Many areas of the United States, particularly rural and inner-city areas, are chronically medically underserved, largely due to a maldistribution of healthcare professionals.1 The physician assistant (PA) profession was established in part to improve access to medical services to rural and underserved populations, especially in primary care.2 Historically, PAs have been more likely than physicians to provide care for the underserved and to practice in rural areas.3,4 This article reports findings on PAs in rural health from the American Academy of Physician Assistants (AAPA) Annual Survey and reviews pertinent items from recent health services research literature.
A recent systematic review of the literature on PAs in rural healthcare examined papers indexed in electronic bibliographic databases in English from 1974 through 2008.5 The criterion for inclusion was original data published on rural PAs. Of the 51 papers identified, 28 had a primary focus on research and specified PAs in a rural setting. Generally, the literature suggests that PAs provide cost-efficient and expanded medical services to underserved rural populations and that these services are valued. Rural PAs also appear to possess a larger scope of practice than urban PAs and that this broad range of skills and procedures may be necessary to meet the extensive healthcare needs of underserved rural populations. Over the 35-year period examined, the literature improved in terms of the numbers of PAs studied and quality of research. However, the lack of longitudinal studies has been a shortcoming of rural health PA (and NP) observational research.6
Data were drawn from the 2013 AAPA Annual Survey, a web-administered national cross-sectional survey conducted by AAPA.7 In mid-2013, the survey was sent via e-mail link to 93,098 PAs, with reminders sent in subsequent weeks. Responses to the survey were received from 15,925 PAs, a response rate of 17.1%. Variables include demographics, PA practice characteristics, nonclinical roles, educational experiences, compensation, and some specific services offered by AAPA. Additional demographic variables include state and county of primary residence, military status, and military branch. Specific questions explored PAs' specialty choice(s), including primary clinical position, years worked in primary specialty, secondary specialty, and the number of times the clinician has changed specialty since graduation from a PA program. The survey was distributed to all PAs regardless of association membership. Data were collected electronically and analyzed by the AAPA research department. Results of the survey were compared with findings from other national census reports and sample surveys of practicing PAs and were found to be quite similar, particularly in the areas of demographics, practice setting (including rural and urban distribution), and specialty. Respondents' location of clinical practice was cross-referenced with the US Department of Agriculture's 2013 rural-urban continuum codes, the federal standard for establishing rural/urban status.8,9
Overall, 12% of all PAs work in rural settings; the corresponding number for 2005 was 17% and for 2010 it was 15%. This trend is likely the inverse of the ongoing trend of PA specialization and subspecialization.10 The 2013 figure is similar to the percentage of physicians who work in rural areas (11.4%).11 Among primary care PAs, 22% work in rural areas and 78% in urban areas.
The survey also found that PAs in rural settings—particularly those in isolated settings—are more likely than nonrural PAs to perform specific procedures such as central line placement, chronic disease management, clinical preventive services, end-of-life care, and minor surgical procedures.7 These PAs also are significantly more likely to be employed by a community healthcare clinic or center. In the AAPA survey, a rural health PA indicated working in a county that was determined to be in a rural designation area based on the USDA guidelines. PAs who work in rural healthcare do not necessarily live in rural locations. The AAPA survey also identifies PAs by population density and estimates that between 9% and 10% of PAs practice in areas with populations of less than 20,000, according to the US Census Bureau.7 PAs in rural settings, in comparison to their urban counterparts, are more likely to see patients who are on Medicaid or eligible for Medicaid and Medicare. This proportion is likely to increase as more newly insured (Medicaid) rural patients seek care. In 2014, Medicaid enrollment and expenditures were projected to increase sharply with the Affordable Care Act's eligibility expansions; starting in 2014, adults under age 65 years in households with income of up to 138% of the federal poverty level were eligible for Medicaid. Enrollment is expected to be 19.5 million persons higher with the eligibility expansion, reaching 75.6 million persons.12
AAPA survey respondents who were identified as working in practices in rural communities were much more likely to be practicing in primary care specialties (Figure 1). More than three-quarters of rural PAs (77%) practice a primary care specialty (family medicine, general internal medicine, and general pediatrics) versus 32% of all PAs. Of interest, an equal percentage of rural and all PAs reported practicing in emergency medicine.
THE CONTEXT: PAS IN RURAL HEALTH
PAs play a key role in increasing access to care in rural areas. PAs and NPs are more likely to be in practice in rural and underserved areas that have fewer primary care physicians.13 In addition, 2012 National Center of Health Statistics (NCHS) data show that the supply of primary care physicians increased as office locations became more urban.13 Of interest, NCHS data (Figure 2) show that the inclusion of PAs or NPs in primary care physician practices increased as office locations became less urban; this latter finding is consistent with previous studies.14 PAs and NPs are proportionally more likely to provide family medicine in rural locations than are physicians, and they do so with lower labor costs.3,4 In 2012, 53% of office-based primary care physicians worked with PAs or NPs.15
In a study of physicians, PAs, and NPs practicing in rural settings, PAs performed more minor office procedures per week than physicians or NPs. The same study found that, adjusted for various practice characteristics, rural PAs had the same number of weekly outpatient visits as physicians, and that PAs and NPs were delivering the same level of care as physicians in outpatient rural settings.5 PAs also are more likely to practice in federally designated rural health clinics than either NPs or physicians.15
A perennial issue facing all industrialized countries is the recruitment of health providers to rural communities and retention in them. Rural practice was among the intended objectives of the founders of the PA profession. The proportion of PAs who practice in rural areas has fallen over the past several decades while the overall number of PAs in practice has substantially increased.1 Studies have determined that the most frequently mentioned reason that PAs leave rural healthcare was professional isolation.16,17 Reasons also include lack of opportunities for PAs to further their education or work in specialty practice, limits on career opportunities for the PA's family, lower salary, and long on-call hours.18,19
PAs and other medical providers are more likely to practice in locations similar to where they have lived.20 Federally funded projects in PA educational programs have had success at increasing the deployment of PAs to rural and underserved regions.21 Education of PAs for primary care roles remains a high priority for member programs of the Physician Assistant Education Association.22
A major driver of PA practice in rural areas was the Rural Health Clinics Act of 1977, which provided funding for rural health clinics and reimbursement to PAs and NPs for services provided to Medicare patients in rural or underserved communities. One of the provisions of the act is that the clinic must employ a PA or NP.23 A modification to the act in 1997 allowed the number of rural health clinics to grow from 600 in 1990 to more than 3,950 in 2012.24
But despite the growing need for rural providers, fewer medical students are from rural locations or intend to practice in rural locations. An Association of American Medical Colleges survey showed that between 2001 and 2011, enrollment in medical schools increased 16.6% and matriculants' interest in primary care careers remained the same, but interest in rural practice declined.25 Evidence shows that newly graduating physicians are not seeking to practice in rural communities and the percentage of PAs in practice in such areas is falling.5 Recruiting a sufficient number of these providers to rural communities remains a challenge.
Although PAs and NPs have been used to provide primary care services for many years, many physicians are still expanding their use of PAs and NPs as a means to increase revenue while meeting the expanding needs of their patients.26 Physician practices employing PAs and NPs create not only employment opportunities and wages for the PAs and NPs, but salaries and benefits for clinical staff, which in turn are returned to the local economy as the clinic employees spend locally and additional referrals are made to the local hospital. Hiring a PA can have a salutary effect on the practice as well as the community. One economic analysis attempted to estimate the total economic effect of employing a PA or NP in a rural practice under four different staffing scenarios. Depending on which scenario is assumed, a rural PA can create between 4.4 and 18.5 local jobs and generate between $280,476 and $940,892 in revenue for the employing clinic and the hospital.26
The principal limitation of the 2013 survey is the relatively low response rate; however, we did not observe differences in response rates between urban versus rural PAs and we believe that the survey respondents are representative of the larger universe of practicing PAs. Additional limitations include the inability to draw cause-effect relationships (due to the nature of cross-sectional studies), potential bias in the reporting of estimates of physician time spent in consultation, and bias inherent in investigations depending on self-reported information.
Physician assistants remain an important component of the rural healthcare workforce in the United States. The 2013 AAPA Annual Survey provides some factual description of PAs who practice in rural communities. Despite trends of increasing urban and suburban localization and specialization, this core component of PAs select and remain in rural practices delivering primary care services. PAs in rural areas often are the usual providers of care for patients with chronic conditions.4 Rural PAs also appear to be cost effective and safe and, in certain cases, increase access to care. Increasing the numbers of PAs in rural practice and ensuring their retention in these communities remains a challenge.
The positive effect of PAs on rural health has been demonstrated. A recent study by the Medicare Payment Advisory Commission found that 24% of rural Medicare beneficiaries saw a PA or nurse practitioner for all or some of their primary care.27 Given the aging of the US population, a bright spot is that this percentage could increase in the future.w
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