How adding PAs and NPs affects physician supply and demand
Assessing the capacity of the nation's future physician workforce is important to give the public sector the information it needs to make the targeted investments necessary for the healthcare system. This report presents new research on implications that important issues, such as an evolving healthcare system and inequities in healthcare use, have on the physician workforce. An updated microsimulation model projects the supply of physicians to 2030. The model takes into consideration trends in key determinants of physician supply and the sensitivity of supply projections to changes in these determinants. The demand projections reflect changing demographics as the population grows and ages, changes in healthcare insurance coverage, the expanding role of PAs and NPs in care delivery, and a growing emphasis on achieving population health goals while improving care access and delivery. Projections of each supply scenario modeled are compared with projections from each demand scenario. Because the degree to which each scenario will manifest cannot be predicted with certainty, this analysis reports the projected shortfalls as a range of the projected scenario pairs (based on the 25th to 75th percentile of the projections) rather than a single projection. During this period, the US population is projected to grow by 11%, from about 324 million to 359 million.1
Commentary by Roderick S. Hooker: Forecasting medical provider supply and patient demand is tricky business—historical events can shift healthcare professional employment trends quickly. When the Great Recession occurred (December 2007–June 2009), a large percentage of healthcare professionals who were expected to retire instead kept working. Ten years later, in 2018, pension investments are at an all-time high and older providers are retiring sooner than anticipated. For the United States, projecting from 2016 to 2030, the population under age 18 years will grow only 3% while the population age 65 years and older will grow by 50%. Because older adults have higher per capita consumption of healthcare than younger groups, the growth in demand for services used by older adults will be much higher than that for services used by children or younger adults. Added to this is a serious shortfall in physician supply, providers demanding a shorter workweek, and higher provider attrition than projected. Furthermore, the future is compounded by a theoretical saturation of demand for PAs and NPs by 2030.2,3 This IHS Markit contract report-generated microsimulation model created for the AAMC is the most sophisticated one to date. Unfortunately, it discounts the productivity of PAs and NPs; a substantial political issue and a purposeful error on the AAMC's part to make the projected demand for physicians appear greater. Forecasting is a science that yearns for more and better data, especially on PAs and NPs, but as a science we should expect uncontested results. As Mark Twain reportedly said, “it is dangerous to make forecasts, especially about the future.”
IHS Markit. The Complexities of Physician Supply and Demand 2018 Update: Projections from 2016 to 2030. March 2018. Prepared for the Association of American Medical Colleges. Washington, DC: Association of American Medical Colleges.
US Department of Health and Human Services. Health workforce projections 2016. https://bhw.hrsa.gov/health-workforce-analysis/research/projections. Accessed January 23, 2019.
Dall TM, West T, Chakrabarti R, et al Health workforce model documentation, 2016. https://cdn.ihs.com/www/pdf/IHS-HDMM-DocumentationApr2016.pdf. Accessed January 23, 2019.
What does an orthopedic patient want in a provider?
To date, no studies have examined patient perspectives toward PAs and NPs in orthopedic sports medicine. Six hundred ninety consecutive new patients of three orthopedic sports medicine physicians were prospectively administered an anonymous questionnaire before their first visit. Content included patient perspectives about PA or NP importance in physician selection, optimal scope of practice, and reimbursement equity with physicians. Of the 690 consecutive patients who were administered the survey, 605 (87.7%) responded. Of these, the mean age was 40.5 ± 15.7 years and 48.1% were women. More than half (51.2%) perceived no differences in training levels between PAs and NPs. Patients had specific preferences about which services should be provided by physicians and which provided by a PA or NP. As healthcare becomes value-driven and consumer-centric, understanding patient perspectives on PAs and NPs will help orthopedic sports medicine physicians optimize efficiency and patient satisfaction. Mentioning PAs or NPs in marketing efforts may be worthwhile, given that patients considered the credentials when initially selecting a new physician. The authors believe the findings are important for understanding the evolving workforce as it continues to grow in response to the increasing demand for orthopedic sports care.1
Commentary by Mark Archambault: Health services research to elucidate the quality, cost, and patient satisfaction of care provided by physicians versus PAs or NPs is driven by the growth of the latter two professions and resultant pressure on scope-of-practice boundaries with physicians. The authors sought to fill a research gap in the literature related to patients' provider preferences. The study design has author-acknowledged limitations of being conducted at a single center and lacking stratification of results based on “determining characteristics.” The authors fail to recognize two limitations related to their optimal scope-of-practice survey design. First, they group PAs with NPs under the single term midlevel provider, which may negatively bias the patient about the quality or ability of the provider and fails to differentiate PAs from NPs. Second, the survey response options are limited to “Can be provided by either midlevel provider or sports medicine physician” or “Should be provided by sports medicine physician only.” Are there items such as “follow-up visits for controlled, nonoperative conditions” that patients prefer “should be provided only by a PA?” Research methodology should let patients share their preferences for PAs and NPs and avoid physician-centric bias.
1. Manning BT, Bohl DD, Hannon CP, et al Patient perspectives of midlevel providers in orthopaedic sports medicine. Orthop J Sports Med. 2018;6(4):1–7.
PAs perform more biopsies but diagnose with similar accuracy
Is there a difference in skin cancer detection and biopsy specificity by clinician type? This retrospective analysis evaluated 20,270 patients over 5 years. Variables included patient sex, age, personal history of melanoma or skin cancer, clinician type, and mean years of experience for PAs and dermatologists. The 15 dermatologists had a mean 13.5 years' experience (excluding 3 years residency training), were more likely to see patients with a history of melanoma, were more likely to diagnose melanoma in situ (58 versus 40), and diagnosed melanoma with the same accuracy as their PA counterparts (26 versus 25). The 15 PAs had a mean 6.9 years' experience, performed more biopsies overall (3,928 versus 3,427), and diagnosed the same percentage (6.1%) of nonmelanoma skin cancers. Compared with dermatologists, PAs performed statistically more biopsies but diagnosed with similar accuracy as dermatologists.1
Commentary by Virginia Valentin: Providing quality care for skin cancers, particularly melanoma, is a concern in the dermatology community. Dermatologists cannot provide this care without the addition of NPs and PAs. Significant provider shortages are projected and diagnoses could be missed.1 Primary care often plays a role in skin cancer management. A systematic review of 32 studies found inconclusive evidence to determine that dermatologists diagnose melanoma with better accuracy than primary care providers (PCPs).2 As of 2013, about 3,250 PAs worked in dermatology.3 In this study, without controlling for years of experience or practice model, the PAs completed more skin biopsies than their dermatologist counterparts. Yet, despite the 9.6-year difference in experience (dermatologists had 3 years of residency training that was not included in the years of experience calculation), the patient outcome, diagnosed nonmelanoma skin cancers, was the same. For melanoma in situ skin cancers, PAs biopsied more and dermatologists were more accurate in diagnosis. This difference was found after analyzing only 98 patients. Previous studies have determined that more than 10 years of experience is associated with increased melanoma diagnosis accuracy.4 Little is known empirically about the use of PAs in dermatology and patient outcomes. This study supports the assertion that PAs increase access to care and, despite their limited training and years of experience, provide quality care in dermatology with similar accuracy in diagnosis as dermatologists.
1. Sargen MR, Shi L, Hooker RS, Chen SC. Future growth of phyusicians and non-physician providers within the US dermatology workforce. Dermatol Online J. 2017;23(9):1.
2. Chen SC, Bravata DM, Weil E, Olkin I. A comparison of dermatologists' and primary care physicians' accuracy in diagnosing melanoma: a systematic review. Arch Dermatol. 2001;137(12):1627–1634.
American Academy of PAs. 2013 AAPA annual survey report. http://www.aapa.org/wp-content/uploads/2016/12/Annual_Server_Data_Tables-S.pdf. Accessed January 23, 2019.
4. Morton CA, Mackie RM. Clinical accuracy of the diagnosis of cutaneous malignant melanoma. Br J Dermatol. 1998;138(2):283–287.
Why are these data confusing?
NPs and PAs are involved in the delivery of healthcare services and their role in primary care has been described. However, less is known about physician specialty practices. The authors characterize levels of and changes in NP and PA employment across different physician practices in the United States in 2008 and 2016, with a particular focus on specialty practices. The 2008 and 2016 SK&A proprietary outpatient provider files were used for analyses. For each practice type, the proportion of practices with an NP or PA (overall and by NPs and PAs) and the percentage change between 2008 and 2016 were calculated. In 2016, about 28% of all specialty practices employed NPs or PAs. Multispecialty practices were most likely (49%) and surgical specialties least likely (21%) to employ NPs or PAs. Specialty practices were more likely to employ NPs than PAs, with the exception of surgical practices, which relied more on PAs. NP employment in specialty practices grew faster compared with PAs (33% versus 20% increase). These data have important limitations in that they only include outpatient providers and provide no information about the specific duties of NPs and PAs in the practice. As the presence of NPs and PAs in the delivery of specialty care increases, research will need to understand their contributions to access, quality, and value.1
Commentary by Richard W. Dehn: This study shows that NPs are being hired in greater numbers than PAs over the last 8 years in specialty practices except for surgery. This seems odd because over the last several decades the proportion of PAs practicing in specialties has increased but the proportion of NPs practicing in specialties has decreased. In 1997, 50% of PAs practiced in specialties, compared with 70% in 2017.2,3 In 2001-2002, 29.7% of NPs practiced in specialties, compared with 19.1% in 2017.4,5 So why have the number of NPs hired in specialty practices surpassed the number of PAs hired? The answer lies in the disparity in the number of PA and NP graduates per year. In 2015-2016, nearly 8,100 PAs graduated, compared with 23,000 NPs.6,7 Thus, these data illustrate what we might expect — because PAs only make up about a quarter of the combined number of PA and NP graduates, growth of NP employment surpasses that of PAs. An interesting analysis of these data would be to control for the number of clinicians graduating annually in each profession, which would give a more accurate picture of the specialty growth of each profession.
1. Martsolf GR, Barnes H, Richards MR, et al Employment of advanced practice clinicians in physician practices. JAMA Intern Med. 2018;178(7):988–990.
American Academy of PAs. 1997 AAPA Physician Assistant Census Report. http://www.aapa.org/wp-content/uploads/2016/12/1997_AAPA_Census_Report.pdf. Accessed January 23, 2019.
National Commission on Certification of Physician Assistants, Inc. 2017 Statistical Profile of Certified Physician Assistants: An Annual Report of the National Commission on Certification of Physician Assistants. http://www.nccpa.net/research. Accessed January 23, 2019.
4. Goolsby MJ. 2001–2002 AANP national nurse practitioner practice site survey. J Am Acad Nurse Pract. 2003;15(11):482–484.
American Association of Nurse Practitioners. 2018 NP facts sheet. http://www.aanp.org/images/documents/about-nps/npfacts.pdf. Accessed January 23, 2019.
Physician Assistant Education Association. By the Numbers: Program Report 32: Data from the 2016 Program Survey. Washington, DC: PAEA; 2017.
American Association of Nurse Practitioners. Number of nurse practitioners hits new record high. http://www.aanp.org/news-feed/number-of-nurse-practitioners-hits-new-record-high. Accessed January 23, 2019.