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Musings: Blog of the JAAPA Editorial Board


Blog of the JAAPA editorial board.

Tuesday, November 11, 2014

Are PAs ready to fill the gaps in rural healthcare in America?

Jennifer M. Coombs, PhD, PA-C

I was recently asked to give a webinar with my colleague Christine Everett, PhD, PA-C, called “Filling the Primary Care Gap: Opportunities and Challenges Facing Rural Physician Assistants.”  The webinar was part of a rural workforce webinar series put on by Vanderbilt University’s Center for Interdisciplinary Health Workforce StudiesI spoke about the history of PAs in rural areas, distribution, scope, and retention challenges. Dr. Everett described some of her latest research on clinical roles and the effect on cost, quality, and access in the rural setting. You can see our talks here

Much can be said about rural healthcare providers now that PAs and NPs together outnumber family medicine physicians.1,2 Promises made because of changes as a result of the Affordable Care Act (ACA) may increase the number of insured Americans, especially in rural areas. The New York Times recently reported that 10 million more people have insurance coverage this year than last as a direct result of the ACA. According to the paper, some of the biggest gains were in rural areas.

Michael Powe from the American Academy of Physician Assistants (AAPA) reported in May that the Centers for Medicare and Medicaid Services (CMS) eliminated the requirement for physicians to be physically on site once every 2 weeks at a certified rural health clinic, federally qualified health center, or critical access hospitals.

PAs will still need to follow their state laws, which contain a considerable amount of variation in terms of adopting the AAPA's “6 key elements of a modern PA practice act” (PDF). The issue is this: only 9% of US physicians practice in rural areas, and among the 2,050 rural counties in this country, 77% are designated health professional shortage areas. 62 million Americans, or 20% of the population, live in rural areas.  Are PAs are ready willing and able to fill those gaps in underserved areas?

I decided to call my friend Amy M. Klingler, MS, PA-C, who lives in a rural and remote area of the country—Stanley, Idaho—and ask what changes she has noticed as a result of the ACA. According the New York Times, Custer County, the central Idaho county where Stanley is located, has gone from 14% uninsured in 2013 to 9% uninsured in 2014. Ms. Klingler is 60 miles from the nearest critical assess hospital and a 45-minute life flight to the nearest major level 2 trauma center. Idaho has no level 1 trauma centers. Her supervising physician visits her clinic once a month. This is a mutually agreed upon supervisory arrangement, and before the latest ruling from the CMS, Ms. Klingler and her supervising physician were able to obtain a waiver allowing for the once monthly visit rather than every 2 weeks.

According to the AAPA, Idaho has only four of the six elements of a modern state practice act. Importantly for a rural state, the delegation of service agreement lets the PA or physician decide the appropriate scope of practice for each PA.  The ratio of physicians to PAs is 1:3; a waiver can be obtained to allow a ratio of 1:6. Most state practice laws allow the flexibility for physicians and PAs together to determine the delegated medical tasks and the method of supervision. Some states require physicians to review a certain percentage of charts; the percentage may depend on how long the PA has been in practice. Being able to decide together how and when Ms. Klingler’s supervising physician was able to visit her is certainly important and critical to her ability to practice so remotely. Her supervising physician or alternate physician are always available by phone. According to the AAPA, 25 states impose some type of travel time or distance limits to their supervision requirements for PAs.

Another important feature to be able to practice remotely is the ability to prescribe controlled substances in categories 2 through 5. All states allow PAs to prescribe medications, but 14 place some limitations on the types of medications PAs can prescribe, a limitation that can hamper PAs practicing in remote areas.

One of Ms. Klingler’s biggest challenges is durable medical equipment and obtaining hospice care for the terminally ill residents in her county.  Older adults make up 13% of the US population, but account for as much as 45% of the population in some rural areas. Hospice and palliative care, Medicare, and rural long-term care facilities are issues facing those aging in remote places.

For Ms. Klingler, living and working in a small town was the reason she went to PA school in the first place. Becoming an MD would not have allowed her to practice in her chosen rural area, where physicians work in the clinics 1 to 2 days per week.  Although most PAs practice in urban areas, PAs and NPs are more prevalent in rural and underserved areas than physicians.3-5 Many rural counties in the United States face serious challenges to provide sufficient healthcare services. The ability of PAs to practice in rural and remote areas is highly variable and depends on many factors, both economic and political. Shortages of PAs and the inefficient use of PAs are the two next great issues in our profession.  As we consider the many changes on the horizon for PAs, aligning our laws and regulations to the needs of rural PAs is paramount. Only then can the maldistribution of providers and shortages of PAs in all areas of medicine be solved.

Jennifer M. Coombs is an assistant professor in the Division of Physician Assistant Studies, Department of Family and Preventive Medicine at the University of Utah School of Medicine in Salt Lake City. The views expressed in this blog post are those of the author and may not reflect AAPA policies.


1. 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.

2. Auerbach DI. Will the NP workforce grow in the future? New forecasts and implications for healthcare delivery. Med Care. 2012;50(7):606-610.

3. Hooker RS, Muchow AN. Supply of physician assistants: 2013-2026. JAAPA. 2014;27(3):39-45.

4. Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community. 2012;20(1):20-31.

5. Sargen M, Hooker RS, Cooper RA. Gaps in the supply of physicians, advance practice nurses, and physician assistants. J Amer Coll Surgeons. 2011;212(6):991-999.