PA Rural_Coombs - Center for Interdisciplinary Health Workforce

Rural Physician Assistants (PAs):
History, Distribution, Scope and
Retention Challenges
Jennifer Coombs, PhD, PA-C
Assistant Professor
University of Utah PA Program
Overview of the rural workforce in US-what is the rural
convergence of crises?
Physician shortages
Brief history and overview of PAs
Current assessment of rural physician assistants (PAs),
and their distribution in rural areas
Discuss the scope of PA practice, and issues facing
retention of the rural PA workforce.
Rural America is facing a
convergence of crises
a) Elderly
b) Economic stagnation
c) Towns without young people
d) Sustainable chronic diseases need more care
e) Native American populations
f) Health profession shortages
84,064 licensed PAs in the US as of 2013 (Provider 360
Program growth (191 programs accredited)
Program growth primarily at private institutions
Projections 125,000 PAs by 2026
Young, primarily white and female
Median compensation~$90,000
Hooker, Roderick S Muchow, Ashley N
JAAPA. 2014 Mar;27(3):39-45. doi: 10.1097/01.
PAs practicing in the rural west
A brief history of PAs in rural areas
PAs since inception designed to
go into rural areas
Most common practice for a rural
PA is primary care
Community health centers,
migrant health centers, indian
health centers and prison
One study showed more than
50% of rural hospitals utilized
Rural Health Providers
62 million Americans, or 20% of
the nation’s population, live in a
rural area. (National Rural Health
Only 9% of the nation’s physicians
practice in rural areas, and 77% of
the 2,050 rural counties in America
are designated as Health
Professional Shortage Areas
PAs and NPs together now
outnumber family medicine
Physician Maldistribution
Clinically Active Physicians per 100,000 Individuals by
Hospital Referral Region (2010)
Dartmouth Atlas of Healthcare Project
215 to 316
200 to < 215
185 to < 200
170 to < 185
118 to < 170
Not Populated
PA distribution
Higher earnings potential in urban areas
Affordable Care Act may benefit rural areas (some
rural states like Utah still debating Medicaid
expansion for example)
Need a workforce to deliver that care
Reimbursement of PAs by Medicaid and Medicare
greater issue in rural areas (elderly populations as
high as 45% in some rural areas)
Percentage of physicians working
with PAs and NPs in rural area
The percentage of primary care physicians working with PAs or
NPs varied by the urbanicity of the physician's office location.
PAs and NPs are more prevalent in rural and underserved
areas, which have fewer primary care physicians.
The supply and access to physicians increases as locations are
more urban…
and, the inclusion of a PA or NP in primary care physician
practices increased as office locations became more rural
Esther Hing, M.P.H., and Chun-Ju Hsiao, Ph.D State Variability in Supply of Office-based
Primary Care Providers: United States, 2012 NCHS Data Brief
PA state laws
American Academy of PAs (AAPA) “Six Key
“Licensure” as the regulatory term (not certification)
Scope of practice determined at the practice site
Adaptable supervision requirements
Full prescriptive authority
Number of PAs a Physician May Supervise Determined at Practice Level
Chart co-signature requirements determined at the practice
American Academy of Physician Assistants, “Statutory and Regulatory Requirements for State Licensure” (February
Example of recent changes
Eliminated the 18 mo direct supervision requirement for
new graduates
Decreased co-signature for chart notes from 100% to
Maybe able to increase PA-physician supervision from 2
PAs to 4.
Kentucky one of two states that cannot prescribe
Physician supervision and
24 states require a physician’s signature on some
percentage of the charts
Most states specify how many PAs a physician may
supervise-generally 2-6 PAs.
Delegation restrictions with some prescribing limits
exist in 14 states, and in 11 states there is
legislation or board sets task
PAs, supervision and
Typically PAs work with physicians at the same site,
but according to AAPA 3.4% of PAs report their
supervising physician is off site.
25 states place restrictions on how often the
physician must be on-site
In some states those can change as the relationship
matures and the PA gains experience
PA and NP regulation and
Considerable cross state variability in NP and PA
Unpublished analysis by Dr. Everett, no correlation
between more restrictive and less restrictive state
practice environments and rurality
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
Which family physicians work
with NPs PAs and CNMs?
Study in Journal of Rural Health by Lars E. Peterson
MD, PhD 2014 used a sample to determine 60%
routinely working with NPs, PAs or CNMs
Conclusion, PA, NPs and CNMs increased access
to healthcare particularly in rural areas.
Peterson LE, Blackburn B, Petterson S, Puffer JC, Bazemore A, Phillips RL.
Which family physicians work routinely with nurse practitioners, physician
assistants or certified nurse midwives. J Rural Health. 2014;30(3):227-234
Some state workforce commissions have
recommended creation of new or expanded PA
programs (Utah, Minnesota, New Mexico and
New programs expanding at private institutions
resulting in higher debt loads for students
Hanover Research, Demand for a Master of Physician Assistant Program (January 2011),
Loan repayment programs, some state, but mostly
federal (National Health Service Corps-NHSC)
Few states offer debt relief or incentives for training
(lack of clinical sites), incentives toward working in
underserved areas are lacking
Primary public funding is through HRSA (Title VII
Health Professions Program) specifically looking for
PA programs that have a mission to serve primary
care and rural populations
Debt continued
Median educational debt for physicians in 2012 was
170,000 and 86% of graduates carried some debt. (AAMC
Physician Education Debt and the Cost to Attend Medical
School 2012 Update)
Recent Robert Graham Center report, “The Impact of Debt
Load on Physician Assistants”, July 2014
More on Debt
From the Graham Center report:
Some surprising findings
• Students who received more than $25,000 in non-loan financial aid for
their PA program were twice as likely as students who received no aid to
express an interest in a rural or underserved area.
• Students at both ends of the debt spectrum—those owing some debt
but less than $50,000 in total debt and those owing more than
$150,000—were more likely to express interest in practicing in a rural
PAs who own their practices
How does a PA employ their supervising physician?
States individually determine if this is allowed
Arizona, Idaho, Maryland, North Carolina, and
Washington all may own their own practices
American Academy of Physician Assistants, Physician Assistants and Practice Ownership (March 2011)
National Governors
Recent IOM report called for nurse practitioners to be allowed to
practice to the full extent of their training. (Institute of Medicine
Similarly the National Governors Association (NGA) issued a
report that called for states to institute better policies for PAs:
“States can ensure that PAs are used efficiently by reviewing
state laws and regulations—especially the definition of
provider—for appropriateness and by facilitating educational and
clinical training opportunities for PAs. Finally, states can
consider creating financial incentives to encourage PAs to work
in underserved communities.” (NGA paper 2014)
Rural PA
PAs provide cost-efficient and supplemental medical
services to underserved rural populations and that
these services are valued.
It is probable that rural PAs possess a larger scope
of practice than urban PAs.
Necessary to match the large scale health care
needs of rural populations.
Henry, Lisa R., Roderick S. Hooker, and Kathryn L. Yates. "The role of physician assistants in rural health c
Critical Access Hospitals
PAs and NPs in CAH
Advantages to CAH in hiring NPs and PAs.
Under the Medicare Conditions of Participation (CoP) hiring NPs
or PAs may have advantages~
“A Critical Access Hospital must have at least one physician,
but that person is not required to be on-site. Midlevel practitioners
can be an independent part of the medical staff and can provide
direct service to patients. CAHs are also required to provide
guidance by a physician, but the provisions are very liberal. This
can be useful in communities that have had difficulty recruiting
Recruitment of PAs
The National Rural Health Resource Center have
many resources:
Recruitment manual
Contract and compensation reviews
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Hooker RS, Everett CM. The contributions of physician assistants in primary care systems. Health Soc Care Community.
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