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Original Research

PAs in primary care

Current status and workforce implications

Coplan, Bettie MPAS, PA-C; Smith, Noel MA; Cawley, James F. MPH, PA-C

Author Information
Journal of the American Academy of Physician Assistants: September 2017 - Volume 30 - Issue 9 - p 35-42
doi: 10.1097/01.JAA.0000522136.76069.15
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Abstract

As the United States confronts unsustainable healthcare costs and ongoing projections of healthcare provider shortages, proposed solutions focus on primary care. A high ratio of primary care visits to specialty visits results in more effective delivery of preventive care, better outcomes, and lower costs.1-3 Primary care visits account for more than half of the 1 billion medical office visits in the United States each year.4 Physician assistants (PAs) and NPs provide a substantial proportion of this primary care and, like new models of care delivery that include greater reliance on teams of healthcare providers, have the potential to increase capacity.5,6

Although some medical organizations challenge predictions of significant physician shortages in the coming years, a 2015 economic modeling study commissioned by the Association of American Medical Colleges (AAMC) projected an overall deficit of 46,000 to 90,000 practicing physicians by 2025, with about one-third of the deficiency occurring among primary care physicians.7,8 Factors driving demand include a growing and aging population, the constrained pipeline for physicians due to limited residency slots, and a diminishing fraction of new physicians entering primary care.8,9

The drift away from primary care that started with physicians now extends to PAs. Until the mid-1990s, most PAs practiced in family medicine and other primary care specialties.10 Although primary care remains the second most common specialty for PAs, those working in primary care settings represent only a quarter of clinically active PAs, a fraction that has fallen over the last decade.11 PAs work with physicians; therefore, the shift in PA practice reflective of the physician shift toward specialties is not surprising.

Evolving models for care delivery and reimbursement, however, have the potential to increase capacity by expanding primary care practice for PAs. Key business policy organizations recommend such strategies as expanding roles and responsibilities for primary care PAs and NPs and moving toward pay-for-value that includes reimbursement based on the quality of services provided rather than the type of provider or setting in which care is delivered.6 Approaches such as these would likely further the goal of greater PA and NP use and may increase access to care as well as broaden the use of team models of delivery.6

Interestingly, physicians established PA education in the mid-1960s in response to a need for medical services not unlike the need that exists today.12 The model succeeded and, over the years, the PA profession has demonstrated an ability to respond to society's healthcare needs. The capacity to do so is perhaps best exemplified by PA practice in rural and underserved areas. Like NPs, PAs are more likely than physicians to serve these communities.6,13,14 In addition, although PAs and NPs in rural practices provide a smaller range of services than physicians, they are more likely to work in areas with higher rates of uninsured residents and lower median household incomes.15 In fact, in areas with the lowest concentration of physicians, the numbers of PAs and NPs combined account for about half of the clinicians providing care.6,13

An important step toward increased mobilization and possible expansion of the PA primary care workforce is to gain a better understanding of PAs who practice in primary care settings. Therefore, the main objective of this study was to identify factors that may be unique to PAs practicing in primary care by describing the general demographic and practice characteristics of PAs in primary care compared with PAs who practice in other specialties.

METHODS

Survey instruments

Data were collected from two separate surveys distributed in 2015: the American Academy of PAs (AAPA) Salary Survey and the AAPA National Survey.16 Questions in these surveys pertain to basic demographics, work environment, and professional concerns; specific questions explore such issues as practice location, specialty, number of hours worked in a typical week, years of clinical experience, and salary. Compensation and benefits data were collected February 2015 through March 2015 using the 2015 AAPA Salary Survey and represent respondent and practice-related information from 2014.16 Remaining data on PA demographics and practice were collected May 2015 through September 2015 using the 2015 AAPA National Survey and represent information from 2015.

In order to ensure an adequate sample size appropriately reflective of the population of clinically active PAs, the AAPA electronically distributes questionnaires to all PAs eligible to practice in the United States who have not opted out of e-mail communications from the organization. The AAPA also uses online platforms, including messages within general organizational communications, Facebook and Twitter posts, and messages on the AAPA website. In addition, as well as being solicited through e-mail and online communication, responses to the AAPA National Survey were collected at the 2015 AAPA conference.

2015 AAPA Salary Survey

At the end of 2014, there were 101,977 certified PAs in the United States.17 In early 2015, AAPA e-mailed the salary survey to 47,387 PAs, nearly half of the total population of PAs eligible to practice clinically; 8,469 responses were received, for a 17.9% e-mail response rate. An additional 1,725 PAs responded to the survey through other communication channels for a total of 10,194 respondents (margin of error ±0.92% at the 95% confidence level).

2015 AAPA National Survey

The AAPA sent the national survey to 49,101 PAs and obtained 6,071 responses (12.4% response rate to e-mailed survey component). An additional 1,985 responses were obtained through other communication methods for a total of 8,056 respondents (margin of error ±1.05% at the 95% confidence level).

Data analysis

Despite the anticipated low response rates, very large sample sizes that were well within acceptable margins of error were obtained. In addition, the use of multiple platforms ensured participation from a variety of PAs, minimizing the possibility of nonresponse bias.18 External validity was further assessed by comparing the AAPA surveys' respondent demographics to those reported by the National Commission on the Certification of Physician Assistants' (NCCPA's) 2014 Statistical Profile of Certified Physician Assistants (Table 1).17

TABLE 1.
TABLE 1.:
Comparison of AAPA survey results to NCCPA Statistical Profile of Certified PAs demographic and practice characteristics

The AAPA survey and NCCPA profile demographics were very similar but do not match exactly (Table 1). Differences may be attributable to variations in data collection and analysis:

  • AAPA surveys are distributed to all PAs regardless of certification status; NCCPA collects information on certified PAs only
  • AAPA limits data analysis to PAs in the United States
  • AAPA limits data analysis to PAs working 32 or more hours per week
  • dates for data collection vary between sources
  • the AAPA and NCCPA use different categories to assess race and specialty.

The AAPA Salary and AAPA National Surveys address different questions and were examined separately. All data were compiled and analyzed using SPSS to generate descriptive statistics. To gain insight into characteristics that may be more or less common among primary care PAs, data from respondents to each survey who indicated that they worked in primary care specialties (family medicine, general internal medicine, and general pediatrics) were analyzed separately from data collected from respondents practicing in all other specialties. Results from these two groups were compared and analyzed for statistical significance using tests of column proportions as well as tests of column means as relevant to the data examined. Incomplete questionnaires resulted in analyses of different sample sizes depending on the characteristic under study.

RESULTS

Demographics and practice setting

Twenty-four percent of PAs reported working in primary care and 10% reported working in urgent care. Although urgent care is more appropriately categorized as a practice setting as opposed to a specialty, the AAPA National Survey distinguishes it from primary care practice. Compared with PAs working in other settings, PAs in primary care were older (40.6 years versus 39.3 years; P<.001) and had more experience in their current specialty (7.6 years versus 6.6 years; P<.001) (Table 2). In addition, a higher percentage of primary care PAs had served in the military (current or in the past: 11.8% versus 7.5%; P<.001) and were Hispanic (Table 2).

TABLE 2.
TABLE 2.:
Comparison of characteristics of PAs in primary care and all other specialties

Higher percentages of primary care PAs were working in patient centered medical homes (38.9% versus 6.3%) and accountable care organizations (11.3% versus 7.5%) as well as in federal/tribal or urban Indian health facilities (2.4% versus 0.6%) (P<.001 for all comparisons). As one might expect, a significantly higher percentage of specialty PAs reported working in an integrated delivery system or network (63.2% versus 37.4%; P<.001).

Practice characteristics

Primary care PAs worked fewer average hours per week than PAs in nonprimary care specialties (42.6 versus 44.0; P<.01) but saw an average of nearly 73 patients per week compared with an average of 63 patients per week for PAs not in primary care (P<.001) (Table 3). Interestingly, compared with PAs in nonprimary care specialties, a higher percentage of PAs in primary care reported taking call (38.6% versus 35.8%; P=.02) and having the time to see more patients or assume more duties (30.8% versus 25.4%; P<.001). PAs in primary care also wrote more than twice as many total prescriptions per week but prescribed fewer schedule II controlled substances (Table 3).

TABLE 3.
TABLE 3.:
Comparison of PAs in primary care and all other specialties: Call, patients seen, and prescriptions written

Nearly 27% of PAs in specialties other than primary care reported providing primary care services; however, a higher percentage of PAs in primary care reported diagnosing (49.6% versus 32.5%) and treating (31.5% versus 19.4%) conditions that are generally managed by providers in other specialties (P<.05 for both comparisons). Not surprisingly, a higher percentage of nonprimary care PAs reported referring patients with conditions unrelated to their specialty to other medical providers (64.8% compared with 61%; P<.05).

PAs in primary care spent less time consulting with a physician compared with PAs in all other specialties (9.1% of total hours worked per week compared with 22.7% of total hours worked per week; P<.001), and a higher percentage of primary care PAs reporting having their own schedules or own panels of patients (Table 4).

TABLE 4.
TABLE 4.:
Practice team and collaboration among PAs in primary care and all other specialties

Compensation

As of 2014, the national median annual compensation for all PAs was $93,800; the mean base salary for PAs in primary care was $91,309 and for nonprimary care PAs was $99,608. Similarly, although the overall median hourly wage for PAs was $51 in 2014, PAs in primary care received an average of $49.87 per hour and all other PAs received an average of $55.09 per hour (Table 5).16 Similar percentages of primary care and all other PAs reported receiving a bonus as part of their compensation, although the average amount of the bonus was much higher for PAs in nonprimary care specialties (Table 5). A higher proportion of nonprimary care PAs reported that their employer provided funds for professional development (80.4% versus 77.6%, P<.05) and contributed to a retirement fund (85.4% versus 78.0%, P<.05). On the other hand, a higher percentage of primary care PAs reported that they chose their specialty due to a loan repayment program (11% compared with 1.6%, P<.05) and, of all PAs who reported receiving loan repayment funds, those in primary care received a significantly higher average amount ($16,699 compared with $6,935; P<.001).

TABLE 5.
TABLE 5.:
Compensation from primary employer for PAs in primary care and in all other specialties

PA attitudes

In response to a question about reasons for choosing to practice in their given specialty, PAs in primary care most frequently (46.9%) responded that it provided the opportunity to treat the whole patient. The percentage dropped to 9.5% for PAs in all other specialties. PAs in primary care also reported the desire to build long-term relationships (45.7%) and to prevent and treat illness (40%). PAs working in other specialties most frequently reported choosing their practice setting because they enjoyed procedures (45%) and for the career opportunities (43.1%; P<.05). Similarly, a higher proportion of PAs in primary care compared with specialty practice reported that patient relationships were the most satisfying aspect of their medical career (27.1% versus 18.2%, respectively; P<.001).

Overall, 61.7% of primary care PAs indicated an intention to stay in their current specialty compared with 65.4% of PAs not in primary care (P<.05). Of those planning to leave their specialty, more PAs in primary care (12%) compared with those in other specialties (2.5%) indicated that they had always intended to change their specialty after establishing a broad knowledge base (P<.05). A greater percentage of PAs in primary care also reported the intention to retire in the near future—18.6% compared with 14.9% of PAs in specialties (P<.05).

DISCUSSION

In the current climate of healthcare reform, the PA profession's capacity to respond to the demand for more primary care remains unknown. Difficult and complex challenges lie ahead. This study provides a glimpse at primary care PAs practicing today and may therefore offer insight to those who wish to recruit and train PAs inclined to practice in primary care settings.

The proportion of PAs in primary care has declined over the past 2 decades, from 51% in 1996 to 24% in 2015, although the ability of PAs to report practice in urgent care beginning in 2013 may partially explain the significant drop. Before 2013, when urgent care was added as a distinct specialty category to the AAPA national survey, many PAs who practiced in urgent care settings likely reported their specialty as primary care. Therefore, the absence of an urgent care category may have falsely minimized the percentage decline of PAs in general primary care.

This study revealed that PAs in primary care were older and more experienced, and that a higher percentage were Hispanic, findings consistent with observations in other national descriptive studies.19 In addition, compared with all PAs, a higher percentage of primary care versus specialty PAs were veterans. A recent Health Resources and Services Administration (HRSA) initiative encourages PA educational programs competing for primary care training money to target veterans.20 Therefore, efforts to increase the number of veterans in PA programs may result in slightly more graduates entering primary care. Notably, the Veterans Administration (VA) recognizes both PAs and NPs as autonomous health practitioners in primary care, a model of PA flexibility that has the potential to improve access to care in the VA system.21

Study findings suggest that other efforts already underway may also affect the PA primary care workforce. For example, a higher percentage of PAs in primary care reported receiving student loan repayment, indicating that financial incentives likely attract some PAs to primary care settings. In addition, primary care PA participation in new models for reimbursement and care delivery was reflected in this study's finding that 56.5% of primary care PAs reported that their main clinical employer receives financial incentives based on quality measures. The trend in healthcare toward fee-for-value as a means to improve outcomes and reduce cost may result in increased reimbursement for PA services, subsequently increasing opportunities for PAs in primary care settings. Already, nearly 39% of primary care PAs reported working in a patient-centered medical home. In addition, a 2015 report from a national physician placement firm reported that demand for PAs was increasing, particularly in primary care.22

Despite the potential for PAs to make more substantial contributions to the provision of primary care, the challenges may be insurmountable. Study findings support previous research suggesting that younger, more recent PA program graduates may be less inclined to practice in primary care.19 Results also indicated that a higher proportion of primary care versus specialty PAs reported having plans to retire.

The decrease in the percentage of PAs in primary care may reflect personal choice but also may be due, at least partially, to the diminishing proportion of physicians entering primary care and a resultant decrease in job opportunities. Recent research findings indicate that in 2014, only 18% of PA job postings were in primary care.23 Although the ratio of physicians to PAs remained relatively constant from 2005 to 2013 in family medicine (decreasing from six physicians for every PA to five physicians for every PA), the ratio of physicians to PAs in multiple specialties decreased significantly.24 In 2005, for example, there were 30 gastroenterologists for every PA in gastroenterology; by 2013, there were only eight for every PA.24

Other challenges include the fact that primary care PAs continue to earn less than PAs overall, that women are more likely than men to practice in primary care, and that few primary care PAs report good work-life balance, a high priority for younger generations.19,25 These may be factors in PAs' decisions to practice in primary care. Notably, compared with PAs in other specialties, a lower percentage of primary care PAs reported that they planned to stay in their specialty.

Finally, some healthcare and PA leaders contend that the NP movement toward independent practice may better position NPs, rather than PAs, to fill workforce needs in primary care.26,27 The Institute of Medicine recommended that scope of practice barriers for NPs be removed on a national level to increase access to primary care services.28 Although PAs in primary care appear to practice with a significant degree of autonomy, they continue to rely on physicians as employers, educators, and collaborators.

The outcome of efforts to increase independent NP practice remains to be seen; however, current projections indicate that despite a predicted rise in the absolute numbers of primary care physicians, PAs, and NPs, a significant shortage will persist, that the job market for PAs is strong, and that efforts to reform healthcare revolve around team-based models of care delivery.5,8,22,29,30

LIMITATIONS

This analysis included a large sample of respondents with demographic and practice characteristics similar to those reported by other national data sources; however, the low AAPA survey response rates raise some risk of self-selection and nonresponse bias. In addition, findings are subject to self-report bias inherent in all survey research. Finally, the surveys are cross-sectional and therefore only provide evidence for a single snapshot in time. Despite these limitations, results are consistent with previous research related to characteristics associated with PA practice and provide insight into the current primary care workforce.

CONCLUSIONS

The shortage of primary care providers presents a challenge for the US healthcare system. Many physicians and members of the public perceive PAs, as well as NPs, as key players in augmenting primary care capacity. Contemporary medical practice has become a typically complex, multilayered endeavor requiring a team approach, and physician supply is unlikely to be sufficient to meet future demands for primary care and many aspects of specialty care. Thus, greater attention will likely be focused on the PA profession and its ability to continue to adapt to meet society's healthcare needs.

The PA-primary care physician model has been successful over the past 50 years. Many primary care physicians embrace NPs and PAs as partners in primary care practice. The American Academy of Family Physicians, the American College of Physicians, and the AAPA have all issued statements outlining important, jointly agreed-upon principles, including team-oriented practice and recognition of PAs as primary care providers.10,31 Generalist education, flexibility in federal and state regulations, and collaboration with physicians have enabled PAs to assume a variety of roles in nearly every facet of medicine. Now may be the right time to mobilize the skill and flexibility of PAs to reconnect with the profession's roots in primary care.

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Keywords:

primary care; physician assistants; PAs; healthcare workforce; specialties; challenges

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