect those of the direct care team.2 However, a startling data point, egregiously omitted in the discussion about role, is that 30.8% of PAs and 23.1% of NPs are reported to work in a role “closer to a ward assistant,” described as “work(ing) directly with a physician, cowriting orders, and making care decisions with physician oversight.” PAs and NPs are providers of many services a physician would otherwise have to provide. When allowed to function to the extent of their education, training, and experience, they are cost-effective and increase access to care. Using these learned and skilled medical professionals as glorified scribes minimizes their role, limits their potential, and creates inefficiencies and redundancies in an already overburdened system. The VHA has an enormous opportunity to increase access for veterans by addressing underuse of their current PA and NP workforce. Further investigation is warranted.
1. Kartha A, Restuccia JD, Burgess JF Jr, et al. Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals. J Hosp Med. 2014; 9(10):615–620.
2. Kulkarni N, Cardin T. Hospital medicine workforce: the impact of nurse practitioner and physician assistant providers. J Hosp Med. 2014;9(10):678–679.
Mental health physician associates in the National Health Service
The role of the physician associate in the United Kingdom's National Health Service (NHS), particularly in the specialty of psychiatry, is reviewed.1 The focus is on training and role of the physician associate, specialties in which they are employed in the United Kingdom, and an insight into their role in psychiatry. Data regarding effectiveness and benefit of employing physician associates, along with some misconceptions and limitations, are described. One conclusion is that physician associates are effective in increasing the workforce and providing continuity of care. As of 2015, physician associates in the United Kingdom are not licensed to prescribe or order radiographs or tests.1
Commentary by Phyllis R. Peterson: The first mention of PAs in mental health was in 1977.2 The authors of this article conclude that the use of physician associates in UK psychiatric settings increases workforce capacity and improves continuity of care. Although more clinicians are being trained and moving into psychiatry, the United Kingdom and United States are experiencing a shortage of mental health providers.3 This crisis is likely to continue until basic mental healthcare is integrated into mainstream medicine. New PAs moving into their first jobs will encounter major depression just as frequently as hypertension. They should feel comfortable and competent in treating both diagnoses. For the most part this is not the case, and referrals to psychiatry are increasing. A few PA postgraduate programs in psychiatry are up and running in the United States, but their contribution pales in comparison to a growing population demand for more mental health services. In many areas, PAs in psychiatry still face regulatory and third-party payer barriers to optimal practice.
1. Gill K, Kauser S, Khattack K, Hynes F. Physician associate: new role within mental health teams. J Mental Health Training Educ Practice. 2014;9(2):79–88.
2. Greenlee RL, Levy JW, Allen AJ. Utilization of a physician assistant in a comprehensive community mental health center. PA J. 1977;7(3):143–147.
Honberg R, Kimball A, Diehl S, et al. State Mental Health Cuts: The Continuing Crisis. Arlington, VA: National Alliance on Mental Illness; 2011.
Estimating the economic value of a rural health PA or NP
Increasing the use of PAs and NPs in primary care delivery presents challenges because of scope of practice laws, regulatory protocols, reimbursement policies, clinical training, experience, and patient health that affect daily productivity. Because PAs and NPs contribute economically to the community, a model was created for community leaders to use. Given four sample scenarios, a rural PA or NP can create between 4.4 and 18.5 local jobs and $280,476 to $940,892 in wages and benefits from the clinic and hospital. The tools in this report enable community leaders to estimate the economic effect of rural PAs and NPs.1
Commentary by Roderick S. Hooker: At the heart of this economic analysis of rural health providers is an employment multiplier effect. In microeconomics and banking, the multiplier measures how much the money supply increases in response to the external effect. For example, a PA in White Talon, N.M., sees patients and is reimbursed. In turn, she employs people to keep the clinic functioning, pays bills, buys her groceries locally, pays taxes and rent; those she employs do the same. In small towns, a dollar may turn over three or four times locally before it goes outside the micropolitan area—more so if it is a small rural hospital. The authors have introduced the downstream benefit of a small rural clinic as a potential economic stabilizer perhaps second only to the local elementary school.2 The fact that the wage of a rural family medicine PA is half that of a physician is irrelevant compared with the social capital such a clinic provides. The authors incorporate a well-developed software model that uses input-output dollar flow based on taxes collected locally. The beauty of this model is it uses secondary data that are publically available to show that just the presence of a PA or NP occupying a small clinic can improve the economic stability of a small town.
Elrich FR, Doeksen GA St. Clair CF. Models to estimate the economic impact of a rural nurse practitioner or physician assistant. National Center for Rural Health Works; 2014.
2. Henry LR, Hooker RS. Retention of physician assistants in rural health clinics. J Rural Health. 2007;23(3):207–214.
Productivity of rural health PAs and NPs
A study quantified the average weekly number of outpatient primary care visits and the types of services provided within and beyond the outpatient setting. A sample of providers with rural addresses in 13 states reported weekly outpatient visits and scope of services provided within and beyond the outpatient setting. Average weekly outpatient visits were 8% lower for PAs and 25% lower for NPs compared with physicians. After multivariate adjustment, this gap became negligible for PAs and decreased to 10% for NPs. Physicians were more likely to provide services beyond the outpatient setting, including hospital care, emergency care, childbirth attending deliveries, and after-hours call coverage. Although these findings suggest that a greater reliance on PAs and NPs in rural primary settings would have a minor effect on outpatient practice volume, this shift might reduce the availability of services that have more often been traditionally provided by rural primary care physicians beyond the outpatient clinic setting.1
Commentary by James F. Cawley: The good news from this study is the indication of increasing reliance on PAs and NPs in US rural primary care delivery. That PA productivity (as measured by weekly outpatient visits) is equivalent to that of primary care physicians also is good news. The bad news is the picture of increasingly challenging trends in rural primary care, including an aging workforce, and an increasing draw of PAs and NPs toward urban clinical specialties and subspecialties.
1. Doescher MP, Andrilla CH, Skillman SM, et al.. The contribution of physicians, physician assistants, and nurse practitioners toward rural primary care: findings from a 13-state survey. Med Care. 2014;52(6):549–556.