Family Physicians as Proceduralists for Medicare Recipients.

PURPOSE: Procedures are manual technical skills clinicians perform for their patients. Family physicians (FPs) acquire these skills during residency; most are undertaken in outpatient settings. We performed a retrospective observational cohort study to describe the extent to which FPs perform the core procedures recommended by the Council of Academic Family Medicine (CAFM) and how this might have changed over time. METHODS: The CAFM recommended a list of procedures all FP residents should perform competently after graduation. We modified this list for Medicare beneficiaries to enable matching with Current Procedural Terminology codes. We probed Medicare Part B databases for modified CAFM procedure claims submitted by FPs in 2021 and how these claims changed from 2014 to 2021. RESULTS: In 2021, there were 904,278 modified CAFM procedures filed by 9,410 FPs in the outpatient setting. All procedures were clustered with respect to organ system (eg, musculoskeletal, skin, pulmonary). Beginning in 2014 and continuously through 2021, there was a 33% decrease in outpatient procedures filed and a 36% decrease in the number of FPs filing them. CONCLUSIONS: Office-based procedures are integral to a primary care physician's role, although the activity is rarely analyzed. At a time when the Medicare population is growing, the number of available FPs and the number of procedures they perform are not. This decrease might result from the changing scope of FP practice, new referral patterns, task shifting, and/or increased delegation to physician associates and nurse practitioners.

Office procedures for older adults by physician associates and nurse practitioners.

OBJECTIVE: We hypothesized that physician associate (PA) and nurse practitioner (NP) procedural roles are expanding. We sought to describe ambulatory procedures these professionals performed in 2021 for older adults. STUDY DESIGN: Retrospective observational cohort study of Medicare Part B data. US Bureau of Labor Statistics data were used to provide overall PA and NP employment context. METHODS: Medicare Part B databases were probed for outpatient events by PAs and NPs using a modified list of the Council of Academic Family Medicine's recommended clinical procedures that focused on 29 procedures organized into 9 categories called procedure clusters. These procedures were linked to Current Procedural Terminology codes and PA and NP National Provider Identifier codes in Medicare Part B and then tabulated and analyzed for 2021. The Bureau of Labor Statistics provided NP and PA employment trends for context. The trend of the procedures and providers spanning 2014-2021 was analyzed. RESULTS: In 2021, 23,581 NPs and PAs filed 9.6 million Medicare Part B enrollee procedure claims. Most procedures (96%) involved skin or the musculoskeletal system. PAs filed more than twice as many claims for skin and musculoskeletal procedures as NPs, and NPs filed 1.25 times as many as PAs for the eye, ear, nose, and throat; pulmonary; genitourinary; gastrointestinal-colorectal; and women's health categories. From 2014 through 2021, the number of PAs and NPs in clinical practice increased by 72%, and the number of those who filed procedure claims increased by 74%. CONCLUSIONS: Overall, PAs performed more skin and musculoskeletal procedures than NPs, and NPs performed more procedures in the other 7 procedure clusters than PAs. PA and NP employment growth does not fully explain these observations. We suggest that outpatient procedural task-shifting activity presents an area for further research.

Demographics of Physician Associates (PAs) in Obstetrics and Gynecology: Where They Work and How They Compare to Other PAs.

As of 2020, maternal and infant health in the US has worsened. At the same time, the number of health professionals available to manage female health issues is changing; the number of physicians in obstetrics and gynecology (Ob-Gyn) and midwives is decreasing, whereas the number of Ob-Gyn physician associates (PAs) is growing. We analyzed PAs practicing in the Ob-Gyn discipline, drawing on the PA Professional Profile, a database maintained by the National Commission on Certification of PAs. In 2021, there were 1,322 Ob-Gyn PAs (1.2% of all clinically active PAs). This health profession has grown by 66.9% since 2013, when only 792 PAs practiced in this specialty. As of 2021, their median age was 38, and 98.0% were female (70.1% of all PAs were female). The practice setting was between office (54.7%) and hospital (34.0%) employment, with 11.3% described as "other." In 2021, the median annual income of Ob-Gyn PAs was $105,000. With the reduction of obstetrician-gynecologists, the relative growth of PAs in this area of medicine and surgery is a natural part of the solution to the projected obstetrical physician deficit.

Prescribing by Physician Associates and Nurse Practitioners in Older Adults Is Outpacing Traditional Prescribers: Implications for Practice in American Medicine.

Prescribing is a significant activity undertaken by physicians, physician associates/assistants (PAs), and nurse practitioners (NPs). We analyzed prescribing data to understand better the growing presence of PAs and NPs in older adults. A trend in frequently prescribed medications was compared with other physicians. All prescriptions in Medicare Part D were grouped into broad categories of drugs and linked to each type of provider. The analysis spanned 9 years (2013-2021). The results revealed that all five providers similarly prescribed the top three main drug classes (antacids, antihypertensives, and statins). In addition, there was a decline in the number of unique prescribers and prescriptions for all three types of physicians (family medicine, internal medicine, and general practice physicians). Concurrently, the number and share of prescriptions for NPs and PAs increased yearly. The findings are consistent with data that PAs and NPs are backfilling physician shortages in treating older adults.

Procedures by Physician Associates in Obstetrics and Gynecology.

Background and Objectives: The number of obstetricians and gynecologists in the United States is decreasing and providers backfilling this service have not been well described. The intent of the study was to identify the skills that physician associates (PAs) in obstetrics and gynecology (OBGyn) contribute to this aspect of medicine and surgery. Methods: A survey of PAs specializing in OBGyn was conducted in 2022. The intent was to list office-based procedures that were part of their skill set. A vetted questionnaire was sent to the 1,630 American Academy of Physician Associates members who identified themselves in OBGyn at some point in their career, and 729 responded (44.7% relative risk). Results: Most PAs (88.7%) in OBGyn first assist in surgery. This first-assist role ranged across the open, laparoscopic, and robotic-type operations. Categories of surgery included Cesarean section, hysterectomy, salpingo-oophorectomy, and subspecialty surgeries such as oncology and urogynecology. In the outpatient setting, PAs listed over 40 procedures ranging from biopsies of the endometrium, cervix, vagina, and vulva, as well as fetal assessment, ultrasonography, and long-acting contraceptive insertion and removals. Conclusions: The proceduralist role of PAs in OBGyn is broad. Furthermore, this role may need to be utilized more at a time of growing scarcity of clinicians. The OBGyn role for PAs adds to their specialization and increasing presence in American medicine.

PA and NP general practice employment in the Netherlands.

ABSTRACT: General practitioners (GPs) are the cornerstone of primary healthcare in the Netherlands. As a national strategy, physician associates/assistants (PAs) and NPs were introduced to address growing healthcare demand. In this study, four representative practices were analyzed quantitatively and qualitatively-two solo practices with a PA or NP and two group practices with a PA or NP. A reference group of GPs served as experts. The annual encounters per full-time GP averaged 6,839; for the NPs, 2,636; and the PAs, 4,926. Billable services were 70% to 100%, averaging 71% for NPs and 85% for PAs, and in three of the four practices, the employment of the NP or PA was cost-efficient. The qualitative data show that PAs and NPs contribute to general practice, easing the workload so that the GP has more time for complex patients. PA and NP employment was financially beneficial in 75% of cases.

The changing employment of physicians, NPs, and PAs.

ABSTRACT: Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics (BLS) employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 NPs, and 139,100 physician associates/assistants (PAs). These three healthcare professionals accounted for about 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than that of physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

The changing employment of physicians, nurse practitioners, and physician associates/assistants.

ABSTRACT: Information on the employment of patient-care clinicians is needed for policy planning and human resource management. The 2021 Bureau of Labor Statistics employment data were probed for occupational settings of 698,700 physicians and surgeons, 246,690 nurse practitioners (NPs), and 139,100 physician associates/assistants (PAs). These three health care professionals accounted for approximately 1.1 million medical and surgical clinicians serving a US population of 331.5 million. Clinician demographics differ-in 2021, the median age of physicians was 45 years; NPs, 43 years; and PAs, 39 years. The largest employment location is "office of a physician" (physician, 53%; NP, 47%; PA, 51%), followed by hospitals (physician, 25%; NP, 25%; PA, 23%), and outpatient centers (physician, 4%; NP, 9%; PA, 10%). The 10-year job outlook predicts physician growth at 3%, NPs at 46%, and PAs at 28%. NP and PA employment is growing more than physicians because of constrained physician postgraduate education funding. Other factors influencing employment changes include medical practice mergers, the rising value of team-based care, the cost of new medical schools, and task shifting.

Rent-a-MEDEX: An early PA prototype.

ABSTRACT: In the 1970s, busy physicians knew little about the capabilities of a new member of the healthcare team-the physician associate/assistant (PA). Internal studies by the University of Utah and University of Washington educational programs demonstrated that the MEDEX/PA could increase access to care by providing quality, cost-effective care in rural primary care practices. Marketing this concept was essential, and in the early 1970s, the Utah program devised an innovative plan, partially funded through a grant from the federal Bureau of Health Resources Development, called Rent-a-MEDEX. Physicians in the Intermountain West were introduced to graduate MEDEX/PAs in order to gain firsthand experience about how these new clinicians could benefit a busy primary care practice.

Characteristics of physician associates/assistants in dermatology.

The dermatology workforce includes physicians, nurse practitioners (NPs), and physician associates/assistants (PAs). The number of dermatologists is growing slowly while the growth of PAs working in dermatology is rapid and accelerating. To understand their characteristics, a descriptive study of PAs practicing in dermatology utilizing the National Commission on Certification of Physician Assistants (NCCPA) workforce dataset on PA practices was undertaken. NCCPA certifies PAs who practice in the United States and queries them about their role, employment, salary, and job satisfaction. Analyses consisted of descriptive statistics, Chi-Square, and Mann-Whitney tests for comparisons between PAs practicing in dermatology versus the total of all other PA specialties. As of 2021, 4,580 certified PAs reported practicing in dermatology-a nearly twofold increase since 2013, when 2323 worked in the specialty. This cohort's median age was 39 years, and 82% were female. Almost all (91.5%) are office based, and 81% work more than 31 h per week. The median salary was $125,000 (2020 dollars). Dermatology PAs work fewer hours and see more patients than their counterparts compared to all 69 PA specialties. At the same time, dermatology PAs are more satisfied and less burnt out when compared to all PAs. The increased number of PAs selecting dermatology as their discipline can help lessen the projected physician shortage in this field.

Assessing the productivity of PAs and NPs.

ABSTRACT: The improvement of healthcare efficiency and productivity is of international interest. Following an expansion phase of physician associate/assistant (PA) and NPs employment, the Department of Veterans Affairs (VA) assessed how and where they were being used. Using data from 134 VA medical centers, annual productivity was examined across 30 medical and surgical specialties spanning primary care, mental health, and surgery. PA productivity differences averaged 82 relative value units per full-time employee per year more than NPs, a difference of 4%. In general, PAs were found in higher productivity ranges than NP counterparts. PAs and NPs have statistically similar productivity levels in primary care and mental health. In specialty medicine and surgery, PAs average higher annual productivity than NPs. This analysis provides some utility for managers regarding workforce composition, given the relative productivity of two types of clinicians.

Physician assistant/associate retirement intent: seeking the exit ramp.

BACKGROUND: Retirement patterns for American physician assistants/associates (PAs) are in flux as the first substantial cadre trained in the 1970s makes their retirement choices. The growing and aging of the US population is increasing the demand for healthcare services. At the same time, provider retirement can decrease patient access to care, disrupt continuity of care and lead to poorer health outcomes. Knowing PA intentions to retire and the retirement patterns can be useful to health system employers and workforce policymakers. The purpose of this study was to investigate the retirement patterns of PAs within the United States. We investigated their characteristics, career roles, and intent to depart from clinical practice. METHODS: Drawing on the National Commission on Certification of Physician Assistants (NCCPA) 2020 health workforce data (N = 105,699), the associations of demographics (age, gender, US region, and years certified), and practice attributes (specialty and practice setting) of clinically active PAs were assessed with intending to retire in the next five years. Analyses for this national cross-sectional study included descriptive statistics, Chi-square, and Fisher's Exact test, as appropriate. A p-value of 0.05 or less was considered statistically significant for all analyses where a comparison was made. RESULTS: Overall, 5.8% of respondents indicated that they intend to retire within five years. We detected significant differences (all p < 0.001) on intentions to retire by age group, gender, US region, years certified, specialty, and practice setting. Respondents 70 years and older compared to those 60-69 were more likely (66.5% vs. 48.9%), males compared to females (8.8% vs. 4.4%), those who have been certified for more than 21 years compared to 11-20 years (25.6% vs. 4.0%), PAs practicing in family medicine compared to dermatology (7.7% vs. 3.4%) and those in the federal government practice setting compared to rural health clinic (13.6% vs. 9.8%) reported they were more likely to retire in the next five years. CONCLUSIONS: Our study provides a comprehensive snapshot of PA retirement intentions using a robust national dataset. Among the most important factors associated with intent to retire in this study were older age and duration of PA career. Most PAs are remaining clinically active into their seventh decade-suggesting that they are integrated into medical systems that value them and they, in turn, value their role.

Physician Associates/Assistants in Primary Care: Policy and Value.

Since the new century, primary care physician supply has worsened. Analysts predict that health service demand in the United States will grow faster than physician supply. One strategy is the utilization of physician assistants/associates (PAs). Most PAs work full-time, and approximately one quarter are employed in family medicine/general medicine. PAs deliver primary care services in a team-oriented fashion in a wide variety of settings, including private health systems and community health centers. One fifth work in rural and medically underserved areas. Together PAs and nurse practitioners provide approximately one third of the medical services in family medicine, urgent care, and emergency medicine.

The PA profession in the 1990s.

ABSTRACT: History is rarely linear, and nowhere is this more evident than the US physician assistant/associate (PA) movement (1965-2021). The 1990s stand out as pivotal years for the PA profession, marked by advances that shaped the profession, experiments in primary care delivery, sex equity, the Balanced Budget Act, and national policy errors in predicting a physician surplus. Rapid growth followed program expansion, doubling from 57 in 1993 to 120 by 1999. By the end of the decade, all states had advanced PA-enabling legislation with broad-based prescribing. During this era, PA-focused research moved from descriptive to predictive, an official journal emerged in 1988, the Accreditation Review Commission on Education for the Physician Assistant became independent, and the American Academy of Physician Associates helped shape federal health policy. Also during this period, the profile of PAs shifted from older males to younger females with important sociological implications in leadership and career development. Notable milestones included national recognition of PAs as Medicare-eligible providers, direct commissioning in the military, and employment surges in the Veterans Health Administration and US Public Health Service. Not least of all this was a time of role shifts toward specialized medicine and surgery.

Forecasting the physician assistant/associate workforce: 2020-2035.

Background: Physician assistant/associates (PAs) are healthcare professionals whose roles expand universal access across many nations. PAs fill medical provider supply and demand gaps. Our paper reports a forecasting project to predict the likely census of PAs in the medical workforce spanning from 2020 to 2035. Methods: Microsimulation modelling of the American PA workforce was performed using the number of clinically active PAs employed in 2020 as the baseline. Graduation rates and PA programme expansion were parameters used to predict annual growth; attrition estimates balanced the equation. Two models, one based on data from the US Bureau of Labor Statistics (BLS) and another based on National Commission on Certification of Physician Assistants (NCCPA) data were used to estimate future annual PA census numbers. Results: As of 2020, the BLS estimated 125,280 PAs were in the medical workforce; the NCCPA estimate was 148,560 PAs in active practice. The BLS model predicted approximately 204,243 clinically active PAs by 2035; the NCCPA-based model predicted 214,248 PAs in clinical practice. Conclusions: A PA predictive model based on four data sources projects that the 2035 census of clinically active PAs to be between 204,000 and 214,000: a growth rate of approximately 35%.

Physician assistants/associates at 6 decades.

The introduction of the American physician assistant/associate (PA) was predicated on the belief that the nation's health care needs had outpaced the supply of physicians. The notion that the medical experience of veterans could be utilized in the civilian sector was at the forefront of discussion. From 1965 to the third decade of the new century, the PA has become established in this role and has become an integrated part of society. As of 2021, more than 125,000 PAs are in clinical practice; most (76%) are female, with a mean age of 41 years. PAs work in 65 distinct areas of medicine and surgery, with a quarter in the primary care disciplines. The most visible practice settings are family medicine, surgical subspecialities, emergency medicine, and orthopedics. Sites of PA employment include primary care offices, emergency departments, and inpatient settings. PAs work as hospitalists and intensivists, with some skilled in cardiac catheterization and traumatology. Increasingly, PAs are utilized in graduate medical education, supporting the continuity of care across hospital teaching wards. In a wide range of studies, the evidence demonstrates that PAs produce care indistinguishable from that of a physician in general medicine. When care by PAs for patients with complex and chronic diseases is compared with physician care, the outcomes are the same but the labor cost is considerably lower. The economics of PAs favor their employment, and patient satisfaction is the same as that with doctors. In 2021, at least 11,000 PAs graduated from 277 accredited programs. This graduation rate is increasing, with 20 more programs in development. Predictive modeling by the Bureau of Labor Statistics suggests that the employment growth of PAs will continue beyond 2030.